Use of the rectus abdominis muscle flap to fill a retroperitoneal defect following blast injury.

PubMed

Talarczyk, Matthew R; Ricci, Michael A

2009-02-01

Wartime injuries from explosive devices have created the need for atypical responses to devastating and unusual injuries. We report a case of an explosive abdominal injury that produced a huge defect in the posterior abdominal wall which was ultimately repaired with a rectus abdominus flap, an usual use of this versatile muscle flap. The rectus abdominus muscle may be another tool available for the repair of wartime injuries.

The Deep Inferior Epigastric Perforator and Pedicled Transverse Rectus Abdominis Myocutaneous Flap in Breast Reconstruction: A Comparative Study

PubMed Central

Tan, Shane; Yek, Jacklyn; Ong, Wei Chen; Hing, Chor Hoong; Lim, Thiam Chye

2013-01-01

Background Our objective was to compare the complication rates of two common breast reconstruction techniques performed at our hospital and the cost-effectiveness for each test group. Methods All patients who underwent deep inferior epigastric perforator (DIEP) flap and transverse rectus abdominis myocutaneous (TRAM) flap by the same surgeon were selected and matched according to age and mastectomy with or without axillary clearance. Patients from each resultant group were selected, with the patients matched chronologically. The remainder were matched for by co-morbidities. Sixteen patients who underwent immediate breast reconstruction with pedicled TRAM flaps and 16 patients with DIEP flaps from 1999 to 2006 were accrued. The average total hospitalisation cost, length of hospitalisation, and complications in the 2 year duration after surgery for each group were compared. Results Complications arising from both the pedicled TRAM flaps and DIEP flaps included fat necrosis (TRAM, 3/16; DIEP, 4/16) and other minor complications (TRAM, 3/16; DIEP, 1/16). The mean hospital stay was 7.13 days (range, 4 to 12 days) for the pedicled TRAM group and 7.56 (range, 5 to 10 days) for the DIEP group. Neither the difference in complication rates nor in hospital stay duration were statistically significant. The total hospitalisation cost for the DIEP group was significantly higher than that of the pedicled TRAM group (P<0.001). Conclusions Based on our study, the pedicled TRAM flap remains a cost-effective technique in breast reconstruction when compared to the newer, more expensive and tedious DIEP flap. PMID:23730591

Vulva reconstruction after pelvic exenteration, using a unique combination of two flaps

PubMed Central

van Bommel, Annelotte C M; Schreuder, Henk W R; Schellekens, Pascal P A

2011-01-01

A 64-year-old woman with recurrence of carcinoma of the vulva in an irradiated area received an en-bloc total pelvic exenteration. Reconstruction of the pelvic defect was performed with an anterolateral thigh (ALT) flap and a rectus abdominis muscle (RAM) flap (PM/RAM). This combination of flaps is unique, with excellent results. In a large defect, often irradiated in advance, well-vascularised tissue should be placed. Multiple flaps can be used to reconstruct these large pelvic defects, each with their own advantages and disadvantages. The combination of flaps used in this case uses the good properties of both flaps: the reliable and well-vascularised PM/RAM in combination with the ALT flap to provide much bulk in extreme large defects. PMID:22692483

Reconstruction Using Locoregional Flaps for Large Skull Base Defects.

PubMed

Hatano, Takaharu; Motomura, Hisashi; Ayabe, Shinobu

2015-06-01

We present a modified locoregional flap for the reconstruction of large anterior skull base defects that should be reconstructed with a free flap according to Yano's algorithm. No classification of skull base defects had been proposed for a long time. Yano et al suggested a new classification in 2012. The lb defect of Yano's classification extends horizontally from the cribriform plate to the orbital roof. According to Yano's algorithm for subsequent skull base reconstructive procedures, a lb defect should be reconstructed with a free flap such as an anterolateral thigh free flap or rectus abdominis myocutaneous free flap. However, our modified locoregional flap has also enabled reconstruction of lb defects. In this case series, we used a locoregional flap for lb defects. No major postoperative complications occurred. We present our modified locoregional flap that enables reconstruction of lb defects.

A reevaluation of the unusual abdominal musculature of squamate reptiles (Reptilia: Squamata).

PubMed

Bhullar, Bhart-Anjan S

2009-08-01

The abdominal muscles of lizards and snakes (Squamata) have been the subject of periodic attention from anatomists, embryologists, and systematists. Until now, the presence of a superficial portion of the m. rectus abdominis, named the m. rectus abdominis lateralis, has been considered a key synapomorphy of the clade Autarchoglossa, which includes all extant squamates save Gekkota and Iguania. However, the precise anatomical relations of the m. rectus abdominis lateralis have never been fully investigated. Here, I show that the m. rectus abdominis lateralis is present in Iguania. Its absence in Gekkota represents rare gross anatomical support for recent molecular-structure-based hypotheses of squamate relationships placing geckoes as sister to the remaining squamates. Where present, it is the most superficial trunk muscle, exterior to the m. obliquus externus. The separation of the m. rectus abdominis lateralis from the m. rectus abdominis occurs as the m. obliquus externus aponeurosis and part of the m. obliquus internus aponeurosis emerge superficially to form the outer portion of the rectus sheath. In Autarchoglossa, the contralateral mm. recti abdomines laterales meet at the midline and are attached to the imbricae of the transverse scale rows characteristic of the clade, suggesting developmental, functional, and evolutionary association. Because the m. rectus abdominis lateralis is sometimes continuous with the pectoralis, its exclusive association with the m. rectus abdominis is questionable. It may be a neomorphic layer that is part of the abaxial developmental system, comprising those muscles whose connective tissue is largely derived from lateral plate as opposed to somatic mesoderm. (c) 2009 Wiley-Liss, Inc.

Laparoscopy in patients following transverse rectus abdominis myocutaneous flap reconstruction.

PubMed

Muller, C Y; Coleman, R L; Adams, W P

2000-07-01

We report our technique and experience performing laparoscopic pelvic surgery on four women after transverse abdominus rectus myocutaneous flap (TRAM). Examination under anesthesia is performed on all patients in the low lithotomy position parallel with the floor. The abdominal aorta is palpated and outlined. A pneumoperitoneum is created either by umbilical or left upper quadrant Veress placement. Patients with an acceptable umbilical location undergo port placement through the incision of the umbilical relocation. Other options include left upper quadrant or paramedian placement avoiding the ligamentum teres vessels. Lateral operative ports (5 mm) are placed with reference to the transverse incision present, the pelvic pathology, and the location of the umbilicus. Techniques of electrocautery, intra- and extracorporeal suturing and knot tying, and clips are preferred to minimize port size. Following unilateral or bilateral TRAM reconstruction, four consecutive breast cancer survivors underwent successful laparoscopic-assisted vaginal hysterectomy with oophorectomy using the periumbilical incision for trocar placement. The only complication was a superficial skin breakdown from an adhesive allergy that required 6 weeks for complete resolution. Laparoscopic pelvic surgery is feasible in women after TRAM reconstruction. Knowledge of anatomic and physiologic variations related to the TRAM procedure is necessary in planning a safe operation.

Congenital Partial Absence of Trapezius with Variant Pattern of Rectus Sheath.

PubMed

Tigga, Sarika Rachel; Goswami, Preeti; Khanna, Jugesh

2016-04-01

Musculocutaneous pedicled/free flaps are an essential prerequisite for reconstructive surgery. Amongst the trunk muscles commonly harvested for flaps, the trapezius and rectus abdominis provide satisfactory coverage for cranial and trunk defects. unilateral/bilateral or partial congenital absence of trapezius muscle is well documented and may result in muscular imbalances compromising posture and limb movements. During routine cadaveric dissection, we encountered a case of bilateral partial absence of occipital part of the trapezius muscle. Concurrently, the ventral abdominal musculature displayed the aponeurosis of transversus abdominis muscle solely forming the posterior wall of the rectus sheath. These conjointly occurring anomalies advocate a compensatory strengthening of the anterior wall of rectus sheath in response to the congenital absence of occipital part of the trapezius, probably to counteract the postural instability. The present study focuses on recognition of compensatory mechanisms resulting from congenital variations as identification of such processes may prevent chronic debilitating conditions.

Extensive Chest Wall Tissue Loss and its Management by Vertical Rectus Abdominis Myocutaneous Flap

PubMed Central

Basu, Sandip Kanti; Bain, Jayanta; Chattopadhyay, Debarati; Majumdar, Bijay Kumar

2017-01-01

Extensive electric burn around the chest in children is rare and this type of injury always poses a great challenge for its management. A 12-year-old male child with extensive electric burn of the chest wall was admitted to hospital. It was a neglected case of 9 days old burn; the young boy was in critical condition having systemic features of toxemia with widespread necrosis of the skin, subcutaneous tissues, and muscles along with exposed bones (ribs and sternum) with the risk of impending rupture of pleura through the exposed intercostal spaces. After initial resuscitation, a thorough debridement of all necrotic tissues was done. Thereafter, a superiorly based vertical rectus abdominis myocutaneous flap was harvested to cover the exposed bones and intercostal spaces. The remaining raw areas were skin grafted. The child made an excellent recovery with good outcome. PMID:28082777

Quadratus lumborum catheters for breast reconstruction requiring transverse rectus abdominis myocutaneous flaps.

PubMed

Spence, Nicole Z; Olszynski, Patrycja; Lehan, Anne; Horn, Jean-Lois; Webb, Christopher A J

2016-06-01

Patients diagnosed with breast cancer may opt to undergo surgical reconstructive flaps at the time of or after mastectomies. These surgeries leave patients with significant postoperative pain and sometimes involve large surgical beds including graft sites from the abdomen to reconstruct the breast. Consequently, multimodal methods of pain management have become highly favored. Quadratus lumborum catheters offer an opioid-sparing technique that can be performed easily and safely. We present a case of a patient who underwent a breast flap reconstruction and had bilateral quadratus lumborum catheters placed for perioperative pain control.

Treatment of elbow osteomyelitis with an interposition arthroplasty using a rectus abdominis free flap.

PubMed

Jaiswal, Rohit; Busse, Brittany; Allen, Robert; Sahar, David

2015-05-01

Osteomyelitis of the elbow may be a complex clinical problem. Treatment goals include the eradication of infection and preservation of maximal joint function. Bony debridement may be necessary in addition to elbow joint arthroplasty. The use of synthetic material or allograft as the arthroplasty material may be contraindicated in the setting of infection. The use of free muscle transfer as an arthroplasty medium has not been well described. A 22-year-old paraplegic man developed recurrent osteomyelitis of the right elbow, necessitating extensive bony debridement by the orthopedic surgery team. Reconstruction arthroplasty was performed using a free rectus abdominis muscle flap as the arthroplasty material to serve as a source of biologically active, well-vascularized arthroplasty medium in the presence of ongoing infection. A successful free muscle flap arthroplasty was performed. External fixation and physical therapy were implemented postoperatively. The patient had resolution of osteomyelitis and excellent functional use of the elbow for activities of daily living and wheelchair motion. Elbow arthroplasty in the setting of active infection may be accomplished by means of free tissue muscle transfer. Elimination of infection and acceptable joint function may be possible with this form of reconstruction.

Relationship between BMI and Postoperative Complications with Free Flap in Anterolateral Craniofacial Reconstruction

PubMed Central

Yagi, Shunjiro; Toriyama, Kazuhiro; Takanari, Keisuke; Fujimoto, Yasushi; Nishio, Naoki; Fujii, Masazumi; Saito, Kiyoshi; Takahashi, Masakatsu; Kamei, Yuzuru

2016-01-01

Background: Although we have seen tremendous advancement in microsurgery over the last 2 decades and free tissue transfer has become standard for head and neck reconstruction, surgeons still struggle to prevent postoperative complications. We examined the relationship between body mass index (BMI) and postoperative complications in patients undergoing rectus abdominis free flap transfer after anterolateral craniofacial resection. Methods: This was a retrospective review of reconstructive surgery using rectus abdominis musculocutaneous free flap in patients with locally advanced maxillary sinus carcinoma from 2003 to 2014 (n = 35, 27 men and 8 women; average age, 60.9 ± 7.8 years). All patients underwent craniofacial reconstruction after anterior and middle cranial fossa skull base resection and maxillectomy (class IV, subtype a) with palatal resection. Patients were categorized based on sex, BMI, and other parameters. Results: Recipient-site infection occurred in 11 patients (31.4%), cerebrospinal fluid leakage in 6 (17.1%), partial flap necrosis in 2 (5.7%), total flap necrosis in 1 (2.9%), and facial fistula in 4 (11.4%). Women showed partial flap necrosis significantly more frequently (P = 0.047), probably owing to poor vascular supply of the subcutaneous fat layer. Patients with low BMI (<20 kg/m2) showed recipient-site infection (P = 0.02) and facial fistula (P = 0.01) significantly more frequently owing to insufficient tissue volume and poor vascular supply. Conclusion: Postoperative recipient-site infection and facial fistula occurred mainly in low-BMI patients. Surgeons should take care to achieve sufficient donor tissue on low-BMI patients. Using a prosthetic obturator in low-BMI patients for craniofacial reconstruction can be a good alternative option to reduce postoperative complications due to insufficient donor tissue volume. PMID:27257566

Postmastectomy reconstruction: comparative analysis of the psychosocial, functional, and cosmetic effects of transverse rectus abdominis musculocutaneous flap versus breast implant reconstruction.

PubMed

Cederna, P S; Yates, W R; Chang, P; Cram, A E; Ricciardelli, E J

1995-11-01

Over 40,000 postmastectomy breast reconstructions are performed annually. In this study, we investigated the psychosocial, functional, and cosmetic effects of transverse rectus abdominis musculocutaneous (TRAM) flap versus breast implant reconstruction. Thirty-three women who had undergone postmastectomy breast reconstruction were contacted by telephone and agreed to participate in the study. Twenty-two women completed the self-assessment questionnaires regarding their quality of life, psychological symptoms, functional status, body image, and global satisfaction. The TRAM and implant groups contained 8 and 14 patients, respectively. The groups were well matched for age, employment status, marital status, race, religion, and severity of medical and surgical illnesses. The average follow-up was 36 months. Statistical analysis of the responses revealed that women who had undergone TRAM flap reconstruction were more satisfied with how their reconstructed breast felt to the touch (p = .01), and there was a trend toward greater satisfaction with the appearance of their reconstructed breast (p = .08). However, these same patients identified more difficulties as far as functioning at work or school, performing vigorous physical activities, participating in community or religious activities, visiting with relatives, and interacting with male friends (p < .04). There were no statistically significant differences in body image or overall satisfaction. In this small cohort study, both the TRAM flap group and the implant group were satisfied with the results of their breast reconstruction, but the TRAM flap group was more satisfied with how their breast felt and tended to be more satisfied with the cosmetic result. The TRAM flap group reported greater psychological, social, and physical impairments as a result of their reconstruction.

Colostomy with Transversus Abdominis Plane Block

PubMed Central

Tekelioğlu, Ümit Yaşar; Demirhan, Abdullah; Şit, Mustafa; Kurt, Adem Deniz; Bilgi, Murat; Koçoğlu, Hasan

2015-01-01

Transversus abdominis plane (TAP) block is one of the abdominal field block. The TAP block is used for both anaesthetic management and post-operative pain therapy in lower abdominal surgery. TAP block is a procedure in which local anaesthetic agents are applied to the anatomic neurofacial space between the internal oblique and the transversus abdominis muscle. TAP block is a good method for post-operative pain control as well as allows for short operations involving the abdominal area. In this article, a case of colostomy under TAP block is presented. PMID:27366540

Comparison of the deep inferior epigastric perforator flap and free transverse rectus abdominis myocutaneous flap in postmastectomy reconstruction: a cost-effectiveness analysis.

PubMed

Thoma, Achilleas; Veltri, Karen; Khuthaila, Dana; Rockwell, Gloria; Duku, Eric

2004-05-01

This study compared the deep inferior epigastric perforator (DIEP) flap and the free transverse rectus abdominis myocutaneous (TRAM) flap in postmastectomy reconstruction using a cost-effectiveness analysis. A decision analytic model was used. Medical costs associated with the two techniques were estimated from the Ontario Ministry of Health Schedule of Benefits for 2002. Hospital costs were obtained from St. Joseph's Healthcare, a university teaching hospital in Hamilton, Ontario, Canada. The utilities of clinically important health states related to breast reconstruction were obtained from 32 "experts" across Canada and converted into quality-adjusted life years. The probabilities of these various clinically important health states being associated with the DIEP and free TRAM flaps were obtained after a thorough review of the literature. The DIEP flap was more costly than the free TRAM flap ($7026.47 versus $6508.29), but it provided more quality-adjusted life years than the free TRAM flap (28.88 years versus 28.53 years). The baseline incremental cost-utility ratio was $1464.30 per quality-adjusted life year, favoring adoption of the DIEP flap. Sensitivity analyses were performed by assuming that the probabilities of occurrence of hernia, abdominal bulging, total flap loss, operating room time, and hospital stay were identical with the DIEP and free TRAM techniques. By assuming that the probability of postoperative hernia for the DIEP flap increased from 0.008 to 0.054 (same as for TRAM flap), the incremental cost-utility ratio changed to $1435.00 per quality-adjusted life year. A sensitivity analysis was performed for the complication of hernia because the DIEP flap allegedly diminishes this complication. Increasing the probability of abdominal bulge from 0.041 to 0.103 for the DIEP flap changed the ratio to $2731.78 per quality-adjusted life year. When the probability of total flap failure was increased from 0.014 to 0.016, the ratio changed to $1384.01 per quality-adjusted life year. When the time in the operating room was assumed to be the same for both flaps, the ratio changed to $4026.57 per quality-adjusted life year. If the hospital stay was assumed to be the same for both flaps, the ratio changed to $1944.30 per quality-adjusted life year. On the basis of the baseline calculation and sensitivity analyses, the DIEP flap remained a cost-effective procedure. Thus, adoption of this new technique for postmastectomy reconstruction is warranted in the Canadian health care system.

Pedicled rectus abdominis muscle and fascia flap sling the bulbar urethra for treatment for male-acquired urinary incontinence: report of ten cases.

PubMed

Xu, Yue-Min; Zhang, Xin-Ru; Xie, Hong; Song, Lu-Jie; Feng, Chao; Fei, Xiao-Fang

2014-03-01

Male urinary incontinence is relatively common complication of radical prostatectomy and of posterior urethroplasty following traumatic pelvic fracture. Here, we investigate the use of pedicled rectus abdominis muscle and fascia flap sling of the bulbar urethra for treatment for male-acquired urinary incontinence. Ten patients with acquired urinary incontinence were included in the study. Urinary incontinence was secondary to TURP in three patients and was secondary to posterior urethroplasty performed following traumatic pelvic fracture in seven patients. Pedicled rectus abdominalis muscle and fascial flaps, approximately 2.5 cm wide and 15 cm long, were isolated. The flaps were inserted into a perineal incision through a subcutaneous tunnel. The free end of the flap was sectioned to form two muscle strips, each 3 cm in length, and inserted into the space between bulbar urethra and corpus cavernosa. After adequate sling tension had been achieved, the two strips of muscle were anastomosed around the bulbar urethra using a 2-zero polyglactin suture. The patients were followed up for between 12 and 82 months (mean 42.8 months). Complete continence was achieved with good voiding in seven of the 10 patients. In other three patients achieved good voiding following catheter removal, but incontinence was only moderately improved. A pedicled rectus muscle fascial sling of the bulbar urethra is an effective and safe treatment for male patients with mild to moderate acquired urinary incontinence, but it may not be suitable for severe incontinence or for patients with weak rectus abdominalis muscles.

Double Back Cut in Post-mastectomy Breast Skin (Fish-Shaped Skin Paddle) in Delayed Pedicled TRAM Flap Breast Reconstruction.

PubMed

Berezovsky, Alexander Bogdanov; Pagkalos, Vasileios A; Shoham, Yaron; Krieger, Yuval; Silberstein, Eldad

2015-08-01

Breast reconstruction has become standard of care for female patients with breast cancer. The transverse rectus abdominis musculo-cutaneous flap (TRAMf) is the most common method of immediate or delayed autologous breast reconstruction following mastectomy. We share our experience with modified, double back cut of post-mastectomy skin in delayed pedicled TRAMf breast reconstruction, resulting in fish-shaped skin paddle. This sort of back cut is a simple, reliable way to obtain a natural, esthetically pleasant breast mound with inconspicuous hidden scars.

[Preoperative CT angiography for planning free perforator flaps in breast reconstruction].

PubMed

Kuekrek, H; Müller, D; Paepke, S; Dobritz, M; Machens, H-G; Giunta, R E

2011-04-01

Preoperative Doppler ultrasonography for planning free perforator flaps is widely established to identify preoperatively perforators. The method allows one to localise the penetrating point of the perforator through the abdominal fascia. By this means it is not possible to see the intramuscular course or the position of the perforator in relation to the inferior epigastric artery. Lately the technique of computed tomographic angiography provides an opportunity for visualising the course of perforator vessels in these tissues. This paper summarises our experience with the preoperative CT angiography in our breast centre. Since spring 2009 we have reconstructed the breasts of 44 female patients by using free flaps from the lower abdominal wall. 6 of these were bilateral. In a total number of 50 breast reconstructions we used 23 deep inferior epigastric perforator (DIEP) flaps and 27 muscle-sparing transverse rectus abdominis muscle (TRAM) flaps. In addition to the preoperative ultrasonography, a CT angiography of the lower abdomen was conducted in 29 patients. On average they showed at least 2 perforators on the left as well as right abdominal sides, which could be used as flap vessels based on their signal intensity. Based on their estimated microsurgical dissection complexity, the perforator vessels could be classified into 3 groups: 1) direct perforators of category A with short intramuscular course (39%), 2) perforators with long intramuscular course of category B (50%) and 3) "turn around" perforators of category C, which pass medially around the rectus abdominis (11%). The technique of CT angiography permits a reliable preoperative visualisation of perforators in their entire course and facilitates the selection of the supplying perforator as well as the intraoperative procedure for the surgeon. The suggested classification of perforators into 3 groups simplifies the preoperative assessment of the microsurgical dissection effort. Compared to the commonly used Doppler ultrasonography there are disadvantages like the additional cost factor and the radiation exposure. However, in our experience the more detailed planning increases the safety of flap raising and reduces surgery time, so that we consider CT angiography a positive tool to facilitate free perforator flaps. © Georg Thieme Verlag KG Stuttgart · New York.

Postoperative morphine requirements of free TRAM and DIEP flaps.

PubMed

Kroll, S S; Sharma, S; Koutz, C; Langstein, H N; Evans GRD; Robb, G L; Chang, D W; Reece, G P

2001-02-01

In a review of the charts of 158 patients who had undergone breast reconstruction with free transverse rectus abdominis musculocutaneous (TRAM) or deep inferior epigastric perforator (DIEP) flaps and who were treated for postoperative pain with morphine administered by a patient-controlled analgesia pump, the total dose of morphine administered during hospitalization for the flap transfer was measured. Patients whose treatment was supplemented by other intravenous narcotics were excluded from the study. The mean amount of morphine per kilogram required by patients who had reconstruction with DIEP flaps (0.74 mg/kg, n = 26) was found to be significantly less than the amount required by patients who had reconstruction with TRAM flaps (1.65 mg/kg; n = 132; p < 0.001). DIEP flap patients also remained in the hospital less time (mean, 4.73 days) than did free TRAM flap patients (mean, 5.21 days; p = 0.026), but the difference was less than one full hospital day. It was concluded that the use of the DIEP flap does reduce the patient requirement for postoperative pain medication and therefore presumably reduces postoperative pain. It may also slightly shorten hospital stay.

Supercharging the transverse rectus abdominis musculocutaneous flap: breast reconstruction for the overweight and obese population.

PubMed

Wu, Liza C; Iteld, Lawrence; Song, David H

2008-06-01

Autologous breast reconstruction with the transverse rectus abdominis musculocutaneous (TRAM) flap is traditionally based on either the superior epigastric vessels (pedicled) or the deep inferior system (free). In the overweight and obese population, both techniques have been shown to have increased complications of the reconstructed breast. Another alternative is supercharging the flap by anastamosing the deep inferior epigastric vessels to either the internal mammary or thoracodorsal systems. We present a single surgeon's experience with unilateral TRAM reconstructions supercharged to either the thoracodorsal vessels, the internal mammary system, or in one case, perforator vessels in overweight and obese patients. Nineteen consecutive overweight or obese patients underwent delayed or immediate, unilateral autologous breast reconstruction with supercharged TRAM flaps between November 2000 and November 2004. The patients ranged in age from 28 to 66 years (average 49) and had an average body mass index (BMI) of 29.5 (24.9-38.3). Twelve patients had a BMI between 25 and 29.9 kg/m2; 7 patients had BMI > or =30 kg/m2. Left-sided reconstructions were 13; right-sided reconstructions were 6. Supercharging was performed by anastamosing the deep inferior epigastric artery and vein to the thoracodorsal vessels, internal mammary vessels, or perforator vessels. Follow-up ranged from 6 to 54 months. There was a qualitative increase in blood flow measured by audible Doppler signals in all patients after the arterial and venous anastamoses. There were no cases of partial or complete flap loss. One patient had a hematoma and subsequently developed minor fat necrosis. One patient had an infection of the reconstructed breast. There were no donor site complications. Supercharging the TRAM flap by means of microvascular augmentation of the deep inferior epigastric vessels provides a safe and effective breast reconstruction in the overweight and obese population with no additional morbidity.

[Surgical issues and outcomes in ischial pressure sores treatment].

PubMed

Voulliaume, D; Grecea, M; Viard, R; Brun, A; Comparin, J-P; Foyatier, J-L

2011-12-01

Ischiatic pressure sores are frequent in spinal cord injury patients, associated with bad prognosis and high recurrence rate. Many surgical techniques were described, including surgical debridement followed by pedicled flap coverage. We aim to propose a practical decision tree for primary or secondary ischial pressure sore treatment. Our series of 48 operated ischial sores with an average follow up of 4 years (range 2 to 8years) is analyzed and compared to previously published reports. Surgical techniques are discussed according to their specific indications. The optimal recurrence rate in published reports about pressure sore treatment is 20%; a rate inferior to 19% is found in our series, showing the equal importance of flap selection and postoperative care and education. Depending on each situation, various available flaps are described and compared: gluteus maximus flap, biceps femoris flap, gracilis flap, tensor fascia lata flap, fasciocutaneous thigh flaps, rectus femoris and vastus lateralis flap, rectus abdominis flap. Specific surgical indications for more extensive wounds are studied: resection arthroplasty of the hip, hip disarticulation, fillet flaps from the leg, microsurgery. Based upon our experience, a decision tree summarizes our proposition of flap selection, depending on the wound size and the patient background. Copyright © 2010 Elsevier Masson SAS. All rights reserved.

Dynamic Article: Tandem Robotic Technique of Extralevator Abdominoperineal Excision and Rectus Abdominis Muscle Harvest for Immediate Closure of the Pelvic Floor Defect.

PubMed

Singh, Puneet; Teng, Edward; Cannon, Lisa M; Bello, Brian L; Song, David H; Umanskiy, Konstantin

2015-09-01

Extralevator abdominoperineal excision for distal rectal cancers involves cylindrical excision of the mesorectum with wide division of the levator ani muscles. Although this technique has been shown to decrease local cancer recurrence and improve survival, it leaves the patient with a considerable pelvic floor defect that may require reconstruction. We developed an innovative technique of robotic extralevator abdominoperineal excision combined with robotic harvest of the rectus abdominis muscle flap for immediate reconstruction of the pelvic floor defect. This was a retrospective review pilot study. This study was conducted at a tertiary care cancer center. Three patients who underwent robotic extralevator abdominoperineal excision with robotic rectus abdominis flap harvest for distal rectal adenocarcinoma were included. Intraoperative and postoperative outcomes included operative time, intraoperative complications, length of hospital stay, wound complications, incidence of perineal hernia, persistent pain, and functional limitations. Three patients underwent this procedure. The median operative time was 522 minutes with median hospital stay of 6 days. One patient experienced perineal wound complication requiring limited incision and drainage followed by complete healing of the wound by secondary intention. The other 2 patients did not experience any wound complications. Longest follow-up was 16 months. None of the patients developed perineal hernias during this time period. The small sample size and retrospective nature were limitations. This technique confers multiple advantages including improved visualization and dexterity within the pelvis and accurate wide margins at the pelvic floor. An incisionless robotic flap harvest with preservation of the anterior rectus sheath obviates the risk of ventral hernia while providing robust tissue closure of the radiated abdominoperineal excision wound. This technique may result in faster postoperative recovery, decreased morbidity, improved functional outcomes and cosmesis. Further studies are needed to prospectively analyze this approach (Supplemental Digital Content 1, video abstract, http://links.lww.com/DCR/A188).

Angiographic delay: a viable alternative to surgical delay.

PubMed

Aboutanos, Sharline Z; Spinos, Efstathios; Blanchet, Nadia P

2012-06-01

Selective embolization of the inferior epigastric arteries can serve as a method for transverse rectus abdominis musculocutaneous (TRAM) flap delay. The purpose of this study was to determine whether delay by selective arterial embolization is comparable to traditionally surgically delayed TRAM flaps as reported in the literature, in terms of skin and fat necrosis, and to examine whether certain risk factors play a role in TRAM flap fat necrosis despite angiographic delay. Retrospective chart review was performed for 88 consecutive patients who underwent unilateral TRAM flap breast reconstruction after selective embolization of bilateral inferior epigastric arteries. Between 1997 and 2009, 88 pedicled TRAM flaps were performed for breast reconstruction in women with a mean age of 49.7 years. No patients had flap skin necrosis or total flap loss. In all, 13.6% patients had TRAM flap fat necrosis. Two patients in the TRAM fat necrosis group (16.7%) had a positive history of smoking, which was a statistically significant risk factor for necrosis (P = 0.048). Outcomes of pedicled TRAM flaps delayed by selective arterial embolization are comparable to historical controls of those delayed by traditional surgical means (ligation of artery and vein) and better than nondelayed flaps. Smoking remains a significant risk factor for TRAM flap fat necrosis despite the benefit of delay.

Reconstruction of soft tissue after complicated calcaneal fractures.

PubMed

Koski, E Antti; Kuokkanen, Hannu O M; Koskinen, Seppo K; Tukiainen, Erkki J

2004-01-01

A total of 35 flap reconstructions were done to cover exposed calcaneal bones in 31 patients. All patients had calcaneal fractures, 19 of which were primarily open. Soft tissue reconstruction for the closed fractures was indicated by a postoperative wound complication. A microvascular flap was used for reconstruction in 21 operations (gracilis, n = 11; anterolateral thigh, n = 5; rectus abdominis, n = 3; and latissimus dorsi, n = 2). A suralis neurocutaneous flap was used in eight, local muscle flaps in three, and local skin flaps in three cases. The mean follow-up time was 14 months (range 3 months-4 years). One suralis flap failed and was replaced by a latissimus dorsi flap. Necrosis of the edges that required revision affected three flaps. Deep infection developed in two patients and delayed wound healing in another four. During the follow-up the soft tissues healed in all patients and there were no signs of calcaneal osteitis. Flaps were considered too bulky in five patients. Soft tissues heal most rapidly with microvascular flaps. In the long term, gracilis muscle covered with free skin grafts gives a good contour to the foot. The suralis flap is reliable and gives a good final aesthetic outcome. Local muscles can be transposed for reconstruction in small defects.

Free flap reconstruction for diabetic foot limb salvage.

PubMed

Sato, Tomoya; Yana, Yuichiro; Ichioka, Shigeru

2017-12-01

Although free flap is gaining popularity for the reconstruction of diabetic foot ulcers, it is unclear whether free flap reconstruction increases the chances of postoperative independent ambulation. The aim of this study is to evaluate the relationship between free flap success and postoperative ambulation. This study reviewed 23 cases of free flap reconstruction for diabetic foot ulcers between January 2007 and March 2014. Free rectus abdominis, latissimus dorsi, and anterolateral thigh flaps were used in ten, eight, and five patients, respectively. A comparison was made between free flap success and postoperative independent ambulation using Fisher's exact test. Two patients developed congestive heart failure with fatal consequences within 14 days postoperatively, resulting in an in-hospital mortality rate of 8.7%. Five patients lost their flaps (21.7%). Of the 16 patients who had flap success, 12 achieved independent ambulation. Five patients with flap loss did not achieve independent ambulation, except one patient who underwent secondary flap reconstruction using a distally based sural flap. Fisher's exact test revealed that independent ambulation was associated with free flap success (p = 0.047). The present study indicates that free flap reconstruction may increase the possibility of independent ambulation for patients with extensive tissue defects due to diabetic ulcers. Intermediate limb salvage rates and independent ambulation rates were favourable in patients with successful reconstruction. The use of foot orthoses and a team approach with pedorthists were effective to prevent recurrence.

Analysis of chronic morphologic changes of small bowel in electrically stimulated canine island-flap rectus abdominis muscle stomal sphincters.

PubMed

Majzoub, R K; Bardoel, J W; Ackermann, D; Maldonado, C; Barker, J; Stadelmann, W K

2001-11-01

Dynamic myoplasty to achieve fecal continence has been used in humans with varying results. A potential complication of the use of dynamic skeletal sphincters to attain fecal continence is the development of ischemic strictures within the bowel encircled by the functional sphincter. This study examines the histologic changes present in the bowel wall used to create a functional dynamic island-flap stomal sphincter in a chronic canine model. The rectus abdominis muscles of canines were used to create island-flap stomal sphincters. Eight dynamic island-flap stomal sphincters were created from the rectus abdominis muscles in mongrel dogs by wrapping them around a blind loop of distal ileum that was no longer in continuity with the terminal small bowel. Temporary pacing electrodes were secured intramuscularly near the intercostal nerve entry point and connected to a subcutaneously placed pulse stimulator. Two different training protocols resulting in different contractile properties were used: Program A (n = 4) and Program B (n = 4). The island-flap sphincters were trained over 3 months to generate stomal intraluminal pressures of more than 60 mmHg in all animals. The intact sphincters, normal bowel, and contralateral stomal bowel were obtained when the animals were killed. Specimens were processed with paraffin embedding, sectioned, and stained with trichrome and hematoxylin-and-eosin stains. Measurements of the different bowel layers were made with a micrometer. The muscular sphincters were biopsied before and after training. Fiber-type histochemistry was performed with a monoclonal antibody to the fast isoforms of myosin. Pretrained and posttrained skeletal muscle specimens were examined histologically. The bowel wall within the functional dynamic stomal sphincter did not exhibit any significant architectural changes related to ischemic fibrosis or mucosal damage. A significant fiber-type conversion was achieved in both training groups with Programs A and B, with a >50 percent conversion from fatigue-prone (type II) muscle fibers to fatigue-resistant (type I) muscle fibers. Biopsy specimens revealed that fiber-type transformation was uniform throughout the sphincters. Skeletal muscle fibers within both groups demonstrated a reduction in their fiber diameter. There was no evidence of significant fibrosis or deposition of fat within the skeletal muscle of the sphincters. Results of our experiment suggest that our anterior abdominal wall dynamic island-flap stomal sphincter, which generates a contractile force over the bowel wall capable of producing enough stomal pressure to achieve fecal continence, is not intrinsically harmful to the bowel that it encircles. The transformation of skeletal muscle to fatigue-resistant (type I) fibers occurred uniformly throughout the skeletal muscle sphincters without evidence of muscle fiber damage or significant fibrosis.

[Vertical rectus abdominis myocutaneous flap for the closure of perineal wound after abdominoperineal resection of the rectum].

PubMed

Orhalmi, J; Vreský, B; Holéczy, P; Jackanin, S; Biath, P

2009-06-01

A major source of morbidity after abdominoperineal resection (APR) after neoadjuvant external beam pelvic radiation are perineal wound complications. Wound complications are common for 25-66% of patients overall. There are many of procedures provided to reconstruct the perineal defect after APR e.g. primary closure, secondary closure, superior gluteal artery flap and vertical rectus abdominus myocutaneous (VRAM) flap. Our purpose was to describe the effect of VRAM flap on reconstruction of perineal wound. VRAM flaps are ideally suited to bring nonirradiated tissue into defect associated with radical surgical extirpation procedures and irradiated fields. This flap, distally based in the deep inferior epigastric vessels, provides several distinct advantages. It is well perfused by the robust dominant pedicle and the deep inferior epigastric artery and vein. In addition, this flap provides adequate muscle bulk to obliterate pelvic dead space. The skin island can be used for resurfacing the perineal region, including the vaginal wall, and provides versatility for all patterns of resection. VRAM flap provides very good aesthetic and functional results, is technically relatively simple and radically decreases wound complications rate. The additional possibility is pull-through the flap transpelvically intraabdominally instead of pull-through via subcutaneous channel, especially with females.

Extensive actinomycosis of the face requiring radical resection and facial nerve reconstruction.

PubMed

Iida, Takuya; Takushima, Akihiko; Asato, Hirotaka; Harii, Kiyonori

2006-01-01

We present a case of extensive actinomycosis of the face, which appeared after dental surgery. Since antibiotic therapy was ineffective, the lesion was radically resected, and the skin, soft tissue and facial nerve were reconstructed using a free rectus abdominis musculocutaneous flap and simultaneously harvested intercostal nerves. Successful reanimation of the face was achieved 14 months postoperatively.

The Anterior Interosseus Artery Perforator Flap: Anatomical Dissections and Clinical Study.

PubMed

Panse, Nikhil S; Joshi, Sheetal B; Sahasrabudhe, Parag B; Bahetee, B; Gurude, Pradnya; Chandanwale, Ajay

2017-05-01

Reconstruction of upper extremity deformities continues to be a challenge to the reconstructive surgeon. Various loco regional, distant and free flaps are available for reconstruction. However, each has its own set of advantages and disadvantages. Of the commonly performed local flaps, radial artery forearm flap, and the posterior interosseus artery flap stand out prominently. Recently, perforator propeller flaps have been used for resurfacing the upper extremity. The anterior interosseus artery perforator flap is an uncommonly used and described flap. This study was divided into anatomical study and clinical application in a IV level of evidence. In the anatomical study, five upper extremities were studied. Clinically, 12 patients underwent reconstruction using the anterior interosseus artery perforator flap. Flaps were performed by a single surgeon. A retrospective review of these cases from November 2008 to May 2014 is presented. The anterior interosseus artery perforator was identified in four out of five cadaver limbs. The septocutaneous perforator was in the fifth extensor compartment around 4 cm proximal to the wrist joint. Of the twelve flaps, there was complete necrosis in one flap, and partial necrosis in one flap. The patient with complete necrosis underwent skin grafting at a later date. The wound healed secondarily in case of partial flap necrosis. Anterior interosseus artery perforator flap must be considered as an important reconstructive option in the armamentarium of the plastic surgeon, while managing hand and wrist defects.

Internal Limiting Membrane Flap Techniques for the Repair of Large Macular Holes: a Short-Term Follow-up of Anatomical and Functional Outcomes.

PubMed

Guber, J; Lang, C; Valmaggia, C

2017-04-01

Background To evaluate the technique of inverted internal limiting membrane (ILM) flaps for the management of large macular holes and autologous ILM free flaps for non-closing macular holes. Patients and methods All macular holes were treated with pars plana vitrectomy and dual blue assisted ILM flap technique. The inverted ILM flap was created as a primary procedure for large macular holes (diameter > 400 µm). On the other hand, the free ILM flap technique was used as a secondary procedure for non-closing macular holes after failed initial standard procedure. SD-OCT images were taken to assess the anatomical outcome of surgery, while best corrected visual acuity (BCVA) was used to evaluate the functional outcome during a 2-month follow-up. Results All patients underwent successful planned manipulation of the ILM flap. In seven patients/eyes, an inverted ILM flap was created, in three patients/eyes a free ILM flap translocation was performed. All patients achieved complete anatomical closure. Partial microstructural reconstruction, demonstrated on SD-OCT as restoration of the external limiting membrane and the ellipsoid zone, was observed in some cases as early as one month after surgery. Functionally, in comparison to baseline, most of the patients showed improvements in BCVA of 1 to 2 lines at the first postoperative follow-up visit. Conclusions Inverted ILM flaps for large macular holes and free flaps for non-closing macular holes appear to be a safe and effective approach, with favourable short-term anatomical and functional results. Georg Thieme Verlag KG Stuttgart · New York.

Exploring New Frontiers of Microsurgery: From Anatomy to Clinical Methods.

PubMed

Wang, Zeng Tao; Zheng, You Mao; Zhu, Lei; Hao, Li Wen; Zhang, Ya Bin; Chen, Chao; Xia, Li Feng; Liu, Lin Feng

2017-04-01

This article presents the authors' understanding and experience concerning anatomic studies and clinical methods in microsurgical hand reconstruction. The 4 parts of this article include anatomic study of the hand for developing new flaps; application of miniflaps from the hand, including clinical experience with 8 unique flaps in the hand; anatomic and clinical considerations concerning several flaps from other parts of the human body; And our experience with vascularized free toe joint transfer. Copyright © 2016 Elsevier Inc. All rights reserved.

The Anterior Interosseus Artery Perforator Flap: Anatomical Dissections and Clinical Study

PubMed Central

Panse, Nikhil S; Joshi, Sheetal B; Sahasrabudhe, Parag B; Bahetee, B; Gurude, Pradnya; Chandanwale, Ajay

2017-01-01

BACKGROUND Reconstruction of upper extremity deformities continues to be a challenge to the reconstructive surgeon. Various loco regional, distant and free flaps are available for reconstruction. However, each has its own set of advantages and disadvantages. Of the commonly performed local flaps, radial artery forearm flap, and the posterior interosseus artery flap stand out prominently. Recently, perforator propeller flaps have been used for resurfacing the upper extremity. The anterior interosseus artery perforator flap is an uncommonly used and described flap. METHODS This study was divided into anatomical study and clinical application in a IV level of evidence. In the anatomical study, five upper extremities were studied. Clinically, 12 patients underwent reconstruction using the anterior interosseus artery perforator flap. Flaps were performed by a single surgeon. A retrospective review of these cases from November 2008 to May 2014 is presented. RESULTS The anterior interosseus artery perforator was identified in four out of five cadaver limbs. The septocutaneous perforator was in the fifth extensor compartment around 4 cm proximal to the wrist joint. Of the twelve flaps, there was complete necrosis in one flap, and partial necrosis in one flap. The patient with complete necrosis underwent skin grafting at a later date. The wound healed secondarily in case of partial flap necrosis. CONCLUSION Anterior interosseus artery perforator flap must be considered as an important reconstructive option in the armamentarium of the plastic surgeon, while managing hand and wrist defects. PMID:28713704

Evolution in Monitoring of Free Flap Autologous Breast Reconstruction after Nipple-Sparing Mastectomy: Is There a Best Way?

PubMed

Frey, Jordan D; Stranix, John T; Chiodo, Michael V; Alperovich, Michael; Ahn, Christina Y; Allen, Robert J; Choi, Mihye; Karp, Nolan S; Levine, Jamie P

2018-05-01

Free flap monitoring in autologous reconstruction after nipple-sparing mastectomy remains controversial. The authors therefore examined outcomes in nipple-sparing mastectomy with buried free flap reconstruction versus free flap reconstruction incorporating a monitoring skin paddle. Autologous free flap reconstructions with nipple-sparing mastectomy performed from 2006 to 2015 were identified. Demographics and operative results were analyzed and compared between buried flaps and those with a skin paddle for monitoring. Two hundred twenty-one free flaps for nipple-sparing mastectomy reconstruction were identified: 50 buried flaps and 171 flaps incorporating a skin paddle. The most common flaps used were deep inferior epigastric perforator (64 percent), profunda artery perforator (12.1 percent), and muscle-sparing transverse rectus abdominis myocutaneous flaps (10.4 percent). Patients undergoing autologous reconstructions with a skin paddle had a significantly greater body mass index (p = 0.006). Mastectomy weight (p = 0.017) and flap weight (p < 0.0001) were significantly greater in flaps incorporating a skin paddle. Comparing outcomes, there were no significant differences in flap failure (2.0 percent versus 2.3 percent; p = 1.000) or percentage of flaps requiring return to the operating room (6.0 percent versus 4.7 percent; p = 0.715) between groups. Buried flaps had an absolute greater mean number of revision procedures per nipple-sparing mastectomy (0.82) compared with the skin paddle group (0.44); however, rates of revision procedures per nipple-sparing mastectomy were statistically equivalent between the groups (p = 0.296). Although buried free flap reconstruction in nipple-sparing mastectomy has been shown to be safe and effective, the authors' technique has evolved to favor incorporating a skin paddle, which allows for clinical monitoring and can be removed at the time of secondary revision. Therapeutic, III.

The Impact of Perioperative Hormonal Therapy for Breast Cancer on Transverse Rectus Abdominis Myocutaneous Flap Abdominal Complications.

PubMed

Huber, Katherine M; Clayman, Eric; Kumar, Ambuj; Smith, Paul

2018-06-01

The pedicled transverse rectus abdominis myocutaneous (TRAM) flap is a reliable reconstructive option in breast cancer patients; however, it carries known risk of donor site hernia formation. Some hormonal therapy drugs have been associated with hernia formation in animal models. Minimal data exist concerning impact of hormonal therapy for breast cancer on abdominal donor site complications after breast reconstruction. Patients who underwent TRAM flap for breast cancer or high-risk status at a single institution by the senior author from 2003 to 2015 were identified. Charts were reviewed. Patient demographics, comorbidities, treatments, and abdominal complications were recorded. Patients were divided into groups based on use of hormonal therapy as well as exposure to specific drugs. Statistical analyses were performed. A total of 358 patients were included. Overall hernia rate was 5.9%. About 231 (64.5%) patients had hormonal therapy, whereas 127 (35.5%) did not. Difference in hernia formation was not statistically significant between the hormonal therapy group (6.9%) and the no hormonal therapy group (3.9%; P = 0.359). Patients exposed to tamoxifen and those exposed to anastrozole had no significant difference in complication rates compared with the no hormonal therapy group, whereas patients exposed to letrozole had increased rate of hernia (13.5%; P = 0.037) and infection (21.6%; P = 0.013) compared with the no hormonal therapy group (3.9% and 7.1%, respectively). Hormonal therapy is a useful adjunct for chemoprevention in breast cancer; however, use of letrozole in patients undergoing reconstruction with pedicled TRAM can lead to increase in certain complication rates.

The anatomical (angiosome) and clinical territories of cutaneous perforating arteries: development of the concept and designing safe flaps.

PubMed

Taylor, G Ian; Corlett, Russell J; Dhar, Shymal C; Ashton, Mark W

2011-04-01

Island "perforator flaps" have become state of the art for free-skin flap transfer. Recent articles by Saint-Cyr et al. and Rozen et al. have focused on the anatomical and the clinical territories of individual cutaneous perforating arteries in flap planning, and it is timely to compare this work with our angiosome concept. The angiosome concept, published in 1987, was reviewed and correlated with key experimental and clinical work by the authors, published subsequently at different times in different journals. In addition, new data are introduced to define these anatomical and clinical territories of the cutaneous perforators and to aid in the planning of safe skin flaps for local and free-flap transfer. The anatomical territory of a cutaneous perforator was defined in the pig, dog, guinea pig, and rabbit by a line drawn through its perimeter of anastomotic vessels that link it with adjacent perforators in all directions. The safe clinical territory of that perforator, seen not only in the same range of animals but also in the human using either the Doppler probe or computed tomography angiography to locate the vessels, was found reliably to extend to include the anatomical territory of the next adjacent cutaneous perforator, situated radially in any direction. The data provided by Saint-Cyr et al. and Rozen et al., coupled with the authors' own original work on the vascular territories of the body and their subsequent studies, reinforce the angiosome concept and provide the basis for the design of safe flaps for patient benefit.

Rotational flaps in oncologic breast surgery. Anatomical and technical considerations.

PubMed

Acea Nebril, Benigno; Builes Ramírez, Sergio; García Novoa, Alejandra; Varela Lamas, Cristina

2016-01-01

Local flaps are a group of surgical procedures that can solve the thoracic closure of large defects after breast cancer surgery with low morbidity. Its use in skin necrosis complications after conservative surgery or skin sparing mastectomies facilitates the initiation of adjuvant treatments and reduces delays in this patient group. This article describes the anatomical basis for the planning of thoracic and abdominal local flaps. Also, the application of these local flaps for closing large defects in the chest and selective flaps for skin coverage by necrosis in breast conserving surgery. Copyright © 2016 AEC. Publicado por Elsevier España, S.L.U. All rights reserved.

The dorsal thoracic fascia: anatomic significance with clinical applications in reconstructive microsurgery.

PubMed

Kim, P S; Gottlieb, J R; Harris, G D; Nagle, D J; Lewis, V L

1987-01-01

The anatomic distribution and potential arterial flow patterns of the circumflex scapular artery were investigated by Microfil injection. These studies demonstrated that the circumflex scapular artery lies within the dorsal thoracic fascia, which plays a significant role in the circulation of the overlying skin and subcutaneous tissue. We conclude that scapular/parascapular flaps are fasciocutaneous flaps, the dorsal thoracic fascia can be transferred as a free flap without its overlying skin and subcutaneous tissue, and intercommunication exists between the myocutaneous perforators of the latissimus dorsi myocutaneous flap and the vascular plexus of the dorsal thoracic fascia. We present microvascular cases in which the vascular properties of the dorsal thoracic fascia facilitated wound closure with free fascia flaps or expanded cutaneous or myocutaneous flaps.

[APPLICATION VALUE OF INDOCYANINE GREEN ANGIOGRAPHY IN FLAP RECONSTRUCTIVE SURGERY].

PubMed

Yang, Kai; Mu, Lan; Liu, Yan; Peng, Zhe; Li, Guangxue

2015-09-01

To investigate the utility of indocyanine green angiography in flap reconstructive surgery and possibility of decrease the complications. Indocyanine green angiography was performed on 14 patients undergoing flap reconstructive surgery between February and December 2014 to evaluate the blood perfusion of the flap and to adjust the operation plan. Of 14 cases, 2 were male and 12 were female, aged 23-58 years (mean, 35.5 years); 11 flaps were used for breast reconstruction [including 3 free deep inferior epigastric antery perforator (DIEP) flaps, 4 pedicled transverse rectus abdominis myocutaneous flaps (TRAM), 2 pedicled TRAM and free TRAM, and 2 pedicled latissimus dorsi myocutaneous flaps and prosthesis], 1 pedicled latissimus dorsi myocutaneous flap for repairing chest wall defect, 1 pedicled profunda artery perforator (PAP) flap for upper leg defect, and 1 pedicled descending genicular artery perforator flap for knee defect. The size of the flaps ranged from 9 cm x 6 cm to 26 cm x 12 cm. A total of 32 indocyanine green angiography were performed. There was no adverse reactions to the infusion of indocyanine green. The surgery management was adjusted according to results of indocyanine green angiography findings in 5 of 14 cases. The distal part of flap were discarded because of poor perfusion in 3 cases (1 DIEP flap, 1 TRAM, and 1 PAP flap) and the other 2 cases (pedicled TRAM) needed additional free anastomosis to ensure sufficient blood supply (pedicled TRAM and free TRAM); the other flaps were harvested according to preoperative plan and repaired defect successfully. The mean follow-up was 5 months (range, 1-9 months). The other flaps survived without infection or fat necrosis except 1 PAP flap with distal necrosis. Intraoperative indocyanine green angiography can provide real-time information of flap perfusion and then the operation plan can be adjusted in time to ensure the flap survival.

Phantom rectal sensations following abdominoperineal excision of the rectum (APER) and vertical rectus abdominis myocutaneous (VRAM) flap perineal reconstruction.

PubMed

Gould, Charlotte R; Branagan, Graham

2016-11-01

Phantom rectum is the sensation of an intact and/or functioning rectum, despite excision at surgery. Abdominoperineal excision of the rectum (APER) may be complemented by reconstructive operations and recently it was reported that patients undergoing APER and vertical rectus abdominis myocutaneous (VRAM) flap reconstruction are more prone to develop phantom sensations at an earlier timeframe and have more persistent symptoms than those who do not have perineal repairs. The aim of this study was to determine the prevalence of phantom rectal sensations in a cohort of these patients. Patients who underwent APER and VRAM flap reconstruction for anorectal carcinomas were identified from May 2008 to July 2012. Patients completed a questionnaire evaluating their experience of rectal symptoms post-surgery. Thirty-four of 47 eligible patients were enrolled in the study. PR sensations were experienced by 50 % of patients, the majority of which (65 %) were present for >1 year. The commonest sensation reported was the feeling of faeces in a normal rectum (24 %). Disturbances in quality of life were apparent in 44 %; notably, sleep was affected, patients expressed increased feelings of stress/sadness, heightened levels of anxiety and limitation of daily activities as consequences of PR symptoms. Few patients sought medical advice. Fifty percent of patients experience PR sensations post-surgery, comparable with reported data for patients who have undergone APER alone. The addition of VRAM reconstruction does not significantly alter the prevalence of PR symptoms. This paper provides further evidence that phantom rectum occurs frequently and thus all patients undergoing excision of the rectum should be counselled appropriately.

Preoperative TRAM free flap volume estimation for breast reconstruction in lean patients.

PubMed

Minn, Kyung Won; Hong, Ki Yong; Lee, Sang Woo

2010-04-01

To obtain pleasing symmetry in breast reconstruction with transverse rectus abdominis myocutaneous (TRAM) free flap, a large amount of abdominal flap is elevated and remnant tissue is trimmed in most cases. However, elevation of abundant abdominal flap can cause excessive tension in donor site closure and increase the possibility of hypertrophic scarring especially in lean patients. The TRAM flap was divided into 4 zones in routine manner; the depth and dimension of the 4 zones were obtained using ultrasound and AutoCAD (Autodesk Inc., San Rafael, CA), respectively. The acquired numbers were then multiplied to obtain an estimate of volume of each zone and the each zone volume was added. To confirm the relation between the estimated volume and the actual volume, authors compared intraoperative actual TRAM flap volumes with preoperative estimated volumes in 30 consecutive TRAM free flap breast reconstructions. The estimated volumes and the actual elevated volumes of flap were found to be correlated by regression analysis (r = 0.9258, P < 0.01). According to this result, we could confirm the reliability of the preoperative volume estimation using our method. Afterward, the authors applied this method to 7 lean patients by estimation and revision of the design and obtained symmetric results with minimal donor site morbidity. Preoperative estimation of TRAM flap volume with ultrasound and AutoCAD (Autodesk Inc.) allow the authors to attain the precise volume desired for elevation. This method provides advantages in terms of minimal flap trimming, easier closure of donor sites, reduced scar widening and symmetry, especially in lean patients.

Measurement of the volume of the pedicled TRAM flap in immediate breast reconstruction.

PubMed

Chang, K P; Lin, S D; Hou, M F; Lee, S S; Tsai, C C

2001-12-01

The transverse rectus abdominis musculocutaneous (TRAM) flap is now accepted as the standard for breast reconstruction, but achieving symmetrical breast reconstruction is still a challenge. A precise estimate of the volume of the flap is necessary to reconstruct a symmetrical and aesthetically pleasing breast. Many methods have been developed to overcome this problem, but they have not been suitable for the pedicled TRAM flap. By using a self-made device based on the Archimedes' principle, the authors can calculate accurately the volume of the pedicled TRAM flap and predict reliably the breast volume intraoperatively. The "procedure" is based on a self-made box into which the pedicled TRAM flap is placed. Warm saline is added to the box and the flap is then removed. Flap volume is calculated easily by determining the difference between the preestimated volume of the box and the volume of the residual water. From February to May 2000, this method was used on 28 patients to predict breast volume for breast reconstruction. This study revealed that the difference of the maximal chest circumferences (the index of the breast volume) demonstrates a positive correlation with the difference of the volumes and weights between the mastectomy specimen and the net TRAM flap. However, a more closely positive correlation exists between the differences of maximal chest circumference volume (r = 0.677) than maximal chest circumference weight (r = 0.618). These data reveal that the reconstructed breast's volume has a closer relationship with the volume of the net pedicled TRAM flap, rather than with its weight.

Reconstruction of the pelvic floor and the vagina after total pelvic exenteration using the transverse musculocutaneous gracilis flap.

PubMed

Kaartinen, Ilkka S; Vuento, Maarit H; Hyöty, Marja K; Kallio, Jukka; Kuokkanen, Hannu O

2015-01-01

Total pelvic exenteration (TPE) is a rare operation in which the pelvic contents are removed entirely. Several options for pelvic floor and vaginal reconstruction have been described including transverse rectus abdominis musculocutaneous (TRAM) or deep inferior epigastric perforator (DIEP) flaps. The transverse musculocutaneous gracilis (TMG) flap has been introduced for breast reconstruction as a free flap. We adopted the pedicled TMG flap for reconstructions after TPE. To the best of our knowledge, this is the first report of this method in the literature. Between November 2011 and February 2014, 12 patients underwent TPE and reconstruction with unilateral (six patients) or bilateral (six patients) pedicled TMG flaps. Five patients underwent vaginal reconstruction with bilateral TMG flaps. We describe the operative procedure and the outcome of the operation in these patients. The total mean operative times for TPE with or without vaginal reconstruction were 467 ± 12 and 386 ± 59 min, respectively. The TMG flaps had enough vascular tissue and mobility for reconstructing the TPE defects. There was distal edge necrosis in one out of 18 flaps, while the rest survived completely. During the follow-up, complete wound healing with no signs of weakening of the pelvic floor was observed in all cases. Soft-tissue reconstructions are needed to reduce complications associated with TPE, to secure the pelvic floor and to reconstruct the vagina in select patients. The TMG flap is a logical flap choice that does not lead to functional deficits, complicate the abdominal ostomies or weaken the abdominal wall. It reduces the length of operation compared to that of abdominal flaps. IV, therapeutic. Copyright © 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

The number of operations required for completing breast reconstruction.

PubMed

Eom, Jin Sup; Kobayashi, Mark Robert; Paydar, Keyianoosh; Wirth, Garrett A; Evans, Gregory R D

2014-10-01

Breast reconstruction often requires multiple surgeries, which demands additional expense and time and is often contrary to the patient's expectation. The aim of this study was to review the number of operations that were needed for completion of breast reconstruction and to determine patient and clinical factors that influenced this number. We retrospectively reviewed the medical records of 254 cases of breast reconstructions (in 185 patients) that were performed between February 2005 and August 2009. We investigated the numbers of operations that were performed for individual case of breast reconstruction and analyzed the influence of variable factors. The purpose of the additional operations was also analyzed. The mean number of operations per breast was 2.37 (range, 1-9). The mean number of operations for mound creation was 2.24. Factors associated with an increased number of operation were use of an implant, contralateral symmetrization, complications, and nipple reconstruction. Considering the reconstruction method, either the use of a primary implant or the use of free abdominal tissue transfer demonstrated fewer surgeries than the use of an expander implant, and the number of operations using free transverse rectus abdominis musculocutaneous or deep inferior epigastric perforator flaps was less than the number of operations using pedicled transverse rectus abdominis musculocutaneous flaps. These data will aid in planning breast reconstruction surgery and will enable patients to be more informed regarding the likelihood of multiple surgeries.

Effect of fibrin sealant in positioning and stabilizing microvascular pedicle: A comparative study.

PubMed

Kim, Jeong Tae; Kim, Youn Hwan; Kim, Sang Wha

2017-07-01

Fibrin sealants have had applications in hemostasis, cohesion, and promotion of healing in plastic surgery. In this article, we review cases where fibrin sealant was used to stabilize microvascular pedicles and compared with previous free flaps performed without fibrin sealant. Between 2008 and 2010, 62 consecutive patients underwent free tissue transfer for reconstruction; this involved 33 latissimus dorsi perforator flaps, 14 thoracodorsal artery perforator flaps, 9 latissimus dorsi myocutaneous flaps, 3 lateral thoracic artery perforator flaps, and 3 transverse rectus abdominis myocutaneous flaps, used in head and neck reconstruction, lower limb reconstructions, breast reconstructions, and facial palsy reconstruction. Following microvascular anastomosis, the microvascular pedicles were placed in the optimal position, and fibrin sealant was used to fix and stabilize them. The complications, such as venous thrombosis, arterial thrombosis, hematoma, and vascular pedicle kinking, were compared with that of 672 previous free flaps without fibrin sealant for stabilizing microvascular pedicles. Among the 62 free tissue transfers using fibrin sealant, there was only one complication involving flap failure (1.6%), in this case due to venous thrombosis. Analysis of 672 free flaps performed without application of fibrin sealant revealed 24 complications (3.6%), due to 3 venous thrombosis, 1 arterial thrombosis, 4 vascular pedicel compression due to hematoma, and 16 pedicle kinking. However, the comparison of complications between the free flap using fibrin sealant and the free flap without fibrin sealant were not statistically significant (P = 0.65). Fibrin sealant can be used to prevent vascular kinking and to position anastomosed vessels after successful micro-anastomosis and allow the reconstructive surgeon to overcome challenging situations of vascular pedicle related complications © 2016 Wiley Periodicals, Inc. Microsurgery 37:406-409, 2017. © 2016 Wiley Periodicals, Inc.

Applying the Keystone Design Perforator Island Flap Concept in a Variety of Anatomic Locations: A Review of 60 Consecutive Cases by a Single Surgeon.

PubMed

Lanni, Michael Alan; Van Kouwenberg, Emily; Yan, Alan; Rezak, Kristen M; Patel, Ashit

2017-07-01

The keystone design perforator island flap has been gaining popularity for reconstruction of cutaneous defects. Published experience of this technique in North America is limited predominantly to the trunk and extremities; our study aims to demonstrate expanding applications. Retrospective chart review was conducted on all patients who underwent keystone flap reconstruction by a single surgeon. Outcomes of interest were wound healing complications (WHC) and surgical site infections (SSI). Mean follow up time was 24.4 months. Sixty consecutive flaps were performed with an overall WHC rate of 26.7% and SSI rate of 11.7%. Reconstructed sites included 25 lower extremity, 20 trunk, 5 upper extremity, and 10 head and neck. Flap size averaged 405.6 cm (range 16-2303). Wound healing complications were associated with coronary artery disease (P = 0.04) and traumatic defects (P = 0.043). Surgical site infections were associated with coronary artery disease (P = 0.02) and flap size of 251 to 500 cm (P = 0.039), although this association was not seen among flaps greater than 500 cm. Although more common in lower extremity reconstructions, no statistically significant associations between flap location and WHC (P = 0.055) or SSI (P = 0.29) were identified. There were no reconstructive failures and no patients required reoperation. This series demonstrates the versatility of the keystone flap in a wide variety of anatomic locations, with similar complication rates to those previously reported and no reoperations. Flap design was frequently modified based on the anatomical topography and adjacent subunits. To our knowledge, this is the largest and most diverse North American series of keystone flap reconstructions to date.

Single-stage interpolation flaps in facial reconstruction.

PubMed

Hollmig, S Tyler; Leach, Brian C; Cook, Joel

2014-09-01

Relatively deep and complex surgical defects, particularly when adjacent to or involving free margins, present significant reconstructive challenges. When the use of local flaps is precluded by native anatomic restrictions, interpolation flaps may be modified to address these difficult wounds in a single operative session. To provide a framework to approach difficult soft tissue defects arising near or involving free margins and to demonstrate appropriate design and execution of single-stage interpolation flaps for reconstruction of these wounds. Examination of our utilization of these flaps based on an anatomic region and surgical approach. A region-based demonstration of flap conceptualization, design, and execution is provided. Tunneled, transposed, and deepithelialized variations of single-stage interpolation flaps provide versatile options for reconstruction of a variety of defects encroaching on or involving free margins. The inherently robust vascularity of these flaps supports importation of necessary tissue bulk while allowing aggressive contouring to restore an intricate native topography. Critical flap design allows access to distant tissue reservoirs and placement of favorable incision lines while preserving the inherent advantages of a single operative procedure.

Ipsilateral pedicled TRAM flaps: the safer alternative?

PubMed

Clugston, P A; Gingrass, M K; Azurin, D; Fisher, J; Maxwell, G P

2000-01-01

Transverse rectus abdominis myocutaneous (TRAM) flap breast reconstruction has become a commonly performed procedure in the 1990s. The original description of the procedure was that of an ipsilaterally based pedicle procedure. Concerns about potential folding of the pedicle with possible compromise of the vascular supply led many surgeons to prefer the contralateral pedicle. Subsequently, there have been several large clinical series of pedicled TRAM flaps showing a relatively high complication rate related to flap vascularity problems. Partial flap necrosis rates in pedicled TRAM series range from 5 to 44 percent. These findings resulted in many centers favoring free TRAM flap breast reconstruction, despite an increase in resource use and negligible differences in complication rates. Ipsilateral pedicle TRAM flap breast reconstruction is not a commonly reported procedure and is reserved for cases for which scars preclude use of the contralateral pedicle. Simplicity and versatility of flap shaping, improved maintenance of the inframammary fold, and lack of disruption of the natural xiphoid hollow give ipsilateral TRAM flaps further advantages. This study reports on a series of 252 consecutive ipsilateral TRAM flap reconstructions in 190 patients. The majority of patients underwent muscle-sparing procedures with preservation of a medial and a lateral strip of rectus muscle. Immediate reconstruction was done in 104 of the 190 patients. Skin-sparing (69 patients) or skin-reduction procedures (21 patients) were used in 90 of the 104 patients (87 percent) undergoing immediate reconstruction. Complication rates were comparable to those of series reported for contralateral TRAM flaps, except that partial flap necrosis (2.0 percent) was less in this series. Risk factors were analyzed with regard to the most common complications seen in this study. Ipsilateral TRAM flap breast reconstruction is our preferred method, if available, because we believe that it has several advantages over the contralateral pedicled TRAM and this report suggests a lower partial flap necrosis rate than previously reported.

DOE Office of Scientific and Technical Information (OSTI.GOV)

Reed, W.P.; Spence, R.J.

We have used a contralateral vertical rectus abdominis musculocutaneous flap based upon the superior epigastric vessels in six patients to provide coverage after resection of locally recurrent breast carcinoma in irradiated tissues. Primary healing of defects as large as 16 cm X 35 cm has been obtained using this technique. Although there is no evidence to suggest that such a procedure significantly lengthens survival, it was clearly beneficial to the quality of life in these patients. Our results suggest that older patients with relatively indolent disease receive the greatest benefit from this procedure.

Pedal macrodactyly: coverage of a large defect with a rectus abdominus free flap.

PubMed

Hendrix, C L; Thomson, J G; Blume, P A

2000-01-01

The authors report a case of a unique reconstructive approach for an isolated macrodactyly of the lower extremity in an otherwise healthy African male. Surgical treatment included excision and local resection of the affected hypertrophied skin, soft tissue, and bone. A rectus abdominis free-tissue transfer and split-thickness skin graft were used for coverage of the defect. The foot healed without complication, and at 2-year follow-up, the patient had an aesthetically pleasing and fully functional result.

Free-style free flaps.

PubMed

Wei, Fu-Chan; Mardini, Samir

2004-09-15

Free-tissue transfer has become the accepted standard for reconstruction of complex defects. With the growth of this field, anatomic studies and clinical work have added many flaps to the armamentarium of the microvascular surgeon. Further advancements and experience with techniques of perforator flap surgery have allowed for the harvest of flaps in a free-style manner, where a flap is harvested based only on the preoperative knowledge of Doppler signals present in a specific region. Between June of 2002 and September of 2003, 13 free-style free flaps were harvested from the region of the thigh. All patients presented with an oral or pharyngeal cancer and underwent resection and immediate reconstruction of these flaps. All flaps were cutaneous and were harvested in a suprafascial plane. The average size of the flaps was 108 cm2 (range, 36 to 187 cm2), and the average length of the vascular pedicle was 10 cm (range, 9 to 12 cm). All flaps were successful in achieving wound coverage and functional outcomes without any vascular compromise necessitating re-exploration. Free-style free flaps have become a clinical reality. The concepts and techniques used to harvest a free-style free flap will aid in dealing with anatomic variations that are encountered during conventional flap harvest. Future trends in flap selection will focus mainly on choosing tissue with appropriate texture, thickness, and pliability to match requirements at the recipient site while minimizing donor-site morbidity.

Funding analysis of bilateral autologous free-flap breast reconstructions in Australia.

PubMed

Sinha, Shiba; Ruskin, Olivia; McCombe, David; Morrison, Wayne; Webb, Angela

2015-08-01

Bilateral breast reconstructions are being increasingly performed. Autologous free-flap reconstructions represent the gold standard for post-mastectomy breast reconstruction but are resource intensive. This study aims to investigate the difference between hospital reimbursement and true cost of bilateral autologous free-flap reconstructions. Retrospective analysis of patients who underwent bilateral autologous free-flap reconstructions at a single Australian tertiary referral centre was performed. Hospital reimbursement was determined from coding analysis. A true cost analysis was also performed. Comparisons were made considering the effect of timing, indication and complications of the procedure. Forty-six bilateral autologous free-flap procedures were performed (87 deep inferior epigastric perforators (DIEPs), four superficial inferior epigastric artery perforator flaps (SIEAs) and one muscle-sparing free transverse rectus abdominis myocutaneous flap (MS-TRAM)). The mean funding discrepancy between hospital reimbursement and actual cost was $12,137 ± $8539 (mean ± standard deviation (SD)) (n = 46). Twenty-four per cent (n = 11) of the cases had been coded inaccurately. If these cases were excluded from analysis, the mean funding discrepancy per case was $9168 ± $7453 (n = 35). Minor and major complications significantly increased the true cost and funding discrepancy (p = 0.02). Bilateral free-flap breast reconstructions performed in Australian public hospitals result in a funding discrepancy. Failure to be economically viable threatens the provision of this procedure in the public system. Plastic surgeons and hospital managers need to adopt measures in order to make these gold-standard procedures cost neutral. Copyright © 2015 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

[The sural medial perforator flap: Anatomical bases, surgical technique and indications in head and neck reconstruction].

PubMed

Struk, S; Schaff, J-B; Qassemyar, Q

2018-04-01

The medial sural artery perforator (MSAP) flap is defined as a thin cutaneo-adipose perforator flap harvested on the medial aspect of the leg. The aims of this study were to describe the anatomical basis as well as the surgical technique and discuss the indications in head and neck reconstructive surgery. We harvested 10 MSAP flap on 5 fresh cadavers. For each case, the number and the location of the perforators were recorded. For each flap, the length of pedicle, the diameter of source vessels and the thickness of the flap were studied. Finally, we performed a clinical application of a MSAP flap. A total of 23 perforators with a diameter superior than 1mm were dissected on 10 legs. The medial sural artery provided between 1 and 4 musculocutaneous perforators. Perforators were located in average at 10.3cm±2cm from the popliteal fossa and at 3.6cm±1cm from the median line of the calf. The mean pedicle length was 12.1cm±2.5cm. At its origin, the source artery diameter was 1.8mm±0.25mm and source veins diameters were 2.45mm±0.9mm in average. There was no complication in our clinical application. This study confirms the reliability of previous anatomical descriptions of the medial sural artery perforator flap. This flap was reported as thin and particularly adapted for oral cavity reconstruction and for facial or limb resurfacing. Sequelae might be reduced as compared to those of the radial forearm flap with comparable results. Copyright © 2017 Elsevier Masson SAS. All rights reserved.

The midabdominal TRAM flap for breast reconstruction in morbidly obese patients.

PubMed

Gabbay, Joubin S; Eby, Joseph B; Kulber, David A

2005-03-01

The transverse rectus abdominis myocutaneous (TRAM) flap is ideal for postmastectomy reconstruction but is tenuous in morbidly obese patients. Because of their relatively high incidence of postoperative complications, morbidly obese patients are often not considered candidates for autogenous reconstruction. The midabdominal TRAM flap has a more favorable anatomy and may represent an alternative technique in this patient population. The records of 18 morbidly obese patients who underwent postmastectomy reconstruction using a mid-abdominal TRAM flap from 1998 through 2002 were retrospectively reviewed. The mid-abdominal TRAM flap territory includes more of the supraumbilical region than the traditional TRAM flap, corresponding to an area with more abundant musculocutaneous perforators and greater dependence on the superior epigastric vascular system. All patients underwent unipedicled mid-abdominal TRAM flap surgery. Four patients with previous subumbilical midline incisions had a delay procedure with ligation of the inferior epigastric vessels. Complications investigated were flap necrosis greater than 10 percent or sufficient to require surgical revision, abdominal donor-site breakdown, seroma formation, umbilical necrosis, abdominal wall bulging or hernia, deep vein thrombosis, infected mesh, surgical revisions, fat necrosis, and extended hospital stay. At a mean follow-up time of 15.6 months (range, 12 to 24 months), three patients had postoperative complications requiring surgical revision. Two of these patients had previous midline abdominal incisions. One patient had both partial flap necrosis and a donor-site complication. The second patient had partial flap necrosis, and the third had an abdominal donor-site complication. No occurrences of abdominal wall hernia, total flap loss, deep vein thrombosis, infected mesh, extensive surgical revision, or extended hospitalization were noted in this series. The mid-abdominal TRAM flap represents an alternative method for postmastectomy breast reconstruction in morbidly obese patients. Autologous reconstruction using a midabdominal TRAM flap may be considered in this patient population; however, additional research is required to conclusively demonstrate an improved outcome when compared with traditional reconstructive methods.

Does the use of an acellular dermal graft in abdominal closure after rectus flap harvest impact the occurrence of post-operative hernia?

PubMed

Saman, Masoud; Kadakia, Sameep; Ducic, Yadranko

2015-12-01

Patients with rectus free flap harvest extending below the arcuate line are predisposed to postoperative hernia formation. As such, many authors have advocated the use of closure adjuncts to increase the integrity of the closure and prevent hernia or abdominal wall bulging. Busy level 1 public trauma center in metropolitan Fort Worth, Texas Following harvest of the rectus free flap, 48 patients underwent primary closure; 24 of these patients had defects extending below the arcuate line. Forty patients were closed with an acellular dermal graft; 22 of these patients had defects extending below the arcuate line. Postoperative hernia formation and local infection rate were examined in a minimum follow-up period of 1 year. Regardless of closure method, no hernias were observed in the postoperative period. Using an unpaired t test and an alpha value of 0.05, there was no statistically significant difference in the infection rate between the two groups. Following rectus abdominis myocutaneous free flap harvest, the use of an acellular dermal graft in abdominal wall closure may not be of any further advantage in the prevention of hernia. Retrospective (Level III).

Anatomical basis of the extended TDAP flap: study of its territories of vascularization and its volume.

PubMed

Dast, Sandy; Havet, Eric; Dessena, Lidia; Abdulshakoor, Abeer; Alharbi, Mohammed; Vaucher, Richard; Herlin, Christian; Sinna, Raphael

2017-08-01

The concept of extended thoracodorsal artery perforator (TDAP) flap was described in 2015 for breast reconstruction. Our anatomical study aims to identify the territories vascularised by the thoracodorsal artery perforator via the deep muscular fascial network. The second goal was to define the volume of the extended TDAP flap. Ten extended TDAP flaps were dissected on 5 fresh human cadavers. Around the classical skin paddle of a TDAP flap, the dissections were performed in a subfascial level, including the muscular fascia and the adipose tissue compartments to increase the volume of the flap. After injection of methylene blue in the thoracodorsal artery, we measured the length and width, the surface and the volume of the coloured flap. The mean sizes of the extended TDAP flap were 24.9 cm × 20.1 cm. The mean surface of the total vascularization zone was 441 cm 2 . The mean volume of the vascularized flap was 193 ml. The thoracodorsal artery perforator via the deep muscular fascial network allows us to harvest a flap of 25 cm × 20 cm with a mean surface of 441 cm² and a mean volume of 193 ml. The extended TDAP flap is a credible option in breast reconstruction.

The Pedicled Buccal Fat Pad: Anatomical Study of the New Flap for Skull Base Defect Reconstruction After Endoscopic Endonasal Transpterygoid Surgery

PubMed Central

Golbin, Denis A.; Lasunin, Nikolay V.; Cherekaev, Vasily A.; Polev, Georgiy A.

2016-01-01

Objectives To evaluate the efficacy and safety of using a buccal fat pad for endoscopic skull base defect reconstruction. Design Descriptive anatomical study with an illustrative case presentation. Setting Anatomical study was performed on 12 fresh human cadaver specimens with injected arteries (24 sides). Internal carotid artery was exposed in the coronal plane via the endoscopic transpterygoid approach. The pedicled buccal fat pad was used for reconstruction. Participants: 12 human cadaver head specimens; one patient operated using the proposed technique. Main outcome measures: Proximity of the buccal fat pad flap to the defect, compliance of the flap, comfort and safety of harvesting procedure, and compatibility with the Hadad–Bassagasteguy nasoseptal flap. Results: Harvesting procedure was performed using anterior transmaxillary corridor. The pedicled buccal fat pad flap can be used to pack the sphenoid sinus or cover the internal carotid artery from cavernous to upper parapharyngeal segment. Conclusion The buccal fat pad can be safely harvested through the same approach without external incisions and is compliant enough to conform to the skull base defect. The proposed pedicled flap can replace free abdominal fat in central skull base reconstruction. The volume of the buccal fat pad allows obliteration of the sphenoid sinus or upper parapharyngeal space. PMID:28180047

A 15-year review of midface reconstruction after total and subtotal maxillectomy: part I. Algorithm and outcomes.

PubMed

Cordeiro, Peter G; Chen, Constance M

2012-01-01

Reconstruction of complex midfacial defects is best approached with a clear algorithm. The goals of reconstruction are functional and aesthetic. Over a 15-year period (1992 to 2006), a single surgeon (P.G.C.) performed 100 flaps to reconstruct the following midfacial defects: type I, limited maxillectomy (n = 20); type IIA, subtotal maxillectomy with resection of less than 50 percent of the palate (n = 8); type IIB, subtotal maxillectomy with resection of greater than 50 percent of the palate (n = 8); type IIIA, total maxillectomy with preservation of the orbital contents (n = 22); type IIIB, total maxillectomy with orbital exenteration (n = 23); and type IV, orbitomaxillectomy (n = 19). Free flaps were used in 94 cases (94 percent), and pedicled flaps were used in six (6 percent). One hundred flaps were performed in 96 patients (69 males, 72 percent; 27 females, 28 percent); four patients underwent a second flap reconstruction due to recurrent disease (n = 4, 4 percent). Average patient age was 49.2 years (range, 13 to 81 years). Free-flap survival was 100 percent, with one partial flap loss (1 percent). Five patients suffered systemic complications (5.2 percent), and four died within 30 days of hospitalization (4.2 percent). Over 50 percent of patients returned to normal diet and speech. Almost 60 percent were judged to have an excellent aesthetic result. Free-tissue transfer offers the most effective and reliable form of reconstruction for complex maxillectomy defects. Rectus abdominis and radial forearm free flaps in combination with immediate bone grafting or as osteocutaneous flaps consistently provide the best functional and aesthetic results. Therapeutic, IV.

The Omental Free Flap-A Review of Usage and Physiology.

PubMed

Mazzaferro, Daniel; Song, Ping; Massand, Sameer; Mirmanesh, Michael; Jaiswal, Rohit; Pu, Lee L Q

2018-03-01

 The omental flap has a rich history of use over the last century, and specifically as a free flap in the last four decades. It has a wide variety of applications in reconstructive surgery and has shown itself to be a reliable donor tissue. We seek to review the properties that make the omental free flap a valuable tool in reconstruction, as well as its many surgical applications in all anatomic regions of the body.  We conducted a narrative review of the literature on Medline and Google Scholar. We reviewed basic science articles discussing the intrinsic properties of omental tissue, along with clinical papers describing its applications.  The omental free flap is anatomically suitable for harvest and wound coverage and has molecular properties that promote healing and improve function at recipient sites. It has demonstrated utility in a wide variety of reconstructive procedures spanning the head and neck, extremities, and viscera and for several purposes, including wound coverage, lymphedema treatment, and vascularization. It is also occasionally employed in the thoracic cavity and chest wall, though more often as a pedicled flap. More novel uses include its use for cerebrospinal fluid leaks.  The omental free flap is a valuable option for reconstructive efforts in nearly all anatomic regions. This is a result of its inherent anatomy and vascularity, and its angiogenic, immunogenic, and lymphatic properties. Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Donor-Site Morbidity After DIEAP Flap Breast Reconstruction—A 2-Year Postoperative Computed Tomography Comparison

PubMed Central

Bosse, Gerhard; Mynarek, Georg Karl; Berg, Thomas; Tindholdt, Tyge Tind; Tønseth, Kim Alexander

2017-01-01

Background: The study was undertaken to provide a more complete picture of donor-site morbidity following the deep inferior epigastric artery perforator (DIEAP) flap harvest in breast reconstruction. Most studies evaluating this subject have been performed using ultrasonography. Computed tomography (CT) might provide valuable information. Methods: In 14 patients who were reconstructed with a DIEAP flap, donor-site morbidity was assessed by comparing routine preoperative CT abdomen with CT abdomen performed 2 years postoperatively. The anteroposterior diameter and transverse diameter (TD) of the rectus muscle were measured bilaterally within 4 standardized zones. Diastasis recti abdominis (DRA) was measured in the same zones. The abdominal wall was assessed for hernias, bulging, and seromas. Results: The operated rectus muscle had a significantly increased anteroposterior diameter in 2 zones and decreased TD in 1 zone compared with preoperative measurements. Comparing the operated and nonoperated rectus muscles, the former had a significantly decreased TD in 1 zone. Supraumbilical DRA was significantly decreased with surgery, whereas infraumbilical DRA was significantly increased. No new hernias or bulging were found. Two patients had seroma formation in the abdominal wall. Conclusions: Symmetry of the 2 hemiabdomens is well preserved after DIEAP flap harvest; however, significant changes to the rectus muscles and DRA were observed. Hernia formation does not seem to be a postoperative complication of importance. The study indicates that DIEAP flaps result in limited donor-site morbidity, which for most patients does not outweigh the benefits of free perforator flap breast reconstruction. PMID:28831346

[Anatomical study and clinical application of a leg flap pedicle-included with cutaneous nerve and its concomitant vessels].

PubMed

Liu, B; Hao, X; Goan, M

2000-05-01

To investigate the blood supply patterns and the clinical liability of a leg flap pedicle-included with cutaneous nerve and its concomitant vessels. Fresh cadaver legs with thirty-two in infants and two in adults were anatomically examined after the intravenous injection of the red Chlorinated Poly Vingl Choride (CPVC). Five patients with the soft tissue defects were selected for the treatment with the flap pedicle-included with the cutaneous nerve and its concomitant vessels. Four main cutaneous nerves were found in the leg after they perforated the deep fascia out. They were companioned with their concomitant vessels with different blood-supply pateeerns, which the upper part of the leg was in an axial pattern and the lower part was in a "chain-type anastomosing" pattern. Following the above-mentioned findings, five cases were successfully treated with this led flap. The leg flap should be designed along the cutaneous nerve and its concomitant vessels. When the flap is applied in the area of blood supply with "chain-type anastomosing" pattern, the deep fascia should also be included in the flap.

A Novel Perforator Flap Training Model Using a Chicken Leg.

PubMed

Cifuentes, Ignacio J; Yañez, Ricardo A; Salisbury, Maria C; Rodriguez, José R; Varas, Julian E; Dagnino, Bruno L

2016-04-01

Living animal models are frequently used for perforator flap dissection training, but no ex vivo models have been described. The aim of this study is to present a novel nonliving model for perforator flap training based on a constant perforator in the chicken leg. A total of 15 chicken legs were used in this study. Anatomical dissection of the perforator was performed after its identification using ink injection, and in four of these specimens a perforator-based flap was raised. The anatomical dissection revealed a constant intramuscular perforator with a median length of 5.7 cm. Median proximal and distal vessel diameters were 0.93 and 0.4 mm, respectively. The median dissection time was 77.5 minutes. This study introduces a novel, affordable, and reproducible model for the intramuscular dissection of a perforator-based flap using an ex vivo animal model. Its consistent perforator and appropriate-sized vessels make it useful for training.

A microneurovascular TRAM flap does not compromise abdominal sensibility more than a conventional one.

PubMed

Puonti, Helena K; Jääskeläinen, Satu K; Hallikainen, Helena K; Partanen, Taina A

2012-09-01

Classic abdominoplasty for a transverse rectus abdominis musculocutaneous (TRAM) flap breast reconstruction impairs abdominal somatosensory function at the donor site. The aim of this study was to investigate whether the type of surgical procedure has an effect on somatosensory alterations of abdominal skin after TRAM flap breast reconstruction. Sixty patients (mean ± SD age, 50 ± 6.0 years) who underwent microvascular TRAM flap breast reconstruction and 20 healthy subjects (control group; mean age, 46 ± 6.7 years) participated in the study. Twenty patients had bilateral-nerve anastomosis, 20 had single-nerve anastomosis, and 20 underwent no nerve dissection for the TRAM flap. Clinical sensory examination and tactile and thermal quantitative sensory testing were performed and a patient questionnaire was administered at a mean of 2 to 4.5 years after surgery. All surgical techniques produced significant sensory impairment below the umbilicus, but there were no significant differences in total sensibility scores between the groups with single-nerve (mean sensibility score, 21.98 ± 2.7) and double-nerve (mean sensibility score, 20.71 ± 3.6) anastomosis of the TRAM flap. The best sensibility scores were found in the group with single-nerve dissection. Fifteen percent of patients complained of mild pain, and 13 percent felt occasional tactile hyperesthesia in their abdominal skin, mostly around the umbilicus and scars. In this study, unilateral or bilateral nerve dissection when preparing and lifting a TRAM flap did not seem to increase sensory alterations or postoperative pain in the abdominal donor site after breast reconstruction surgery. Cautious microneurovascular dissection techniques may even improve sensory recovery of the abdominal skin after TRAM flap breast reconstruction surgery.

Reconstruction techniques after extralevator abdominoperineal rectal excision or pelvic exenteration: meshes, plasties and flaps.

PubMed

Frasson, Matteo; Flor-Lorente, Blas; Carreño, Omar

2014-03-01

Perineal wound complications after abdomino-perineal rectal resection are frequent and clinically relevant for their impact on the length of hospitalization, costs, patients' quality of life and oncologic results. With the diffusion of the preoperative radiotherapy and the gradual shift to the extra-elevator technique, the perineal morbidity rate has increased. Many series describing different techniques of primary closure of the perineal defect have been published, but high-quality clinical studies, indicating which is the best option, are missing. A biologic mesh, associated if possible to an omentoplasty, seems to be sufficient to close the perineal defect after extra-elevator abdomino-perineal rectal resection. However, when the proctectomy is associated to the resection of other organs, as for example vagina or sacrum, resulting in an ample perineal defect, the vertical rectus abdominis flap seems to be the best option. If the perineal defect is smaller, the gracilis or gluteus flaps could be other valid alternatives. Copyright © 2014 Asociación Española de Cirujanos. Published by Elsevier Espana. All rights reserved.

A comparison of the effects of epidural and spinal anesthesia with ischemia-reperfusion injury on the rat transverse rectus abdominis musculocutaneous flap.

PubMed

Acar, Yusuf; Bozkurt, Mehmet; Firat, Ugur; Selcuk, Caferi Tayyar; Kapi, Emin; Isik, Fatma Birgul; Kuvat, Samet Vasfi; Celik, Feyzi; Bozarslan, Beri Hocaoglu

2013-11-01

The purpose of this study is to compare the effects of spinal and epidural anesthesia on a rat transverse rectus abdominus myocutaneous flap ischemia-reperfusion injury model.Forty Sprague-Dawley rats were divided into 4 experimental groups: group I (n = 10), sham group; group II (n = 10), control group; group III (n = 10), epidural group; and group IV (n = 10), spinal group. After the elevation of the transverse rectus abdominus myocutaneous flaps, all groups except for the sham group were subjected to normothermic no-flow ischemia for 4 hours, followed by a reperfusion period of 2 hours. At the end of the reperfusion period, biochemical and histopathological evaluations were performed on tissue samples.Although there was no significant difference concerning the malonyldialdehyde, nitric oxide, and paraoxonase levels in the spinal and epidural groups, the total antioxidant state levels were significantly increased, and the total oxidative stress levels were significantly decreased in the epidural group in comparison to the spinal group. The pathological evaluation showed that findings related to inflammation, nuclear change rates and hyalinization were significantly higher in the spinal group compared with the epidural group.Epidural anesthesia can be considered as a more suitable method that enables a decrease in ischemia-reperfusion injuries in the muscle flaps.

The Trapezius Muscle Flap: A Viable Alternative for Posterior Scalp and Neck Reconstruction.

PubMed

Yang, Hee Jun; Lee, Dong Hun; Kim, Yang Woo; Lee, Sang Gu; Cheon, Young Woo

2016-11-01

The trapezius muscle flap is not usually the first reconstructive option for skin and soft tissue defects in the posterior neck and scalp due to surgeons' unfamiliarity with the surgical anatomy and developments in free tissue transfer techniques. The goals of this study were to describe the clinical use of trapezius flaps in posterior neck and scalp reconstruction, and to investigate the vascular anatomy of trapezius flaps in Asians in order to obtain information facilitating the safe design and elevation of flaps in which most of the muscle is preserved. A retrospective chart review was performed of 10 patients who underwent trapezius muscle flap for posterior neck and scalp defects. We also performed an anatomical study of 16 flaps harvested from 8 preserved Asian adult cadavers and evaluated the main landmarks relevant for trapezius muscle flap. In the anatomical study, the mean vertical height from the inferior angle of the scapula to the point at which the superficial cervical artery penetrated the trapezius was 4.31±2.14 cm. The mean vertical height of the trapezius muscle flap pivot point was 9.53±2.08 cm from the external occipital protuberance. Among the 10 flaps, partial necrosis on the overlaid skin graft occurred in 1 patient and postoperative seroma occurred in another patient. Vascular variations in the trapezius muscle flap are uncommon in Asians, but when present, such variations appear to have little impact on harvesting the flap or on its circulation. The trapezius muscle flap is a viable alternative for posterior neck and scalp reconstruction.

The Trapezius Muscle Flap: A Viable Alternative for Posterior Scalp and Neck Reconstruction

PubMed Central

Yang, Hee Jun; Kim, Yang Woo; Lee, Sang Gu

2016-01-01

Background The trapezius muscle flap is not usually the first reconstructive option for skin and soft tissue defects in the posterior neck and scalp due to surgeons' unfamiliarity with the surgical anatomy and developments in free tissue transfer techniques. The goals of this study were to describe the clinical use of trapezius flaps in posterior neck and scalp reconstruction, and to investigate the vascular anatomy of trapezius flaps in Asians in order to obtain information facilitating the safe design and elevation of flaps in which most of the muscle is preserved. Methods A retrospective chart review was performed of 10 patients who underwent trapezius muscle flap for posterior neck and scalp defects. We also performed an anatomical study of 16 flaps harvested from 8 preserved Asian adult cadavers and evaluated the main landmarks relevant for trapezius muscle flap. Results In the anatomical study, the mean vertical height from the inferior angle of the scapula to the point at which the superficial cervical artery penetrated the trapezius was 4.31±2.14 cm. The mean vertical height of the trapezius muscle flap pivot point was 9.53±2.08 cm from the external occipital protuberance. Among the 10 flaps, partial necrosis on the overlaid skin graft occurred in 1 patient and postoperative seroma occurred in another patient. Conclusions Vascular variations in the trapezius muscle flap are uncommon in Asians, but when present, such variations appear to have little impact on harvesting the flap or on its circulation. The trapezius muscle flap is a viable alternative for posterior neck and scalp reconstruction. PMID:27896183

Chest wall reconstruction using iliac bone allografts and muscle flaps.

PubMed

Garcia-Tutor, Emilio; Yeste, Luis; Murillo, Julio; Aubá, Cristina; Sanjulian, Mikel; Torre, Wenceslao

2004-01-01

Technically we can divide full-thickness thoracic reconstruction into 2 parts: providing a rigid support and ensuring well-vascularized coverage. Since 1986, the authors' center has had ample experience with bone banks and the use of cryopreserved bone grafts, which led them to consider the possibility of using these grafts for full-thickness chest wall reconstruction. They describe 3 patients in whom resection of the tumor and reconstruction of the thorax were carried out using iliac bone allografts covered with muscle flaps (1 pectoralis major and 2 rectus abdominis). None of the patients experienced breathing difficulties, pain, or instability after 14 months, 18 months, and 11 years of follow-up. The result of the reconstruction was excellent in all 3 patients in terms of function and aesthetics. The advantage of allografts compared with synthetic materials is their potential integration; they can become part of the host patient's living tissue.

Better anatomical and cosmetic results using tunneled lotus petal flap for plastic reconstruction after demolitive surgery for vulvar malignancy.

PubMed

Buda, Alessandro; Confalonieri, Pier Luigi; Rovati, Luca Carlo Vittorio; Fruscio, Robert; Giuliani, Daniela; Signorelli, Mauro; Dell'Anna, Tiziana; Pirovano, Cecilia; Milani, Rodolfo

2012-06-01

To evaluate the efficacy of tunneled lotus petal flap in terms of anatomical and cosmetic results in patients who underwent vulvoperineal reconstruction for vulvar malignancy. Between March 2010 and July 2011, 22 women underwent vulvoperineal reconstruction using tunneled lotus petal flap for primary or recurrent disease at San Gerardo Hospital, Monza. In 16 cases, lotus flaps were bilateral, whereas in 6 cases, they were monolateral. The median age was 72 years (range, 53-87 years). The mean operating time was 85 minutes. The mean length of follow-up was 10 months (range, 2-16 months). Postoperative complications occurred in 2 patients, including one case of partial flap necrosis and one case of donor site breakdown. Tunneled lotus petal flap is safe, easy and fast to perform, has a low rate of complications, and good functional and cosmetic results. This technique represents an optimal solution for plastic reconstruction in case of primary or recurrent vulvar disease, or in case of introital stenosis after primary inadequate closure.

A Novel Perforator Flap Training Model Using a Chicken Leg

PubMed Central

Cifuentes, Ignacio J.; Yañez, Ricardo A.; Salisbury, Maria C.; Rodriguez, José R.; Varas, Julian E.; Dagnino, Bruno L.

2016-01-01

Introduction  Living animal models are frequently used for perforator flap dissection training, but no ex vivo models have been described. The aim of this study is to present a novel nonliving model for perforator flap training based on a constant perforator in the chicken leg. Methods  A total of 15 chicken legs were used in this study. Anatomical dissection of the perforator was performed after its identification using ink injection, and in four of these specimens a perforator-based flap was raised. Results  The anatomical dissection revealed a constant intramuscular perforator with a median length of 5.7 cm. Median proximal and distal vessel diameters were 0.93 and 0.4 mm, respectively. The median dissection time was 77.5 minutes. Conclusion  This study introduces a novel, affordable, and reproducible model for the intramuscular dissection of a perforator-based flap using an ex vivo animal model. Its consistent perforator and appropriate-sized vessels make it useful for training. PMID:27616823

An international comparison of reimbursement for DIEAP flap breast reconstruction.

PubMed

Reid, A W N; Szpalski, C; Sheppard, N N; Morrison, C M; Blondeel, P N

2015-11-01

The deep inferior epigastric artery perforator (DIEAP) flap is currently considered the gold standard for autologous breast reconstruction. With the current economic climate and health cutbacks, we decided to survey reimbursement for DIEAP flaps performed at the main international centres in order to assess whether they are funded consistently. Data were collected confidentially from the main international centres by an anonymous questionnaire. Our results illustrate the wide disparity in international DIEAP flap breast reconstruction reimbursement: a unilateral DIEAP flap performed in New York, USA, attracts €20,759, whereas the same operation in Madrid, Spain, will only be reimbursed for €300. Only 35.7% of the surgeons can set up their own fee. Moreover, 85.7% of the participants estimated that the current fees are insufficient, and most of them feel that we are evolving towards an even lower reimbursement rate. In 55.8% of the countries represented, there is no DIEAP-specific coding; in comparison, 74.4% of the represented countries have a specific coding for transverse rectus abdominis (TRAM) flaps. Finally, despite the fact that DIEAP flaps have become the gold standard for breast reconstruction, they comprise only a small percentage of all the total number of breast reconstruction procedures performed (7-15%), with the only exception being Belgium (40%). Our results demonstrate that DIEAP flap breast reconstruction is inconsistently funded. Unfortunately though, it appears that the current reimbursement offered by many countries may dissuade institutions and surgeons from offering this procedure. However, substantial evidence exists supporting the cost-effectiveness of perforator flaps for breast reconstruction, and, in our opinion, the long-term clinical benefits for our patients are so important that this investment of time and money is absolutely essential. Copyright © 2015 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

The Extended Nasoseptal Flap for Skull Base Reconstruction of the Clival Region: An Anatomical and Radiological Study

PubMed Central

Peris-Celda, Maria; Pinheiro-Neto, Carlos Diogenes; Funaki, Takeshi; Fernandez-Miranda, Juan C.; Gardner, Paul; Snyderman, Carl; Rhoton, Albert L.

2013-01-01

Objective Reconstruction of large clival defects after an endoscopic endonasal procedure is challenging. The objective is to analyze the morphology, indications, and limitations of the extended nasoseptal flap, which adds the nasal floor and inferior meatus mucosa, compared with the standard nasoseptal flap, for clival reconstruction. Design Twenty-seven sides of formalin-fixed anatomical specimens and 13 computed tomography (CT) scans were used. Under 0-degree endoscopic visualization, a standard flap on one side and an extended flap on the other side were performed, as well as exposure of the sella, cavernous sinus, and clival dura mater. Coverage of both flaps was assessed, and they were incised and extracted for measurements. Results The extended flap has two parts: septal and inferior meatal. The extended flaps are 20 mm longer and add 774 mm2 of mucosal area. They cover a clival defect from tuberculum to foramen magnum in 66.6% cases and from below the sella in 91.6%. They cover both parasellar and paraclival segments of the internal carotid arteries. The lateral inferior limits are the medial aspect of the hypoglossal canals and Eustachian tubes. CT scans can predict the need or limitation of an extended nasoseptal flap. Conclusions The nasal floor and inferior meatus mucosa adds a significant area for reconstruction of the clivus. A defect laterally beyond the hypoglossal canals is not likely covered with this variation of the flap. Preoperative CT scans are useful to guide the reconstruction techniques. PMID:24436940

Free flap reconstructions of tibial fractures complicated after internal fixation.

PubMed

Nieminen, H; Kuokkanen, H; Tukiainen, E; Asko-Seljavaara, S

1995-04-01

The cases of 15 patients are presented where microvascular soft-tissue reconstructions became necessary after internal fixation of tibial fractures. Primarily, seven of the fractures were closed. Eleven fractures had originally been treated by open reduction and internal fixation using plates and screws, and four by intramedullary nailing. All of the patients suffered from postoperative complications leading to exposure of the bone or fixation material. The internal fixation material was removed and radical revision of dead and infected tissue was carried out in all cases. Soft tissue reconstruction was performed using a free microvascular muscle flap (11 latissimus dorsi, three rectus abdominis, and one gracilis). In eight cases the nonunion of the fracture indicated external fixation. The microvascular reconstruction was successful in all 15 patients. In one case the recurrence of deep infection finally indicated a below-knee amputation. In another case, chronic infection with fistulation recurred postoperatively. After a mean follow-up of 26 months the soft tissue coverage was good in all the remaining 13 cases. All the fractures united. Microvascular free muscle flap reconstruction of the leg is regarded as a reliable method for salvaging legs with large soft-tissue defects or defects in the distal leg. If after internal fixation of the tibial fracture the osteosynthesis material or fracture is exposed, reconstruction of the soft-tissue can successfully be performed by free flap transfer. By radical revision, external fixation, bone grafting, and a free flap the healing of the fracture can be achieved.

Immediate transverse rectus abdominis musculocutaneous (TRAM) flap breast reconstruction in underweight Asian patients.

PubMed

Kim, Eun Key; Eom, Jin Sup; Hwang, Chang Heon; Ahn, Sei Hyun; Son, Byung Ho; Lee, Taik Jong

2014-11-01

TRAM breast reconstruction is commonly thought to be inadequate for underweight patients and LD flap with implant is usually recommended. However, it is often difficult to find an appropriate implant for thin Asian women with small breasts. The authors present the results of using TRAM flap alone for immediate breast reconstruction in underweight Asian patients. Between September 2001 and October 2006, 564 patients underwent immediate TRAM flap-only breast reconstruction. Among these, 18 were underweight (BMI <18.5 kg/m(2)) and 317 were normal weight (18.5 kg/m(2) ≤ BMI < 23.0 kg/m(2)). Complications were classified as systemic, breast, and donor site. Complication rate, oncologic outcome and overall satisfaction and recommendation were compared between two groups. Standardized postoperative photographs were also subject to a panel for cosmetic assessment. the overall complication rate was 22.2 % in underweight group and 27.1 % in normal weight group (p = 0.32). There was a tendency that the breast complication rate was higher in the normal weight group and the abdominal complication rate was higher in the underweight group. However, neither of these was statistically significant. Mean satisfaction was not statistically different, either (8.44 vs. 8.60, p = 0.54). Panel assessment for overall cosmesis, symmetry and scarring showed no significant between-group differences. Immediate breast reconstruction using TRAM flap alone can be performed with acceptable complication rates and comparable patients' satisfaction score in a well selected underweight Asian women as in a normal weight group.

Propeller Flaps With Reduced Rotational Angles: Clinical Experience on 40 Consecutive Reconstructions Performed at Different Anatomical Sites.

PubMed

Brunetti, Beniamino; Tenna, Stefania; Poccia, Igor; Persichetti, Paolo

2017-02-01

Despite of the widespread use of 180-degree propeller flaps in the field of soft tissue reconstruction, less information are available in the current literature to standardize the use of propeller flaps with reduced degrees of rotation.The authors report their experience with propeller flaps with reduced rotational angles reviewing clinical applications and outcomes of the technique in a series of 40 consecutive reconstructions. Forty elective defects of various etiologies located in different regions of the body (head and neck, trunk, buttocks and perineum, extremities) were reconstructed with less than 180 degrees rotated propeller flaps. The technique was applied to patients presenting with a strong audible perforator detected in close proximity to the wound and the defect located in a position adjacent to the axis of the chosen perforasome. Defect size ranged from 2 × 2 to 15 × 9 cm. Flap dimensions ranged from 5 × 2 to 21 × 10 cm. The flaps were based on 1 (34) or 2 (6) perforators and were mobilized with an angle of rotation of 45, 90, and 135 degrees in 7, 24, and 9 patients, respectively. Mean operative time was 105 minutes. All flaps survived postoperatively. In only 4 cases (10%) partial flap necrosis was registered. All flaps achieved adequate and durable reconstruction with excellent contour, with a follow-up ranging between 6 months and 2 years. Propeller flaps with reduced rotational angles represent a safe and versatile option to reconstruct soft tissues defects at different anatomical sites.

Use of a 3D Skull Model to Improve Accuracy in Cranioplasty for Autologous Flap Resorption in a 3-Year-Old Child.

PubMed

Maduri, Rodolfo; Viaroli, Edoardo; Levivier, Marc; Daniel, Roy T; Messerer, Mahmoud

2017-01-01

Cranioplasty is considered a simple reconstructive procedure, usually performed in a single stage. In some clinical conditions, such as in children with multifocal flap osteolysis, it could represent a surgical challenge. In these patients, the partially resorbed autologous flap should be removed and replaced with a precustomed prosthesis which should perfectly match the expected bone defect. We describe the technique used for a navigated cranioplasty in a 3-year-old child with multifocal autologous flap osteolysis. We decided to perform a cranioplasty using a custom-made hydroxyapatite porous ceramic flap. The prosthesis was produced with an epoxy resin 3D skull model of the patient, which included a removable flap corresponding to the planned cranioplasty. Preoperatively, a CT scan of the 3D skull model was performed without the removable flap. The CT scan images of the 3D skull model were merged with the preoperative 3D CT scan of the patient and navigated during the cranioplasty to define with precision the cranioplasty margins. After removal of the autologous resorbed flap, the hydroxyapatite prosthesis matched perfectly with the skull defect. The anatomical result was excellent. Thus, the implementation of cranioplasty with image merge navigation of a 3D skull model may improve cranioplasty accuracy, allowing precise anatomic reconstruction in complex skull defect cases. © 2017 S. Karger AG, Basel.

Functional resurfacing of the palm: flap selection based on defect analysis.

PubMed

Engelhardt, T O; Rieger, U M; Schwabegger, A H; Pierer, G

2012-02-01

Extensive defect coverage of the palm and anatomical reconstruction of its unique functional capacity remains difficult. In manual laborers, reconstruction of sensation, range of motion, grip strength but also mechanical stability is required. Sensate musculo-/fasciocutaneous flaps bear disadvantages of tissue mobility with shifting/bulkiness under stress. Thin muscle and fascial flaps show adherence but preclude sensory nerve coaptation. The purpose of this review is to present our algorithm for reliable selection of the most appropriate procedure based on defect analysis. Defect analysis focusing on units of tactile gnosis provides information to weigh needs for sensation or soft tissue stability. We distinguish radial unit (r)-thenar, ulnar unit (u)-hypothenar and unit (c)-central plus distal palm. Individual parameters need similar consideration to choose adequate treatment. Unit (r) and unit (u) are regions of secondary touch demanding protective sensation. Restoration of sensation using neurovascular, fasciocutaneous flaps is recommended. In unit (c), tactile gnosis is of less, mechanical resistance of greater value. Reconstruction of soft tissue resistance is suggested first in this unit. In laborers, free fascial- or muscle flaps with plantar instep skin grafts may achieve near to anatomical reconstruction with minimal sensation. Combined defects involving unit (c) require correlation with individual parameters for optimal flap selection. Defect coverage of the palm should not consist of merely providing sensate vascularized tissue. The most appropriate procedure should be derived from careful defect analysis to achieve near to anatomical reconstruction. In laborers, defect related demands need close correlation with sensation and mechanical stability to be expected. Copyright © 2011 Wiley Periodicals, Inc.

Anatomical study of the popliteal artery perforator-based propeller flap and its clinical application.

PubMed

Onishi, Tadanobu; Shimizu, Takamasa; Omokawa, Shohei; Sananpanich, Kanit; Kido, Akira; Mahakkanukrauh, Pasuk; Tanaka, Yasuhito

2018-05-30

There is lack of anatomical information regarding cutaneous perforator of the popliteal artery and its connections with the descending branch of the inferior gluteal and profunda femoris arteries. We aimed to evaluate the anatomical basis of popliteal artery perforator-based propeller flap from the posterior thigh region and to demonstrate our experience utilizing this flap. Ten fresh cadaveric lower extremities were dissected following injection of a silicone compound into the femoral artery. We investigated the number, location, length, and diameter of cutaneous perforators of the popliteal artery. Based on the results, we treated three cases with a large soft tissue defect around the knee using popliteal artery perforator-based propeller flap. We found a mean of 1.9 cutaneous perforators arising from the popliteal artery with a mean pedicle length of 6 cm and a mean arterial internal diameter of 0.9 mm, which were located at an average of 4 cm proximal to the bicondylar line. The most distal perforator consistently arose along the small saphenous vein and connected proximally with concomitant artery of the posterior femoral cutaneous nerve, forming a connection with perforating arteries of the profunda femoris artery. A mean of 4.5 cutaneous perforators branched from the arterial connection sites. All clinical cases healed without any complications. The popliteal artery perforator-based propeller flap is reliable for reconstruction of soft tissue defects around the knee. The flap should include the deep fascia and concomitant artery along with the posterior femoral cutaneous nerve for maintaining the blood supply.

Analysis of effect isoxsuprine hydrochloride and nicotine in the Transverse Rectus Abdominis Myocutaneous flap (TRAM) in rats.

PubMed

Costa, Walder; Silva, Alcino Lázaro da; Costa, Gustavo Rocha; Vidigal, Paula Vieira Teixeira; Pereira, Fernando Henrique

2015-07-01

To evaluate the effects of isoxsuprine and nicotine on TRAM. Forty eight 48 Wistar rats distributed into four Groups (n=12). All rats received medication managed daily for 20 days: saline solution (SA), nicotine solution (NI), isoxsuprine solution (IS) and nicotine solution (NI) + isoxsuprine solution (IS). On day 21st the rats were submitted to the caudally based, right unipedicled TRAM flap and after 48 hours, made the macroscopic evaluation of the surface of the flap, photographic documentation and collection of material for histology. Data from macroscopic evaluation were analyzed by ANOVA and microscopic evaluation by Kruskal-Wallis test, with significance level of 5%. In the macroscopic evaluation of isoxsuprine Group retail presented absolute numbers: final area (p=0.001*) and viable area (p=0.006*) with the highest values; necrosis (p=0.001*) had the lowest value. Microscopic examination revealed no significant findings in the study of TRAM under the action of isoxsuprine and nicotine to the percentage of necrosis in the left and right cranial and caudal regions. There was significant improvement in viability of TRAM using the isoxsuprine solution alone. No influence using nicotine alone and in association with isoxsuprine.

Vascular anatomy of the supraclavicular area revisited: feasibility of the free supraclavicular perforator flap.

PubMed

Cordova, Adriana; Pirrello, Roberto; D'Arpa, Salvatore; Jeschke, Johannes; Brenner, Erich; Moschella, Francesco

2008-11-01

The supraclavicular skin has been studied extensively and used as a pedicled flap for face and neck reconstruction. Its use as a free flap has not paralleled its use as a pedicled flap. The authors performed an anatomical investigation to assess the possibility of harvesting a free supraclavicular flap with the donor-site scar lying in the supraclavicular crease. In this article, the authors present the results of their anatomical study together with the preliminary clinical applications. Skin vascularization and feasibility of a free supraclavicular perforator flap were studied on 25 cadavers (15 fresh cadavers injected with colored latex at the Universiteé René Descartes in Paris; and 10 formalin-fixed, noninjected cadavers at the Innsbruck Medical University). The flap was used in two patients at the Plastic Surgery Department of the University of Palermo for a cutaneous facial reconstruction and intraoral reconstruction after cancer excision. An average of four perforators were consistently found in the supraclavicular area coming from the transverse cervical artery. Venous perforators drain into the superficial venous plexus rather than into the venae comitantes of the transverse cervical artery. Two flaps were successfully used based on these vessels. The vascularization of the supraclavicular skin depends on skin perforators coming from the transverse cervical artery and draining into the superficial venous plexus. Based on these vessels, a reliable free supraclavicular flap seems to be safe to harvest, with the scar hidden in the supraclavicular crease. The preliminary clinical applications of such a flap gave promising results, suggesting its potential applications.

Reconstruction of maxillectomy and midfacial defects with free tissue transfer.

PubMed

Santamaria, Eric; Cordeiro, Peter G

2006-11-01

The maxillary bones are part of the midfacial skeleton and are closely related to the eyeglobe, nasal airway, and oral cavity. Together with the overlying soft tissues, the two maxillae are responsible to a large extent for facial contour. Maxillectomy defects become more complex when critical structures such as the orbit, globe, and cranial base are resected, and reconstruction with distant tissues become essential. In this article, we describe a classification system and algorithm for reconstruction of these complex defects using various pedicled and free flaps. Most defects that involve resection of the maxilla and adjacent soft tissues may be classified into one of the following four types: Type I defects, Limited maxillectomy; Type II defects, Subtotal maxillectomy; Type III defects, Total maxillectomy; and Type IV defects, Orbitomaxillectomy. Using this classification, reconstruction of maxillectomy and midfacial defects may be approached considering the relationship between volume and surface area requirements, that is, addressing the bony defect first, followed by assessment of the associated soft tissue, skin, palate, and cheek-lining deficits. In our experience, most complex maxillectomy defects are best reconstructed using free tissue transfer. The rectus abdominis and radial forearm free flap in combination with immediate bone grafting or as an osteocutaneous flap reliably provide the best aesthetic and functional results. A temporalis muscle pedicled flap is used for reconstruction of maxillectomy defects only in those patients who are not candidates for a microsurgical procedure.

Free tissue transfer with distraction osteogenesis is effective for limb salvage of the infected traumatized lower extremity.

PubMed

Chim, Harvey; Sontich, John K; Kaufman, Bram R

2011-06-01

Salvage of acute and chronic tibial osseocutaneous defects in the lower extremity poses a formidable problem. Although local, distant, and free tissue transfer or bone grafting alone may be adequate for repair of small wounds or osseous defects, large or complicated defects necessitate a different approach. The authors describe their experience with free tissue transfer in combination with distraction osteogenesis for complex composite osteocutaneous defects. The authors reviewed a consecutive series of 28 patients who underwent treatment over an 8-year period, with follow-up ranging from 1 to 8.5 years. Mean time to flap after injury was 1082 days (range, 6 days to 30 years). Indications for treatment included infected nonunion of the tibia (n = 18), acute traumatic bone loss (n = 5), skin and soft-tissue breakdown that occurred during distraction osteogenesis (n = 4), and exposed bone following previous failed free flap (n = 1). Free flaps used included the rectus abdominis (n = 17), latissimus dorsi (n = 5), gracilis (n = 5), and radial forearm (n = 1). Mean length of bone gap was 63 mm (range, 30 to 140 mm), and mean area of wound requiring flap coverage was 219 cm (range, 35 to 400 cm). Twenty-five patients (89.3 percent) had successful flap coverage and went on to ambulate independently and return to work. The minor complication rate was 42.9 percent. Distraction osteogenesis in combination with free tissue transfer is a powerful technique that allows limb salvage, particularly when local and regional flaps are unavailable or inadequate. For infected nonunion of the tibia, it permits a staged approach that allows underlying osteomyelitis to declare itself and provides vascularized healthy soft-tissue coverage that facilitates repeated operations for the purpose of distraction.

Myosonographic study of abdominal wall dynamics to assess donor site morbidity after microsurgical breast reconstruction with a DIEP or an ms-2 TRAM flap.

PubMed

Seidenstuecker, K; Legler, U; Munder, B; Andree, C; Mahajan, A; Witzel, C

2016-05-01

Currently, autologous breast reconstruction with a free tissue transfer from the lower abdomen is considered to be a safe method that provides a stable long-term solution. The DIEP-flap and the ms-2-TRAM-flap reconstructions have helped reduce donor site morbidity. In order to assess the potential differences between these techniques, we carried out myosonographic evaluations that assessed the muscle dynamics pre- and post-operatively. In addition to investigating the properties of the rectus abdominis muscle post-operatively, this prospective study also allowed us to analyse the muscle preoperatively and to investigate the prospects for harvesting a DIEP-flap as opposed to a TRAM-flap. Sixty patients underwent breast reconstruction with 71 (11 bilateral) free abdominal wall flaps (DIEP-: n = 48; ms-2-TRAM-flap: n = 23). Myosonographic examinations were performed preoperatively and at 3 and 6 months post-operatively. The thickness of the muscle at relaxation and maximum contraction and the difference between the muscle thickness measured at the two states were measured. A general-linear-model (GLM) was used for statistical analysis. The main variable was the surgical method, and the co-variables included BMI and patient age. The decision on whether to harvest a DIEP- or ms-2-TRAM-flap was made intra-operatively and based on the dominant perforator. It shows that the patients who underwent breast reconstruction with a DIEP-flap had significantly better muscle function (p < 0.05) in the follow-up. In addition, the analysis revealed that better muscle function before surgery made it more likely that a patient would undergo a DIEP-flap-reconstruction successfully. Patient age also had a highly significant effect on muscle recovery (p < 0.0005). This prospective study used a dynamic ultrasound evaluation of the abdominal wall and showed that the DIEP-flap significantly reduces donor site morbidity compared to the ms-2-TRAM-flap. The study also showed that good preoperative muscle function might increase the probability of surgeons performing a DIEP-flap reconstruction. Copyright © 2015 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

Long-term outcomes of patients with breast cancer after nipple-sparing mastectomy/skin-sparing mastectomy followed by immediate transverse rectus abdominis musculocutaneous flap reconstruction: Comparison with conventional mastectomy in a single center study.

PubMed

Lee, Sae Byul; Lee, Jong Won; Kim, Hee Jeong; Ko, Beom Seok; Son, Byung Ho; Eom, Jin Sup; Lee, Taik Jong; Ahn, Sei-Hyun

2018-05-01

To evaluate the oncological outcomes of patients with breast cancer after nipple-sparing mastectomy (NSM)/skin-sparing mastectomy (SSM), followed by immediate reconstruction, as compared to conventional mastectomy (CM).SSM/NSM has been increasingly used to treat women with breast cancer who wish to preserve the overlying breast skin, but concern exist regarding its oncological safety due to the potential for residual breast tissue. We report our experience performing SSM/NSM for breast cancer treatment compared to CM with a long follow-up period.All consecutive patients who underwent mastectomy for breast cancer at Asan Medical Center between January 1993 and December 2008 were identified by retrospective medical chart review. The patients who underwent NSM/SSM, followed by immediate breast reconstruction with a pedicled transverse rectus abdominis musculocutaneous flap (TRAM), were compared to the patients who underwent CM in terms of breast-cancer specific survival (BCSS) rate, distant metastasis-free survival (DMFS) rate, and local recurrence (LR) rate.During the study period, 6028 patients underwent mastectomy for breast cancer. Of these, 1032 and 4996 underwent NSM/SSM with TRAM and CM, respectively. Their median follow-up durations were 94.4 (range, 8.1-220.2) and 110.8 (range, 6.1-262.0) months, respectively. Their 5 year BCSS rates were 95.4% and 88.1%, respectively (log-rank, P < .001). Their 5 year DMFS rates were 93.0% and 85.6%, respectively (log-rank, P < .001).Relative to CM, NSM/SSM, followed by immediate breast reconstruction, may be a viable and oncologically safe surgical treatment in selected patients with breast cancer.

Fat necrosis in autologous abdomen-based breast reconstruction: a systematic review.

PubMed

Khansa, Ibrahim; Momoh, Adeyiza O; Patel, Priti P; Nguyen, John T; Miller, Michael J; Lee, Bernard T

2013-03-01

Fat necrosis is a common and potentially exasperating complication of autologous breast reconstruction. The authors performed a systematic review of the English literature on autologous breast reconstruction to determine significant patient and surgical factors that are predictors of postoperative fat necrosis. A PubMed search using the terms "fat necrosis" and "breast reconstruction" was conducted. Articles were screened using predetermined inclusion and exclusion criteria. Data collected included patient characteristics, reconstructive techniques used, and the specific postoperative morbidity of interest. Patient cohorts were pooled, and the incidence of fat necrosis was calculated in the presence and absence of each risk factor. Chi-square analysis was applied, and p < 0.05 was considered statistically significant. Of 172 articles found, 70 met the inclusion criteria. The mean rate of fat necrosis was 11.3 percent. Deep inferior epigastric artery perforator flaps had the highest rate of fat necrosis (14.4 percent), followed by pedicled transverse rectus abdominis musculocutaneous (12.3 percent), superficial inferior epigastric artery (8.1 percent), and free transverse rectus abdominis musculocutaneous flaps (6.9 percent). Significant predictors of fat necrosis included obesity (p = 0.035), prereconstruction irradiation (p = 0.022), postreconstruction irradiation (p < 0.001), active smoking (p < 0.001), and abdominal scars (p = 0.05). Protective factors included supercharging (p < 0.001) and bilateral reconstruction (p = 0.01). Although there is little agreement in the literature regarding risk factors for fat necrosis, the authors were able to demonstrate several significant predictors by systematically analyzing 70 articles. Improved knowledge of the risk factors for fat necrosis can help surgeons provide improved preoperative counseling and take measures to minimize the risk of this complication.

Superficial ulnar artery perforator flap.

PubMed

Schonauer, Fabrizio; Marlino, Sergio; Turrà, Francesco; Graziano, Pasquale; Dell'Aversana Orabona, Giovanni

2014-09-01

Superficial ulnar artery is a rare finding but shows significant surgical implications. Its thinness and pliability make this flap an excellent solution for soft tissue reconstruction, especially in the head and neck region. We hereby report a successful free superficial ulnar artery perforator forearm flap transfer for tongue reconstruction. A 64-year-old man presenting with a squamous cell carcinoma of the left tongue underwent a wide resection of the tumor, left radical neck dissection, and reconstruction of the tongue and the left tonsillar pillar with the mentioned flap. No complications were observed postoperatively. The flap survived completely; no recurrence at 6 months of follow-up was detected. Superficial ulnar artery perforator flap has shown to be a safe alternative to other free tissue flaps in specific forearm anatomic conditions.

Free intra-osseous muscle transfer for treatment of chronic osteomyelitis.

PubMed

Lê Thua, Trung-Hau; Boeckx, Willy D; Zirak, Christophe; De Mey, Albert

2015-06-10

Chronic osteomyelitis is still a big reconstructive challenge. Even with standard care, therapeutic failures and recurrences are common. Multiple techniques of tissue transfer have increased the success rate. This study recommends free muscle transfers into the intramedullary bone cavities for treatment of chronic osteomyelitis. The review included 29 patients that were treated for chronic osteomyelitis. Osteomyelitis was located at the femur in four patients, the tibia in 22 patients, and the foot in three patients. Dead bone and scar tissue were replaced with durable free muscle flap with special attention to fill the dead space. The average age of these patients was 48.5 years old (range = 23-70 years old). The average duration of osteomyelitis was 8.2 years (range = 1-45 years). Gracilis was applied in 20 cases (69%), latissimus dorsi was used in five cases (17.2%), and rectus abdominis was performed in four cases (13.8%). There was one flap failure, one partial superficial flap necrosis, two arterial thrombosis, and one venous thrombosis. All the remaining 28 muscle flaps survived. From 1-10 years follow-up, there was one recurrence of the osteomyelitis in the distal end of the intra-medullary cavity of a femur after reconstructing using the gracilis flap. The present study demonstrated that free intramedullary muscle transfers are effective in providing a high rate of success in the treatment of chronic osteomyelitis. The secondary filling of the intramedullary cavity after extensive removal of all infected bony sequesters has proven to give a long-term arrest of chronic osteomyelitis.

The Lateral Proximal Phalanx Flap for Contractures and Soft Tissue Defects in the Proximal Interphalangeal Joint: An Anatomical and Clinical Study.

PubMed

Beltrán, Aldo G; Romero, Camilo J

2017-01-01

Background: The management of contractures and soft tissue defects in the proximal interphalangeal (PIP) finger joint remains a challenge. We report a transposition flap from the lateral skin of the proximal phalanx that is based on perforating branches of the digital arteries and can be used safely for both palmar and dorsal cover defects. Methods: We first completed an anatomic study, dissecting 20 fingers in fresh cadavers with arterial injections and made the new flap in patients with dorsal or palmar defects in PIP joints. Results: In cadavers, we can reveal 4 constant branches from each digital artery in the proximal phalanx, with the more distal just in the PIP joint constituting the flap pedicle. Between February 2010 and February 2015, we designed 33 flaps in 29 patients, 7 for dorsal and 26 for palmar defects, with no instances of flap necrosis and 4 distal epidermolysis. The patients were between 4 and 69 years with no major complications, and all of the skin defects in the PIP joint were resolved satisfactorily without any relevant sequelae at the donor site. Conclusions: This flap procedure is an easy, reliable, versatile, and safe technique, and could be an important tool for the management of difficult skin defects and contractures at the PIP joint level.

[Anatomical study of muscular latissimus dorsi surface vascularized by the transverse branch of thoraco-dorsal artery].

PubMed

Boucher, F; Pinatel, B; Shipkov, H; Mertens, P; Rouviere, O; Braye, F; Mojallal, A

2014-10-01

The latissimus dorsi muscle flap is a type V according to Mathes and Nahai. It is vascularized by a proximal main pedicle represented by the thoraco-dorsal pedicle and pedicle distal accessory represented by the dorsal branches of the posterior intercostal arteries. The main thoraco-dorsal pedicle has a descending branch and a transverse branch. This anatomical study clarifies the muscular territory vascularized by the transverse branch of thoraco-dorsal artery for a secondary use after harvesting a thoraco-dorsal artery perforator flap or a muscle-sparing latissimus dorsi flap. Our study focused on ten dissections latissimus dorsi muscle taken from five fresh cadavers chest, carried out within the University Department of Anatomy. The descending branch of thoraco-dorsal artery was ligated, the transverse branch was cannulated and injected with a mixture of barium sulfate/gelatin. After freezing, a static angiotomodensitometry (3D) of each flap was performed. The average muscular surface vascularized by the transverse branch is measured at 80% (77% minimum value, maximum value 83%) of the complete latissimus dorsi muscle. Intermuscular connections between the two branches of thoraco-dorsal pedicle were shown. The use of a ipsilateral latissimus dorsi muscle is a therapeutic option after harvesting a thoraco-dorsal artery perforator flap (TAP) or a muscle-sparing latissimus dorsi flap (MSLD-flap). Copyright © 2014 Elsevier Masson SAS. All rights reserved.

DOE Office of Scientific and Technical Information (OSTI.GOV)

Bostwick, J.; Stevenson, T.R.; Nahai, F.

Major complications of radiation directed to the breast, axilla, and mediastinum were treated in 54 patients from 1974 to 1983. A classification of these complications facilitates both an understanding of the pattern of injury and the development of a treatment plan. Classification: I. Breast necrosis; II. Radionecrosis and Chest Wall Ulceration; III. Accelerated Coronary Atherosclerosis with Median Sternotomy Wound Failure After Coronary Revascularization; IV. Brachial Plexus Pain and Paresis; V. Lymphedema and Axillary Cicatrix; VI. Radiation-induced Neoplasia. The treatment has evolved during the 10-year study period to excision of the necrotic wound, including any tumor, and closure with a transposedmore » muscle or musculocutaneous flap of latissimus dorsi (II, III, V) or rectus abdominis (I, II, VI). This strategy reflects a change from primary use of the omentum during the first years of the study. The vascularity, oxygen and antibiotic delivery of these muscle and musculocutaneous flaps promote wound healing, usually with one operation. The transfer of these muscles has not caused significant functional deficits.« less

A multi-disciplinary approach to the management of fungal osteomyelitis: current concepts in post-traumatic lower extremity reconstruction: a case report.

PubMed

Cetrulo, Curtis L; Leto Barone, Angelo A; Jordan, Kathleen; Chang, David S; Louie, Kevin; Buntic, Rudolf F; Brooks, Darrell

2012-02-01

Limb salvage in fungal osteomyelitis of the post-traumatic lower extremity represents a difficult clinical problem requiring aggressive management. We report lower extremity salvage by radical bony debridement, free tissue transfer, distraction osteogenesis with bone-docking, and a novel antifungal regimen in a clinical setting of infection with Scedosporium inflatum, historically requiring amputation in 100% of cases. We treated Scedosporium inflatum osteomyelitis of the tibia and calcaneus with radical debridement of infected bone, free partial medial rectus abdominis muscle flap coverage, transport distraction osteogenesis, and combination voriconazole/terbinafine chemotherapy, a novel antifungal regimen. We achieved successful control of the infection, limb salvage, and an excellent functional outcome through aggressive debridement of infected bone and soft tissue, elimination of dead space within the bony defect, the robust perfusion provided by the free flap, the hypervascular state induced by distraction osteogenesis, and the synergism of the novel antifungal regimen.

The fusion of craniofacial reconstruction and microsurgery: a functional and aesthetic approach.

PubMed

Broyles, Justin M; Abt, Nicholas B; Shridharani, Sachin M; Bojovic, Branko; Rodriguez, Eduardo D; Dorafshar, Amir H

2014-10-01

Reconstruction of large, composite defects in the craniofacial region has evolved significantly over the past half century. During this time, there have been significant advances in craniofacial and microsurgical surgery. These contributions have often been in parallel; however, over the past 10 years, these two disciplines have begun to overlap more frequently, and the techniques of one have been used to advance the other. In the current review, the authors aim to describe the available options for free tissue reconstruction in craniofacial surgery. A review of microsurgical reconstructive options of aesthetic units within the craniofacial region was undertaken with attention directed toward surgeon flap preference. Anatomical areas analyzed included scalp, calvaria, forehead, frontal sinus, nose, maxilla and midface, periorbita, mandible, lip, and tongue. Although certain flaps such as the ulnar forearm flap and lateral circumflex femoral artery-based flaps were used in multiple reconstructive sites, each anatomical location possesses a unique array of flaps to maximize outcomes. Craniofacial surgery, like plastic surgery, has made tremendous advancements in the past 40 years. With innovations in technology, flap design, and training, microsurgery has become safer, faster, and more commonplace than at any time in history. Reconstructive microsurgery allows the surgeon to be creative in this approach, and free tissue transfer has become a mainstay of modern craniofacial reconstruction.

Free Vastus Intermedius Muscle Flap: A Successful Alternative for Complex Reconstruction of the Neurocranium in Preoperated Patients.

PubMed

Horn, Dominik; Freudlsperger, Christian; Berger, Moritz; Freier, Kolja; Ristow, Oliver; Hoffmann, Jürgen; Sakowitz, Oliver; Engel, Michael

2017-07-01

The reconstruction of large cranial and scalp defects is a surgical and esthetic challenge. Single autologous tissue transfer can be insufficient due to the defect size and the anatomic complexity of the recipient site. Alloplastic patient-specific preformed implants can be used to recover hard tissue defects of the neurocranium. Nevertheless, for long-term success adequate soft tissue support is required. In this brief clinical study, the authors describe calvarian reconstruction in a 33-year-old patient with wound healing disorder after an initial resection of ependymoma. The patient suffered from osteonecrosis and wound breakdown in the fronto-parietal region. An alloplastic polymethylmethacrylate implant for hard tissue support was manufactured based on 3-dimensional visualization of a computed tomography scan. After the resection of remaining pathologic bone from earlier surgical procedures, the alloplastic implant was inserted to achieve functional coverage of the brain. Due to anatomic variation of donor site vessels during anterolateral thigh flap preparation, the authors performed a vastus intermedius free flap as a new muscular flap for craniofacial reconstruction. The authors achieved excellent functional and esthetic results. The muscular vastus intermedius free flap in combination with a split skin graft proves to be a new alternative to the anterolateral thigh flap for soft tissue reconstruction of the neurocranium.

Mathematical modelling of the growth of human fetus anatomical structures.

PubMed

Dudek, Krzysztof; Kędzia, Wojciech; Kędzia, Emilia; Kędzia, Alicja; Derkowski, Wojciech

2017-09-01

The goal of this study was to present a procedure that would enable mathematical analysis of the increase of linear sizes of human anatomical structures, estimate mathematical model parameters and evaluate their adequacy. Section material consisted of 67 foetuses-rectus abdominis muscle and 75 foetuses- biceps femoris muscle. The following methods were incorporated to the study: preparation and anthropologic methods, image digital acquisition, Image J computer system measurements and statistical analysis method. We used an anthropologic method based on age determination with the use of crown-rump length-CRL (V-TUB) by Scammon and Calkins. The choice of mathematical function should be based on a real course of the curve presenting growth of anatomical structure linear size Ύ in subsequent weeks t of pregnancy. Size changes can be described with a segmental-linear model or one-function model with accuracy adequate enough for clinical purposes. The interdependence of size-age is described with many functions. However, the following functions are most often considered: linear, polynomial, spline, logarithmic, power, exponential, power-exponential, log-logistic I and II, Gompertz's I and II and von Bertalanffy's function. With the use of the procedures described above, mathematical models parameters were assessed for V-PL (the total length of body) and CRL body length increases, rectus abdominis total length h, its segments hI, hII, hIII, hIV, as well as biceps femoris length and width of long head (LHL and LHW) and of short head (SHL and SHW). The best adjustments to measurement results were observed in the exponential and Gompertz's models.

The unique and valuable soft tissue free flap in head and neck reconstruction: Lateral arm.

PubMed

Kang, Stephen Y; Eskander, Antoine; Patel, Krupal; Teknos, Theodoros N; Old, Matthew O

2018-07-01

While the lateral arm free flap has been well described, there is a relative paucity in its use compared to other free flaps and regional flaps. The lateral arm free flap is a unique soft tissue free flap that provides several reconstructive advantages in head and neck reconstruction: excellent contour and color match to facial skin, well compartmentalized fat, donor nerves for nerve grafting, and the ability to two-team harvest and close the donor site without a skin graft. A detailed anatomic and harvest technique is described, along with indications and advantages of using lateral free flap for head and neck reconstruction. A scoping literature review was also conducted to tabulate indications, overall success and complications of the flap. The lateral arm flap is a primary option for defects requiring soft tissue reconstruction in the head and neck. Copyright © 2018 Elsevier Ltd. All rights reserved.

Visualization of Skin Perfusion by Indocyanine Green Fluorescence Angiography—A Feasibility Study

PubMed Central

Steinbacher, Johannes; Yoshimatsu, Hidehiko; Meng, Stefan; Hamscha, Ulrike M.; Chan, Chun-Sheng; Weninger, Wolfgang J.; Wu, Chieh-Tsai; Cheng, Ming-Huei

2017-01-01

Summary: Plastic and reconstructive surgery relies on the knowledge of angiosomes in the raising of microsurgical flaps. Growing interest in muscle-sparing perforator flaps calls for reliable methods to assess the clinical feasibility of new donor sites in anatomical studies. Several injection techniques are known for the evaluation of vascular territories. Indocyanine green–based fluorescence angiography has found wide application in the clinical assessment of tissue perfusion. In this article, the use of indocyanine green–based fluorescence angiography for the assessment of perforasomes in anatomical studies is described for the first time. PMID:29062637

Immediate breast reconstruction with a Latissimus dorsi flap has no detrimental effects on shoulder motion or postsurgical complications up to 1 year after surgery.

PubMed

de Oliveira, Riza Rute; do Nascimento, Simony Lira; Derchain, Sophie F M; Sarian, Luís Otávio

2013-05-01

Mastectomy negatively affects scapulothoracic and glenohumeral kinematics. Breast reconstructive methods such as the latissimus dorsi flap can result in anatomical modifications that may in theory further affect the shoulder apparatus. The purpose of this study was to examine the effects of latissimus dorsi flap reconstruction on the recovery of shoulder motion and other postsurgical problems during the first year after mastectomy. This was a prospective cohort study of 104 consecutive mastectomies (47 with immediate latissimus dorsi flaps). Shoulder range of motion was assessed before and at 1, 3, 6, and 12 months after surgery. Pain, tissue adhesion, scar enlargement, and web syndrome were assessed during follow-up. There was a 30 percent decrease of shoulder range of motion 1 month after surgery, with gradual recovery over time. However, mean abduction and flexion capacities did not reach baseline levels and were on average 5 to 10 percent lower than baseline, even after 1 year. Over time, the latissimus dorsi flap was not associated with restriction of flexion or abduction. Scar enlargement (at the first month, p = 0.009) and tissue adhesion (at month 12, p = 0.032) were significantly less common in the latissimus dorsi flap group. The authors' study clearly suggests that the additional anatomical manipulation required for the latissimus dorsi flap procedure does not further affect shoulder kinematics and is associated with a lower incidence of tissue adhesion. Therapeutic, II.

Distally based posterior interosseous flap: primary role in soft-tissue reconstruction of the hand.

PubMed

Agir, Hakan; Sen, Cenk; Alagöz, Sahin; Onyedi, Murat; Isil, Eda

2007-09-01

A series of 15 consecutive patients with various hand defects requiring flap coverage was reviewed in this study. The defects were all covered with the distally based posterior interosseous flap. Its main indications were in complex hand trauma, severe burn injury, or skin cancer ablation, either acute or postprimary. In 12 of the patients, flaps survived completely. In 3 patients, there was partial necrosis of the distal part of the flap, which did not require additional surgical procedure. Radial nerve palsy was noted in one of the cases, with a complete recovery after 3 months. Donor site was closed directly in up to 4-cm-wide flaps, while larger flaps required skin grafting. No major anatomic variation was observed. Distally based posterior interosseous flap is a reliable choice for various types and areas of hand defects, with very low donor-site morbidity, and should be more commonly considered in clinical practice.

Free-style puzzle flap: the concept of recycling a perforator flap.

PubMed

Feng, Kuan-Ming; Hsieh, Ching-Hua; Jeng, Seng-Feng

2013-02-01

Theoretically, a flap can be supplied by any perforator based on the angiosome theory. In this study, the technique of free-style perforator flap dissection was used to harvest a pedicled or free skin flap from a previous free flap for a second difficult reconstruction. The authors call this a free-style puzzle flap. For the past 3 years, the authors treated 13 patients in whom 12 pedicled free-style puzzle flaps were harvested from previous redundant free flaps and recycled to reconstruct soft-tissue defects at various anatomical locations. One free-style free puzzle flap was harvested from a previous anterolateral thigh flap for buccal cancer to reconstruct a foot defect. Total flap survival was attained in 12 of 13 flaps. One transferred flap failed completely. This patient had received postoperative radiotherapy after the initial cancer ablation and free anterolateral thigh flap reconstruction. Another free flap was used to close and reconstruct the wound. All the donor sites could be closed primarily. The free-style puzzle flap, harvested from a previous redundant free flap and used as a perforator flap to reconstruct a new defect, has proven to be versatile and reliable. When indicated, it is an alternative donor site for further reconstruction of soft-tissue defects.

The Differential Use of Bilobed and Trilobed Transposition Flaps in Cutaneous Nasal Reconstructive Surgery.

PubMed

Knackstedt, Thomas; Lee, Kachiu; Jellinek, Nathaniel J

2018-05-22

Bilobed and trilobed transposition flaps are versatile random pattern transposition flaps which reliably restore nasal symmetry, topography, light reflex, contour and are frequently used in cutaneous nasal reconstructive surgery. We wish to compare the characteristics of bilobed and trilobed flaps in cutaneous reconstructive surgery and to identify scenarios for their differential use. A retrospective chart review over 7 years of consecutive patients reconstructed with a bilobed or trilobed flap after Mohs micrographic surgery was performed. Statistical analysis of patient and surgery characteristics, anatomic distribution, postprocedural events and need for revisions after both flap types was conducted. One hundred eleven patients with bilobed flaps and 74 patients with trilobed flaps were identified. Bilobed flaps are significantly more frequently used on the inferior nasal dorsum and on the sidewall whereas trilobed flaps are significantly more frequently used on the nasal tip and infratip. No significant difference in postprocedural events (complications, erythema, trapdoor, etc) was noted between the two flap types. Bilobed and trilobed transposition flaps are versatile repairs for nasal reconstruction. Trilobed flaps may be used to repair defects in a more distal nasal location than bilobed flaps. Regardless of flap type, complications are rare.

Safety of Microsurgery Under Loupes Versus Microscope: A Head-to-Head Comparison of 2 Surgeons With Similar Experiences.

PubMed

Ehanire, Tosan; Singhal, Dhruv; Mast, Bruce; Leyngold, Mark

2018-01-24

Microsurgery is performed using either the operating microscope or loupe magnification. Use of the operating microscope is considered the "criterion standard"; however, loupes are emerging as a safe and reliable technique to perform microsurgery. The purpose of this study was to analyze the safety of microsurgery under loupe magnification compared with the microscope. Previous studies discussing the safety of loupe magnification during microsurgery have been published; however, this is the first study to compare free flap outcomes from 2 surgeons at the same institution, each using their respective technique. The outcomes were compared by retrospective chart review of 116 patients, and 148 microvascular free tissue transfers were performed between January 1, 2013, and July 15, 2016, by 2 surgeons (D.S.) and (M.L.). Patients' demographics, free flap failure rate, and other surgical complications were analyzed. Statistical significance was determined by unpaired t test, and χ analysis was used to determine statistical significance in proportions between groups. Thirty-eight percent of flaps were performed under ×3.5 loupe magnification and 62% under the operating microscope. Most free flaps used were deep inferior epigastric perforator or muscle sparing transverse rectus abdominis flaps (52%) for breast reconstruction, remainder of free flaps included ALT, radial forearm, and latissimus dorsi for a variety of reconstructive applications. There was no significant difference between the loupes and microscope groups in intraoperative anastomotic revision rate (27% vs 17%), postoperative arterial or venous thrombosis (4.4% vs 2.6%, 5.4% vs 2.2%), flap loss (3.6% vs 2.2%), or median length of stay (6 days vs 6.5 days). The loupe magnification group had statistically significant shorter setup time (20 minutes, P < 0.01). Consistent with previously reported studies, we found no statistical difference in free flap outcomes and safety under loupe magnification compared with the operating microscope. This is the first study to demonstrate these findings with 2 microsurgeons both in their first 3 years in practice, with similar training and experience, operating at the same institution and given the same resources, each using either microscopes or loupes for microsurgery.

The application of multilobed flap designs for anatomic and functional oropharyngeal reconstructions.

PubMed

Choi, Jong Woo; Lee, Min Young; Oh, Tae Suk

2013-11-01

The oropharynx has a variety of functions, such as mastication, deglutition, articulation, taste, and airway protection. Because of its many roles, recent goals in head and neck reconstruction have focused on anatomic and functional reconstructions to minimize functional deficits. Since chemoradiation has earned a good reputation in the management of head and neck cancer, the manifestation of oropharyngeal defects has changed. Although we could not control the anatomic defects that were known to be related to the oropharyngeal functions, we hypothesized that optimizing the flap designs would be helpful for minimizing the functional deficits.Two hundred fifty cases of the head and neck reconstruction using free flaps were carried out between March 2006 and December 2010, where modified flap designs were applied. Among these, 37 tongue and 15 tonsillar reconstructions were analyzed for functional outcomes. The patients were of Asian ethnic background, and the average age was 52 years, including 38 males and 17 females. The average follow-up period was 20.5 months. Based on previous studies, the flap designs were categorized into type I, unilobe; type II, bilobe; type III, trilobe; type IV, quadrilobe; type V, additional lobe for lateral and posterior pharyngeal wall; and type VI, additional lobe for tongue base. The functional outcomes of both tongue and tonsillar reconstructions were investigated.To quantify the outcome in terms of swallowing and pronunciation, we analyzed the patients' function based on the 7-scale parameter. In terms of swallowing, the tongue reconstruction group scored 5.70 on average, whereas the tonsillar reconstruction group showed an average score of 4.53. With regard to speech intelligibility, the tongue reconstruction group revealed an average score of 5.67, whereas the tonsillar reconstruction group scored 5.46 on average.Our findings indicate that specification of the flap designs is helpful for minimizing the functional deficits in head and neck reconstructions.

Electrically stimulated free-flap graciloplasty for urinary sphincter reconstruction: a new surgical procedure.

PubMed

van Aalst, V C; Werker, P M; Stremel, R W; Perez Abadia, G A; Petty, G D; Heilman, S J; Palacio, M M; Kon, M; Tobin, G R; Barker, J H

1998-07-01

In electrically stimulated (dynamic) graciloplasty for urinary incontinence, the gracilis muscle is transposed into the pelvis, and the distal part is used to reconstruct a neosphincter. Clinical outcomes using this technique have been disappointing due to stricture of the urethra caused by ischemia in the distal part of the gracilis and limited gracilis length available for neosphincter construction. Furthermore, the urethra is twisted by the contracting gracilis, rather than circumferentially squeezed. The purpose of the present study was to test the anatomical and functional feasibility of a new surgical approach to reconstruct a urinary sphincter, using the gracilis muscle as a free flap. In 12 human cadavers, the anatomical feasibility for creating a neosphincter by using the gracilis free flap was determined. In all cases, transfer of the gracilis muscle into the pelvis as a free flap (with the nerve intact) was feasible, and ample muscle was available to construct a neosphincter around the bladder neck. Gracilis neosphincter function was studied in seven dogs. The left gracilis muscle was subjected to transfer into the pelvis as an innervated free flap to create a neosphincter around the urethra. The right (control) gracilis muscle was lifted as a single pedicle flap, remained in situ, and was wrapped around a stent to mimic the urethra. Function (expressed as peak pressure generation and fatigue rate) and surface perfusion were determined for all gracilis muscles. In each dog, both sides were compared using the paired Student's t test for statistical analysis, and no significant difference was measured for the two groups. In conclusion, an innervated gracilis free flap can be used to create a neosphincter around the bladder neck. In an acute study in dogs, function and perfusion of the innervated gracilis free flap are not compromised.

Extended experience and modifications in the design and concepts of the keystone design island flap.

PubMed

Moncrieff, Marc D; Thompson, John F; Stretch, Jonathan R

2010-08-01

This paper describes modifications to the design of the keystone design island flap for the reconstruction of oncological defects. In particular, the paper outlines a spectrum of modifications to the design that permit the design to be tailored to a broad range of reconstructive needs, factoring in the anatomical location of the soft tissue defect and the quality of the integument in that locality. The biomechanics of the flap are also discussed in detail. Copyright 2009. Published by Elsevier Ltd.

Advances in imaging technologies for planning breast reconstruction

PubMed Central

Mohan, Anita T.

2016-01-01

The role and choice of preoperative imaging for planning in breast reconstruction is still a disputed topic in the reconstructive community, with varying opinion on the necessity, the ideal imaging modality, costs and impact on patient outcomes. Since the advent of perforator flaps their use in microsurgical breast reconstruction has grown. Perforator based flaps afford lower donor morbidity by sparing the underlying muscle provide durable results, superior cosmesis to create a natural looking new breast, and are preferred in the context of radiation therapy. However these surgeries are complex; more technically challenging that implant based reconstruction, and leaves little room for error. The role of imaging in breast reconstruction can assist the surgeon in exploring or confirming flap choices based on donor site characteristics and presence of suitable perforators. Vascular anatomical studies in the lab have provided the surgeon a foundation of knowledge on location and vascular territories of individual perforators to improve our understanding for flap design and safe flap harvest. The creation of a presurgical map in patients can highlight any abnormal or individual anatomical variance to optimize flap design, intraoperative decision-making and execution of flap harvest with greater predictability and efficiency. This article highlights the role and techniques for preoperative planning using the newer technologies that have been adopted in reconstructive clinical practice: computed tomographic angiography (CTA), magnetic resonance angiography (MRA), laser-assisted indocyanine green fluorescence angiography (LA-ICGFA) and dynamic infrared thermography (DIRT). The primary focus of this paper is on the application of CTA and MRA imaging modalities. PMID:27047790

Use of the omentum in chest-wall reconstruction

DOE Office of Scientific and Technical Information (OSTI.GOV)

Fix, R.J.; Vasconez, L.O.

1989-10-01

Increased use of the omentum in chest-wall reconstruction has paralleled the refinement of anatomic knowledge and the development of safe mobilization techniques. Important anatomic points are the omental attachments to surrounding structures, the major blood supply from the left and right gastroepiploic vessels, and the collateral circulation via the gastroepiploic arch and Barkow's marginal artery. Mobilization of the omentum to the thorax involves division of its attachments to the transverse colon and separation from the greater curvature to fabricate a bipedicled flap. Most anterior chest wounds and virtually all mediastinal wounds can be covered with the omentum based on bothmore » sets of gastroepiploic vessels. The arc of transposition is increased when the omentum is based on a single pedicle, allowing coverage of virtually all chest-wall defects. The final method of increasing flap length involves division of the gastroepiploic arch and reliance on Barkow's marginal artery as collateral circulation to maintain flap viability. With regard to chest-wall reconstruction, we have included the omentum in the armamentarium of flaps used to cover mediastinal wounds. The omentum is our flap of choice for the reconstruction of most radiation injuries of the chest wall. The omentum may also be used to provide protection to visceral anastomoses, vascular conduits, and damaged structures in the chest, as well as to cover defects secondary to tumor excision or trauma. In brief, the omentum has proved to be a most dependable and versatile flap, particularly applicable to chest-wall reconstruction.« less

Three-step orbitofacial reconstruction after extended total maxillectomy using free RAM flap and expanded cervicofacial flap with cartilage grafts.

PubMed

Kajikawa, Akiyoshi; Ueda, Kazuki; Katsuragi, Yoko; Hirose, Taro; Asai, Emiko

2010-10-01

Facial defect after an extended total maxillectomy is one of the most difficult deformities to reconstruct aesthetically, because the defect is not only large but also three-dimensional. Although free-flap reconstruction is useful, the patchwork-like scar, bad colour match and poor texture match are major problems. The contracture and displacement of the reconstructed eyelids and eye socket are also serious matters. To resolve these problems, we have performed a three-step reconstruction using a free rectus abdominis myocutaneous (RAM) flap and an expanded cervicofacial flap with cartilage grafts. In the first step, a free RAM flap was transplanted to the defect after extended total maxillectomy. In the second step, tissue expanders were placed under the skin of the cheek and neck a year after the RAM flap transplantation. After expansion of the cheek and neck skin, the third step was performed. The inferior part of the external skin island of the RAM flap was raised and sutured to the superior margin of the skin island to create a pouch for the eye socket. Costal cartilage was grafted to reconstruct the orbital floor and malar prominence, and auricular cartilage was grafted to reconstruct the tarsal plates. Finally, the expanded cervicofacial flap was rotated to cover this construct. Two weeks after reconstruction, the neo-eyelids were divided to form the lid fissure. We performed the three-step reconstruction on six cases after extended total maxillectomy. In all cases, a deep and stable eye socket was reconstructed. The reconstructed eyelids and cheek were natural in appearance with good colour and texture match without conspicuous scars. To obtain symmetry and natural appearance in the orbitomaxillary reconstruction, there are five points that should be formed; the eye socket, the groundwork of the eye socket, the orbital floor and malar prominence, the tarsal plates and the surface of the eyelids and cheek. We do not reconstruct the palate to set prosthetic dentures and to clean the surface of the skin island in the nasal cavity. To reconstruct the indispensable five points and achieve satisfying results, we propose this three-step reconstruction. Copyright 2009 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

The Type of Breast Reconstruction May Not Influence Patient Satisfaction in the Chinese Population: A Single Institutional Experience

PubMed Central

Chen, Jiaying; Chen, Ying; Hu, Zhen; Liu, Guangyu; Shen, Zhenzhou; Shao, Zhimin; Wu, Jiong

2015-01-01

Background The goal of this study was to evaluate patient satisfaction with four common types of breast reconstruction performed at our institution: latissimus dorsi myocutaneous (LDM) flap reconstruction with or without implants, pedicled transverse rectus abdominis musculocutaneous (TRAM) flap reconstruction, and free deep inferior epigastric perforator (DIEP) flap reconstruction. Methods A custom survey consisting of questions that assessed general and aesthetic satisfaction was sent to patients who had undergone breast reconstruction in the last 5 years. The clinical data and details of the surgery were also collected from the patients who returned the surveys. We compared satisfaction rates across the four breast reconstruction types and analyzed the effects of various factors on overall general and aesthetic satisfaction rates using a binary logistic regression model. Result A total of 207 (72%) patients completed the questionnaires. Overall, significant differences in general and aesthetic satisfaction among the four procedures were not observed. A multivariate analysis revealed that the factor “complications” (p = 0.001) played a significant role in general satisfaction and that the factors “> 2 years since reconstruction” (p = 0.043) and “age > 35 years” (p = 0.05) played significant roles in overall aesthetic satisfaction. Conclusion The present study demonstrated that the type of breast reconstruction might not influence satisfaction in Chinese patients. PMID:26562294

Outcomes in head and neck reconstruction by surgical site and donor site.

PubMed

Frederick, John W; Sweeny, Larissa; Carroll, William R; Peters, Glenn E; Rosenthal, Eben L

2013-07-01

Define surgical outcomes of specific donor sites for free tissue transfer in head and neck reconstruction. Retrospective cohort review at an academic tertiary care center. A review was made of free tissue transfer procedures performed at a university-based tertiary care facility from October 2004 to April 2011. A total of 1,051 patients underwent six types of free flaps: fasciocutaneous radial forearm (53%), osteocutaneous radial forearm (16%), rectus abdominis (11%), fibula (10%), anterior lateral thigh (7%), and latissimus dorsi (2%). Demographic data were collected, and outcomes measured were: length of hospital stay, flap viability, and major complications (infection, fistula, and hematoma). Of the 1,051 flaps performed, the most common operative site was oral cavity (40%, n = 414) followed by hypopharynx/larynx (22%, n = 234), cutaneous (20%, n = 206), oropharynx (9%, n = 98), midface (7%, n = 76), and skull base (2%, n = 23). The median hospital stay was 7.9 days (range, 1-76), and the overall failure rate was 2.8%. Cutaneous defects required the shortest length of hospitalization (5.8 days, P < .0001), a low free flap failure rate (1.5%, n = 3), and limited major complications (6%, n = 12). Conversely, oropharynx defects were associated with the longest hospitalization (8.9 days). Midface defects had a high incidence of complications (15%, n = 11, P = .10). Defects above the angle of the mandible had higher overall complications when compared to below. Similarly, reconstruction for primary or recurrent cancer had a total failure rate of 2.5%, whereas secondary reconstruction and radionecrosis had a failure rate of 4.0% (P = .29). Additionally, there was no statistical difference between outcomes based on donor site. This review demonstrates that certain subsets of patients are at higher risk for complications after free tissue transfer. Patients undergoing free flap reconstruction for cutaneous defects have substantially shorter hospital stays and are at lower risk of flap complications, whereas reconstruction for radionecrosis and secondary reconstruction tend to have higher overall flap failure rates. Copyright © 2013 The American Laryngological, Rhinological and Otological Society, Inc.

Surgical management of cosmetic mucogingival defects.

PubMed

Dym, Harry; Tagliareni, Jonathan M

2012-01-01

Mucogingival conditions are deviations from the normal anatomic relationship between the gingival margin and the mucogingival junction. Mucogingival surgery is plastic surgery designed to correct defects in the gingiva surrounding the teeth. Common mucogingival conditions are recession, absence, or reduction of keratinized tissue, and probing depths extending beyond the mucogingival junction. Surgical techniques used to augment cosmetic mucogingival defects include the free gingival autograft, the subepithelial connective tissue graft, rotational flaps, lateral sliding flaps, coronally repositioned flaps, and the use of acellular dermal matrix grafts. Copyright © 2012 Elsevier Inc. All rights reserved.

Magnetic resonance angiography in perforator flap breast reconstruction

PubMed Central

Levine, Joshua L.

2016-01-01

Magnetic resonance angiography (MRA) is an extremely useful preoperative imaging test for evaluation of the vasculature of donor tissue to be used in autologous breast reconstruction. MRA has sufficient spacial resolution to reliably visualize 1 mm perforating vessels and to accurately locate vessels in reference to a patient’s anatomic landmarks without exposing patients to ionizing radiation or iodinated contrast. The use of a blood pool contrast agent and the lack of radiation exposure allow multiple studies of multiple anatomic regions in one examination. The following article is a detailed description of our MRA protocol developed with our radiologists with examples that illustrate the utility of MRA in perforator flap breast reconstruction. PMID:27047787

The clinical application of anterolateral thigh flap.

PubMed

Lee, Yao-Chou; Chiu, Haw-Yen; Shieh, Shyh-Jou

2011-01-01

The anterolateral thigh flap can provide a large skin paddle nourished by a long and large-caliber pedicle and can be harvested by two-team work. Most importantly, the donor-site morbidity is minimal. However, the anatomic variations decreased its popularity. By adapting free-style flap concepts, such as preoperative mapping of the perforators and being familiar with retrograde perforator dissection, this disadvantage had been overcome gradually. Furthermore, several modifications widen its clinical applications: the fascia lata can be included for sling or tendon reconstruction, the bulkiness could be created by including vastus lateralis muscle or deepithelization of skin flap, the pliability could be increased by suprafascial dissection or primary thinning, the pedicle length could be lengthening by proximally eccentric placement of the perforator, and so forth. Combined with these technical and conceptual advancements, the anterolateral thigh flap has become the workhorse flap for soft-tissue reconstructions from head to toe.

The Clinical Application of Anterolateral Thigh Flap

PubMed Central

Lee, Yao-Chou; Chiu, Haw-Yen; Shieh, Shyh-Jou

2011-01-01

The anterolateral thigh flap can provide a large skin paddle nourished by a long and large-caliber pedicle and can be harvested by two-team work. Most importantly, the donor-site morbidity is minimal. However, the anatomic variations decreased its popularity. By adapting free-style flap concepts, such as preoperative mapping of the perforators and being familiar with retrograde perforator dissection, this disadvantage had been overcome gradually. Furthermore, several modifications widen its clinical applications: the fascia lata can be included for sling or tendon reconstruction, the bulkiness could be created by including vastus lateralis muscle or deepithelization of skin flap, the pliability could be increased by suprafascial dissection or primary thinning, the pedicle length could be lengthening by proximally eccentric placement of the perforator, and so forth. Combined with these technical and conceptual advancements, the anterolateral thigh flap has become the workhorse flap for soft-tissue reconstructions from head to toe. PMID:22567234

[Free vascularized popliteal artery cutaneous branch flap for repair of wound on foot and ankle].

PubMed

Shen, Lilin; Song, Suping; Lin, Cuixia; Li, Wenlong; Sun, Xuesheng; Zhu, Tao; Li, Qiang

2014-01-01

To investigate the feasibility and effectiveness of free popi iteal artery cutaneous branch flap anastomosed with lateral tarsal artery and vein for the repair of wound on the foot and ankle by anatomical observation and clinical application. Latex was poured into the blood vessels of 8 cadavers, then perforator vessel of posterolateral upper calf was dissected, and the popl iteal artery cutaneous branch flap was designed with a pedicle of 2.5 cm in length; the lateral tarsal artery of the foot was dissected, could be freed to 6 cm in length; the diameter of these vessels was measured, and the number of the accompanying veins was counted. Between March 2010 and January 2013, 13 cases of foot and ankle wounds were repaired with popliteal artery cutaneous branch flap anastomosed with lateral tarsal artery and vein. The size of flaps ranged from 6.0 cm x 4.0 cm to 7.5 cm x 5.5 cm. There were 11 males and 2 females, aged from 41 to 65 years (mean, 47.3 years). The causes of injury included traffic accident in 8 cases, crushing in 4 cases, and twist by machine in 1 case. The size of wounds, ranged from 5.0 cm x 3.5 cm to 7.0 cm x 5.0 cm. The donor sites were sutured directly. According to anatomical observation, the popliteal artery cutaneous branch flap was designed by using the lateral popliteal artery perforator for shaft. The vessel of the pedicle perforator flaps from the popliteal artery cutaneous branch flap matched well with the lateral tarsal artery. vascular crisis occurred in 2 flaps, which survived after symptomatic treatment; the other flaps survived, with primary healing of wound and incision at donor site. The patients were all followed up 5-18 months (mean, 11 months). The flap had normal color and good elasticity. Second stage operation was performed to make the flap thinner in 3 female patients because of bulky flaps. The remaining patients had no obvious fat flap. According to American Orthopaedic Foot and Ankle Society (AOFAS) score for evaluation of the ankle function at 6 months after operation, the results were excellent in 7 cases, good in 5 cases, and fair in 1 case, with an excellent and good rate of 92.3%. Free popliteal artery cutaneous branch flap anastomosed with lateral tarsal artery and vein for the repair of wound on the foot and ankle is simple and effective. The donor site is hidden.

Comparison of Hand-Sewn versus Coupled Venous Anastomoses in Traumatic Lower Extremity Reconstruction.

PubMed

Stranix, John T; Rifkin, William J; Lee, Z-Hye; Anzai, Lavinia; Jacoby, Adam; Ceradini, Daniel J; Thanik, Vishal; Saadeh, Pierre B; Levine, Jamie P

2018-06-15

 Microvascular reconstruction of the lower extremity has the highest reported complication and flap failure rates of any anatomical region. Despite widespread adoption of the mechanical anastomotic venous coupler and encouraging results in other anatomical regions, there are limited reports examining its use in the lower extremity. This study compares outcomes between coupled and hand-sewn venous anastomoses in traumatic lower extremity reconstruction.  Retrospective review of our institutional flap registry from 1979 to 2016 identified soft tissue free flaps performed for the reconstruction of Gustilo type IIIB/IIIC open tibial fractures. Patient demographics, flap characteristics, use of a venous anastomotic coupler, and perioperative outcomes were examined. Analysis was performed using chi-square and Student's t -tests.  A total of 361 patients received a microvascular free flap for coverage of a Gustilo type IIIB or IIIC tibial fracture following traumatic injury. After excluding cases that lacked adequate information on coupler use, 358 free flaps were included in the study. There were 72 (20%) free flaps performed using a venous coupler and 286 (80%) performed with hand-sewn venous anastomoses. There were comparable rates of major complications (22.2 vs. 26.1%; p  = 0.522), total flap failure (6.5%, vs. 10.2%; p  = 0.362), and partial flap failure (9.7 vs. 12.2%; p  = 0.579) between venous coupler and hand-sewn anastomoses, respectively. Furthermore, use of the venous coupler was not associated with increased rates of operative take backs (22.8 vs. 23.0%; p  = 0.974). However, reconstructions performed using a venous coupler were significantly more likely to have a second venous anastomosis performed (37.5 vs. 21.3%; p  = 0.004).  Complication and flap failure rates were similar between reconstructions performed with a venous coupler and those performed with hand-sewn venous anastomoses. These findings suggest that use of the venous anastomotic coupler is safe and effective in lower extremity reconstruction, with comparable outcomes to conventional sutured anastomoses. Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

[Free gracilis muscle flap with plantar intermediate thickness skin graft: case report, review of anatomy and functional reconstruction of the palm].

PubMed

Engelhardt, T O; Rieger, U M; Baltaci, M; Pierer, G; Schwabegger, A H

2011-08-01

Skin and soft-tissue architecture of the palm are unique. Coverage of extensive soft-tissue defects restoring the functional capacity of the palm remains a challenging task. Anatomic restoration with skin from another area is hardly possible. In manual labourers, reconstruction of mechanical soft-tissue stability is required in addition to sensation, range of motion and grip strength. Sensate fasciocutaneous flaps bear disadvantages of tissue mobility, shifting and bulkiness. Published criteria for defect-related flap selection are sparse. Defect analysis (anatomy, units of tactile gnosis, individual parameters) provides information to weigh needs for sensation or tissue stability, influencing selection of most appropriate procedures. We distinguished 4 units: hypothenar (H), thenar (T) and central palm (Z). (Z) consists of a central palmar unit (c') and the distal palm (d'). Individual parameters (age, profession, dominant hand, psychosocial aspects) were also considered. Units (T) and (H), regions of secondary touch, demand protective sensation by applying sensate fasciocutaneous flaps. In labourers tactile gnosis in (Z) is of less, tissue stability of greater value. An extensive palmar defect (9×13 cm, affecting unit (Z), partially affecting units (T) and (H), of the dominant hand) with combined vessel, nerve, tendon injuries (male labourer, 21 years) was covered after defect analysis with a free gracilis muscle flap and a glabrous intermediate (0.5 mm) thickness skin graft from the instep region. 29 months postoperatively anatomic conditions of palmar soft tissue (Vancouver scar scale: 1), high mechanical soft-tissue stability including normal hand function were evident. Semmes Weinstein testing showed positive pressure sensation. Professional reintegration after 5 months was possible. Defect coverage of the palm must not consist of merely providing sensate vascularised tissue. The most appropriate procedure can be derived from careful defect analysis focusing on the affection of units of tactile gnosis to achieve near to anatomic reconstruction. In labourers, patient- and defect-related demands need close correlation with the value of the selected flaps regarding the sensation and mechanical stability to be expected. In selected cases (mechanical irritation, affection of unit (Z), younger age) by combining microvascular muscle flaps with plantar intermediate thickness skin grafts promising functional results with early professional reintegration can be achieved by reconstructing like with like. © Georg Thieme Verlag KG Stuttgart · New York.

Vascular anatomy of the medial sural artery perforator flap: a new classification system of intra-muscular branching patterns.

PubMed

Dusseldorp, Joseph R; Pham, Quy J; Ngo, Quan; Gianoutsos, Mark; Moradi, Pouria

2014-09-01

The medial sural artery perforator (MSAP) flap is a versatile fasciocutaneous flap. The main difficulty encountered when raising the MSAP flap is in obtaining adequate pedicle length during intra-muscular dissection. The objective of this study was to determine the pattern of intra-muscular course of the MSAP flap pedicle. 14 cadaveric specimens were dissected and CT angiograms of 84 legs were examined. The intra-muscular branching pattern and depths of the medial sural artery branches were analyzed. The number of perforators, position of the dominant perforator and both intra-muscular and total pedicle length were also recorded and compared to existing anatomical data. Three types of arterial branching pattern were identified within the medial gastrocnemius, demonstrating one (31%), two (59%) or three or more (10%) main branches. A dominant perforator from the medial sural artery was present in 92% of anatomical specimens (13/14). Vertically, the location of the perforator from the popliteal crease was on average 13 cm (±2 cm). Transversely, the perforator originated 2.5 cm (±1 cm) from the posterior midline. Using CT angiography it was possible in 10 consecutive patients to identify a more superficial intra-muscular branch and determine the leg with the optimal branching pattern type for flap harvest. This study is the first to describe the variability of the intra-muscular arterial anatomy of the medial head of gastrocnemius muscle. Surgeons utilizing the MSAP flap option should be aware of the possible branching pattern types and consequently the differing perforator distribution and depths of intra-muscular branches. Routine use of pre-operative CT angiogram may help determine which leg has the most favorable branching pattern type and intra-muscular course for flap harvest. Copyright © 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

A propeller flap based on the thoracoacromial artery for reconstruction of a skin defect in the cervical region: a case report.

PubMed

Okada, Mitsuhiro; Ikeda, Mikinori; Uemura, Takuya; Takada, Jun; Nakamura, Hiroaki

2013-05-01

A propeller flap is useful for coverage of an adjacent skin defect without dissection back to source vessels and harvesting muscle tissues. The thoracoacromial artery is one of the vascular pedicles of the flaps for reconstruction in the cervical region. Use of a propeller flap based on the thoracoacromial artery has not previously been reported for reconstruction in the cervical region. We report a case in which a propeller flap based on the thoracoacromial artery was used for skin coverage after tumour resection in the cervical region together with an anatomical investigation. The propeller flap based on the thoracoacromial artery was harvested in the supine position, requiring no change in position after tumour resection. The skin defect was successfully reconstructed using the propeller flap based on the thoracoacromial artery with linear closure of the donor site. The propeller flap based on the thoracoacromial artery offers an alternative for reconstruction in the cervical region. Copyright © 2012 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

Evaluation of dynamic infrared thermography as an alternative to CT angiography for perforator mapping in breast reconstruction: a clinical study.

PubMed

Weum, Sven; Mercer, James B; de Weerd, Louis

2016-07-15

The current gold standard for preoperative perforator mapping in breast reconstruction with a DIEP flap is CT angiography (CTA). Dynamic infrared thermography (DIRT) is an imaging method that does not require ionizing radiation or contrast injection. We evaluated if DIRT could be an alternative to CTA in perforator mapping. Twenty-five patients scheduled for secondary breast reconstruction with a DIEP flap were included. Preoperatively, the lower abdomen was examined with hand-held Doppler, DIRT and CTA. Arterial Doppler sound locations were marked on the skin. DIRT examination involved rewarming of the abdominal skin after a mild cold challenge. The locations of hot spots on DIRT were compared with the arterial Doppler sound locations. The rate and pattern of rewarming of the hot spots were analyzed. Multiplanar CT reconstructions were used to see if hot spots were related to perforators on CTA. All flaps were based on the perforator selected with DIRT and the surgical outcome was analyzed. First appearing hot spots were always associated with arterial Doppler sounds and clearly visible perforators on CTA. The hot spots on DIRT images were always slightly laterally located in relation to the exit points of the associated perforators through the rectus abdominis fascia on CTA. Some periumbilical perforators were not associated with hot spots and showed communication with the superficial inferior epigastric vein on CTA. The selected perforators adequately perfused all flaps. This study confirms that perforators selected with DIRT have arterial Doppler sound, are clearly visible on CTA and provide adequate perfusion for DIEP breast reconstruction. Retrospectively registered at ClinicalTrials.gov with identifier NCT02806518 .

Subacute reconstruction of lower leg and foot defects due to high velocity-high energy injuries caused by gunshots, missiles, and land mines.

PubMed

Celiköz, Bahattin; Sengezer, Mustafa; Işik, Selçuk; Türegün, Murat; Deveci, Mustafa; Duman, Haluk; Acikel, Cengiz; Nişanci, Mustafa; Oztürk, Serdar

2005-01-01

The present study reviews 215 male patients suffering high velocity-high energy injuries of the lower leg or foot caused by war weapons such as missiles, gunshots, and land mines. They were treated in the Department of Plastic and Reconstructive Surgery at Gulhane Military Medical Academy (Ankara, Turkey) between November 1993-January 2001. Severe soft-tissue defects requiring flap coverage and associated open bone fractures that were treated 7-21 days (mean, 9.6 days) after the injury were included in the study. Twenty-three of 226 extremities (10.2%) underwent primary below-knee amputation. The number of debridements prior to definitive treatment was between 1-3 (mean, 1.9). Gustilo type III open tibia fractures accompanied 104 of 126 soft-tissue defects of the lower leg. Sixty-four bone defects accompanied 83 soft-tissue defects of the feet. Eighteen local pedicled muscle flaps and 208 free muscle flaps (latissimus dorsi, rectus abdominis, and gracilis) were used in soft-tissue coverage of 209 defects. Overall, the free muscle flap success rate was 91.3%. Bone defects were restored with 106 bone grafts, 25 free fibula flaps, and 14 distraction osteogenesis procedures. Osseous and soft-tissue defects were reconstructed simultaneously at the first definitive treatment in 94% of cases. The mean follow-up after definitive treatment was 25 (range, 9-47) months. The average full weight-bearing times for lower leg and feet injuries were 8.4 months and 4 months, respectively. Early, aggressive, and serial debridement of osseous and soft tissue, early restoration of bone and soft-tissue defects at the same stage, intensive rehabilitation, and patient education were the key points in the management of high velocity-high energy injuries of the lower leg and foot. copyright 2005 Wiley-Liss, Inc.

Ex Vivo Machine Perfusion in CTA with a Novel Oxygen Carrier System to Enhance Graft Preservation and Immunologic Outcomes

DTIC Science & Technology

2014-10-01

rectus abdominal muscle, autotransplantation, heterotopic, superior epigastric vein, cold ischemia time, immunomodulation, transcriptomics...composite flap (muscle, adipose tissue and skin) from the whole rectus abdominal muscle (RAM). This model was maximized through extensive anatomical...The biopsies included Skin - Subcutaneous Fat – Muscle. (9 tissue samples per each biopsy time point for each flap) The biopsies were taken by punches

In situ monitoring of surgical flap viability using THz imaging (Conference Presentation)

NASA Astrophysics Data System (ADS)

Bajwa, Neha; Sung, Shijun; Grundfest, Warren; Taylor, Zachary

2016-03-01

This paper explores the utility of reflective THz imaging to assess the viability of surgical flaps. Flap surgery is a technique where tissue is harvested from a donor site and moved to a recipient while keeping the blood supply intact. This technique is common in head and neck tumor resection surgery where the reconstruction of complex and sensitive anatomic structures is routine following the resection of large and/or invasive tumors. Successful flap surgery results in tissue that is sufficiently perfused with both blood and extracellular water. If insufficient fluid levels are maintained, the flap tissue becomes necrotic and must be excised immediately to prevent infection developing and spreading to the surrounding areas. The goal of this work is to investigate the hydration of surgical flaps and correlate image features to successful graft outcomes. Advancement flaps were created on the abdomens of rat models. One rat model was labeled control and care was taken to ensure a successful flap outcome. The flap on the second rat was compromised with restricted blood flow and allowed to fail. The flaps of both rats were imaged once a day over the course of a week at which point the compromised flap had begun to show signs of necrosis. Significant differences in tissue water content were observed between rats over the experimental period. The results suggest that THz imaging may enable early assessment of flap viability.

[Preliminary evaluation on seroma prevention and treatment with transposition of tissue flaps and arista hemostatic powder].

PubMed

Zhang, Ruming; Tan, Yiwen; Wang, Heqi

2006-12-01

To investigate and evaluate prevention and treatment of seroma by transposition of tissue flaps and Arista hemostatic powder after regional lymph node resection in patients with malignant tumors. Twelve patients (6 males, 6 females; aged 31-81 years, with metastatic tumors underwent prevention and treatment of seroma with the tissue flaps and Arista hemostatic powder spray after regional lymph node resection. The metastatic tumors involved the axilla in 1 patient with breast carcinoma, the iliac and inguinal regions in 2 patients with carcinomas of the uterine cervix and the rectum, and the inguinal region in 9 patients, including 4 patients with malignant fibrous histiocytoma(3 in the thigh, 1 in the leg), 2 patients with squamous carcinomas in the leg, 1 patient with synovial sarcoma in the knee, 1 patient with epithelioid sarcoma in the leg, and 1 patient with malignant melanoma in the foot. As for the lymph node removal therapy. 1 patient underwent axillary lymph node removal, 2 patients underwent lymph node removal in theiliac and inguinal regions, and 9 patients underwent lymph node removal in the inguinal region. Meanwhile, of the 12 patients, 6 patients underwent transposition of sartorius flaps with Arista hemostatic powder, 3 patients underwent transposition of the rectus abdominis myocutaneous flaps (including 2 patients treated with Arista spray befor the wound closure and 1 patient treated by transposition of local skin flaps with Arista spray used again),and 3 patients underwent only the suturing of the wounds combined with Arista. At the same time, of the 12 patients,only 4 patient underwent the transplantation of artificial blood vessels. The follow-up for 2-10 months after operation revealed that 10 patients, who had received the transposition of tissue flaps and the spray of Arista hemostatic powder, had the first intention of the incision heal with seroma cured. Nine patients were given a preventive use of Arista hemostatic powder and therefore no seroma developed. The combined use of the transposition of tissue flaps and Arista hemostatic powder spray achieved a success rate of 100% in the prevention or treatment of seroma. However, 1 patient developed microcirculation disturbance 24 hours after operation and underwent disarticulation of the hip; 1 patient developed pelvic cavity hydrops and died 10 months after operation. The combined use of transposition of tissue flaps and Arista hemostatic powder spray can effectively prevent or treat seroma after regional lymph node removal in a patient with malignant tumor.

[Treatment of radiation-induced iliofemoral arterial complications with groin radionecrosis].

PubMed

Fichelle, J-M

2017-12-01

Long-term iliofemoral complications induced by radiation include vascular (arterial and venous) lesions, nervous lesions and soft tissue loss that can be cutaneous and subcutaneous and potentially lead to radionecrosis with vessel exposure. We present five cases of groin radionecrosis. There were three men and two women (age 30-73 years). Radiotherapy had been delivered 15 years earlier in three cases, and 2 years earlier in two cases. Symptoms were intermittent claudication (n=1), critical ischemia (n=1), and septic hemorrhage (n=1). Two patients had no vascular symptoms. Four patients underwent scheduled surgery after complete cardiac and cardiovascular evaluation with duplex-Doppler, CT scan and/or intra-arterial angiography. One woman underwent emergency surgery after septic hemorrhage of a previous in situ femoral revascularization fashioned 2 months earlier. Revascularization was achieved with trans-iliac (n=3), trans-muscular (n=1, and in situ (n=1) iliofemoral bypass. A retroperitoneal approach with section of large muscles was used. In three cases, a trans-iliac route was used by perforating the iliac wing with a 8-mm PTFE graft. Proximal anastomosis was done on the abdominal aorta (n=1) and the homolateral common iliac artery (n=2). Distal anastomosis was done on the distal profunda artery and popliteal artery (n=1) and on the distal femoral superficial artery (n=2). In two cases, an iliofemoral bypass was done with a 7-mm PTFE vascular graft. The proximal anastomosis was done on the proximal external iliac artery and the distal anastomosis on the proximal superficial femoral artery. A plastic procedure was performed in four cases. Three patients had a homolateral (n=1) or controlateral (n=2) rectus abdominis flap. In one case, plastic coverage was done with an antebrachial flap (Chinese flap), which has been released at 6 weeks. One patient had post-radiotherapy iliofemoral vascular disease, but there was no vascular exposure, and no plastic coverage was necessary. The postoperative course was uneventful in four cases. The patient treated with an in situ bypass developed septic hemorrhage at day 10, requiring revision. The patient died of multiple organ system failure, with a patent graft and a viable flap. The other four patients had no early or late complications. These patients have been followed annually for clinical examinations and duplex scans, and angio-scans. One patient died of ischemic heart disease. The three other patients are alive with a patent bypass with 11, 8 and 3 years follow-up. One patient had a late occlusion of the bypass treated by thrombectomy after 7 and 10 years. In conclusion, patients with femoral radionecrosis can be treated by an extra-anatomic bypass, with plastic coverage. The trans-iliac is a relatively simple and safe procedure. Copyright © 2017. Published by Elsevier Masson SAS.

Reconstruction of Nasal Cleft Deformities Using Expanded Forehead Flaps: A Case Series.

PubMed

Ramanathan, Manikandhan; Sneha, Pendem; Parameswaran, Ananthnarayanan; Jayakumar, Naveen; Sailer, Hermann F

2014-12-01

Reconstruction of the nasal clefts is a challenging task considering the nasal anatomic complexity and their possible association with craniofacial defects. The reconstruction of these defects needs extensive amounts of soft tissue that warrant the use of forehead flaps. Often presence of cranial defects and low hairline compromise the amount of tissue available for reconstruction warrenting tissue expansion. To evaluate the efficacy of tissue expansion in reconstruction of congenital nasal clefts. 9 patients with congenital nasal clefts involving multiple sub units were taken up for nasal reconstruction with expanded forehead flaps. The average amount of expansion needed was 200 ml. The reconstruction was performed in 3 stages. Expanded forehead flaps proved to be best modality for reconstruction providing the skin cover needed for ala, columella and dorsum with minimal scarring at the donor site. Expansion of the forehead flap is a viable option for multiple sub unit reconstruction in congenital nasal cleft deformities.

DOE Office of Scientific and Technical Information (OSTI.GOV)

Arnold, P.G.; Pairolero, P.C.

In the patient with a radiation ulcer of the chest wall, the first question is whether the lesion contains persistent or recurrent cancer. It is also important to determine whether any other local problems such as mediastinal abscess may interfere with the reconstruction. Whether or not cancer is present, all nonviable tissue must be removed. If cancer is not present, and a partial thickness of the chest remains, the authors prefer transposition of the greater omentum for repair. If cancer is present, the physiologic defect resulting from cancer resection and wound debridement is far more severe, and a muscle ormore » musculocutaneous flap usually is appropriate. The pectoralis major, latissimus dorsi, external oblique, rectus abdominis, and trapezius muscles have been utilized; the authors most often use the pectoralis or latissimus muscles. 27 references.« less

The vascularized groin lymph node flap (VGLN): Anatomical study and flap planning using multi-detector CT scanner. The golden triangle for flap harvesting.

PubMed

Zeltzer, Assaf A; Anzarut, Alexander; Braeckmans, Delphine; Seidenstuecker, Katrin; Hendrickx, Benoit; Van Hedent, Eddy; Hamdi, Moustapha

2017-09-01

A growing number of surgeons perform lymph node transfers for the treatment of lymphedema. When harvesting a vascularized lymph node groin flap (VGLNF) one of the major concerns is the potential risk of iatrogenic lymphedema of the donor-site. This article helps understanding of the lymph node distribution of the groin in order to minimize this risk. Fifty consecutive patients undergoing abdominal mapping by multi-detector CT scanner were included and 100 groins analyzed. The groin was divided in three zones (of which zone II is the safe zone) and lymph nodes were counted and mapped with their distances to anatomic landmarks. Further node units were plotted and counted. The average age was 48 years. A mean number of nodes of 6.5/groin was found. In zone II, which is our zone of interest a mean of 3.1 nodes were counted with a mean size of 7.8 mm. In three patients no nodes were found in zone II. In five patients nodes were seen in zone II but were not sufficient in size or number to be considered a lymph node unit. On average the lymph node unit in zone II was found to be 48.3 mm from the pubic tubercle when projected on a line from the pubic tubercle to the anterior superior iliac spine, 16.0 mm caudal to this line, and 20.4 mm above the groin crease. On average the lymph node unit was a mean of 41.7 mm lateral to the SCIV-SIEV confluence. This study provides increased understanding of the lymphatic anatomy in zone II of the groin flap and suggests a refined technique for designing the VGLNF. As with any flap there is a degree of individual patient variability. However, having information on the most common anatomy and flap design is of great value. © 2017 Wiley Periodicals, Inc.

MRA of the skin: mapping for advanced breast reconstructive surgery.

PubMed

Thimmappa, N D; Vasile, J V; Ahn, C Y; Levine, J L; Prince, M R

2018-02-27

Autologous breast reconstruction using muscle-sparing free flaps are becoming increasingly popular, although microvascular free flap reconstruction has been utilised for autologous breast reconstructions for >20 years. This innovative microsurgical technique involves meticulous dissection of artery-vein bundle (perforators) responsible for perfusion of the subcutaneous fat and skin of the flap; however, due to unpredictable anatomical variations, preoperative imaging of the donor site to select appropriate perforators has become routine. Preoperative imaging also reduces operating time and enhances the surgeon's confidence in choosing the appropriate donor site for harvesting flaps. Although computed tomography angiography has been widely used for preoperative imaging, concerns over excessive exposure to ionising radiation and poor iodinated contrast agent enhancement of the intramuscular perforator course has made magnetic resonance angiography, the first choice imaging modality in our centre. Magnetic resonance angiography with specific post-processing of the images has established itself as a reliable method for mapping tiny perforator vessels. Multiple donor sites can be imaged in a single setting without concern for ionising radiation exposure. This provides anatomical information of more reconstruction donor site options, so that a surgeon can design a flap of tissue centralised around the best perforator, as well as a back-up perforator, and even a back-up flap option located on a different region of the body. This information is especially helpful in patients with a history of scar tissue from previous surgeries, where the primary choice perforator is found to be damaged or unsuitable intraoperatively. In addition, chest magnetic resonance angiography evaluates recipient site blood vessel suitability including vessel diameters, course, and branching patterns. In this article we provide a broad overview of various skin flaps, clinical indications, advantages and disadvantages of each of these flaps, basic imaging technique, along with advanced sequences for visualising tiny arteries in the groin and in the chest. Post-processing techniques, structure of the report and how automation of the reporting system improves workflow is described. We also describe applications of magnetic resonance angiography in postoperative imaging. Copyright © 2018 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.

Anatomical and technical tips for use of the superficial inferior epigastric artery (SIEA) flap in breast reconstructive surgery.

PubMed

Dorafshar, Amir H; Januszyk, Michael; Song, David H

2010-08-01

Techniques for autologous breast reconstruction have evolved to minimize donor-site morbidity and reduce flap-specific complications. When available, the superficial inferior epigastric artery (SIEA) flap represents the optimal method to achieve the former. However, many microsurgeons have been reluctant to adopt this procedure due to technical challenges inherent to the surgery, as well as concerns with the intrinsic capacity of the superficial vessel system to adequately support this flap. This article sets forth a simple approach to the SIEA flap harvest and demonstrates that favorable results may be achieved even for small caliber vessels. A total of 46 patients underwent 53 SIEA breast reconstructions over a 6-year period using a modified approach for pedicle dissection and arterial inclusion criteria solely on the basis of presence of a palpable pulse. Average pedicle length harvested for all SIEA flaps was 6.07 cm; and mean arterial (0.96 mm) and venous (2.27 mm) diameters represent the lowest published values. Three flaps (5.7%) demonstrated fat necrosis or partial flap necrosis, with one (1.9%) complete flap loss. These results compare favorably with those of previous SIEA series employing diameter-based selection criteria, suggesting that the presence of a palpable arterial pulse may be sufficient to permit successful utilization of this flap. (c) Thieme Medical Publishers.

Indocyanine Green Fluorescence for Free-Flap Perfusion Imaging Revisited: Advanced Decision Making by Virtual Perfusion Reality in Visionsense Fusion Imaging Angiography.

PubMed

Bigdeli, Amir Khosrow; Gazyakan, Emre; Schmidt, Volker Juergen; Hernekamp, Frederick Jochen; Harhaus, Leila; Henzler, Thomas; Kremer, Thomas; Kneser, Ulrich; Hirche, Christoph

2016-06-01

Near-infrared indocyanine green video angiography (ICG-NIR-VA) has been introduced for free-flap surgery and may provide intraoperative flap designing as well as postoperative monitoring. Nevertheless, the technique has not been established in clinical routine because of controversy over benefits. Improved technical features of the novel Visionsense ICG-NIR-VA surgery system are promising to revisit the field of application. It features a unique real-time fusion image of simultaneous NIR and white light visualization, with highlighted perfusion, including a color-coded perfusion flow scale for optimized anatomical understanding. In a feasibility study, the Visionsense ICG-NIR-VA system was applied during 10 free-flap surgeries in 8 patients at our center. Indications included anterior lateral thigh (ALT) flap (n = 4), latissimus dorsi muscle flap (n = 1), tensor fascia latae flap (n = 1), and two bilateral deep inferior epigastric artery perforator flaps (n = 4). The system was used intraoperatively and postoperatively to investigate its impact on surgical decision making and to observe perfusion patterns correlated to clinical monitoring. Visionsense ICG-NIR-VA aided assessing free-flap design and perfusion patterns in all cases and correlated with clinical observations. Additional interventions were performed in 2 cases (22%). One venous anastomosis was revised, and 1 flap was redesigned. Indicated by ICG-NIR-VA, 1 ALT flap developed partial flap necrosis (11%). The Visionsense ICG-NIR-VA system allowed a virtual view of flap perfusion anatomy by fusion imaging in real-time. The system improved decision making for flap design and surgical decisions. Clinical and ICG-NIR-VA parameters correlated. Its future implementation may aid in improving outcomes for free-flap surgery, but additional experience is needed to define its final role. © The Author(s) 2015.

Availability of the lateral calcaneal region as a donor site of free flaps.

PubMed

Cho, Seung Woo; Park, Ji Ung; Kwon, Sung Tack

2017-09-01

Various methods have been used for the coverage of soft-tissue defects, such as local and free flaps, as well as perforator flaps performed using even supermicrosurgery. However, the techniques have some limitations regarding flap size and location when used to reconstruct small defects. We introduced the lateral calcaneal region as a donor site for free flaps in order to overcome these disadvantages and presented the results from a series of cases. A retrospective chart review was performed on 10 patients with small soft-tissue defects who underwent reconstruction with a lateral calcaneal free flap between January 2011 and May 2014. The reconstruction was performed on the defects at medial and lateral plantar area, dorsum of the foot, great toes and preauricular area. The size of the flaps ranged from 2.5 × 2.5 cm to 4.5 × 4.5 cm. The flaps exhibited complete survival in five cases. Partial necrosis occurred in three cases, two cases healed with secondary intention, and one case required a skin graft. The donor sites were treated with skin grafts and healed completely, with no complications. Lateral calcaneal free flaps have several advantages, such as anatomically constant pedicles, a pliable and thin texture, and the ability to be used as sensory flaps. They therefore represent an alternative option when conventional local or free flaps are not suitable, especially in cases of small defects. © 2016 Wiley Periodicals, Inc. Microsurgery 37:494-501, 2017. © 2016 Wiley Periodicals, Inc.

Reliable harvest of a dorsal scapular artery perforator flap by augmenting its perfusion.

PubMed

Kim, So-Young; Lee, Kyeong-Tae; Mun, Goo-Hyun

2016-02-01

Despite confirmation of a reliable perforasome in the dorsal scapular artery in an anatomic study, a true perforator flap has not been recommended in previous clinical studies because of concerns regarding insufficient perfusion in the distal region. In this report, we present two cases of reconstruction for occipital defects caused by tumor extirpation using pedicled dorsal scapular artery perforator flaps without a muscle component. To secure the perfusion of the dorsal scapular artery perforator flap, inclusion of an additional perforator was attempted for perfusion augmentation. The second dorsal scapular artery perforator was harvested in one case. In an additional case, the sixth dorsal intercostal artery perforator with a branch that directly connected with the dorsal scapular artery within the trapezius muscle was additionally harvested. The flaps survived without any perfusion-related complications, including tip necrosis, and no donor site morbidities were observed. We suggest that a perfusion augmented dorsal scapular artery perforator flap by harvesting multiple perforators could be a safe and useful alternative for reconstructive surgery of head and neck defects. © 2014 Wiley Periodicals, Inc.

Profunda Femoris Artery Perforator Propeller Flap: A Valid Method to Cover Complicated Ischiatic Pressure Sores.

PubMed

Scalise, Alessandro; Tartaglione, Caterina; Bolletta, Elisa; Pierangeli, Marina; Di Benedetto, Giovanni

2015-08-01

We report the case of a 50-year-old paraplegic man with a complicated grade III/IV ischiatic pressure sore treated with a propeller flap based on the first perforator of the profunda femoris artery. Our aim was to surgically reconstruct an ischiatic pressure sore in a patient with ankylosis using a fasciocutaneous perforator propeller flap obtained from the posterior region of the thigh. Our decision to perform a profunda femoris artery perforator propeller flap reconstruction was mainly due to the anatomical contiguity of the flap with the site of the lesion and the good quality of the skin harvested from the posterior region of the thigh. The use of the perforator fasciocutaneous flap represents a muscle-sparing technique, providing a better long-term result in surgical reconstruction. The choice of the 180-degree propeller flap was due to its ability to provide a good repair of the pressure ulcer and to pass over the ischiatic prominence in the patient in the forced decubitus position. The operatory course did not present any kind of complication. Using this reconstructive treatment, we have obtained complete coverage of the ischiatic pressure sore.

Free sural artery perforator flap: An occasional gift in oral cavity reconstruction.

PubMed

Pease, Natalie L; Davies, Andrew; Townley, William A

2016-07-01

The medial sural artery perforator (MSAP) flap is becoming a popular strategy for reconstructing intraoral defects. We present a case in which no MSAPs were present, however, a perforator-based calf flap was successfully raised on the sural artery and used for tongue reconstruction. A corresponding anatomic study was undertaken to establish if this finding was reproducible. A 58-year-old woman underwent left hemiglossectomy for a squamous cell carcinoma of the tongue. Subsequently, 6 fresh frozen cadaveric limbs were dissected examining the blood supply of the posterior calf skin. The sural artery perforator (SAP) flap successfully reconstructed the defect. Our cadaveric study similarly demonstrated a septocutaneous SAP supplying the posterior calf skin in 1 of 6 limbs. SAPs allow a favorable flap dissection, as opposed to the musculocutaneous course of MSAPs. Our findings provide further evidence of the versatility of the calf donor site. © 2016 Wiley Periodicals, Inc. Head Neck 38: E2454-E2456, 2016. © 2016 Wiley Periodicals, Inc.

Lower trapezius flap for recalcitrant wounds of the posterior skull and spine

DOE Office of Scientific and Technical Information (OSTI.GOV)

Seyfer, A.E.

1988-05-01

The lower trapezius muscle and musculocutaneous flap has been useful in providing a reliable, expeditious closure for compromised defects of the upper spine and dorsal calvarium. It has been successfully employed in 6 patients as a one-stage procedure, all of whom had recalcitrant, postoperative wounds that failed to heal. It provides serviceable tissue that is able to withstand additional radiotherapy and also offers useful palliation without apparent disability. Pertinent anatomical and clinical considerations are discussed.

Streptococcal toxic shock syndrome after breast reconstruction.

PubMed

Agerson, Ashley N; Wilkins, Edwin G

2005-05-01

Streptococcal toxic shock syndrome (STSS) is an increasingly common disease entity but has rarely been described in the plastic surgery literature. We present the first known case of STSS associated with a reconstructive procedure. Two weeks postoperatively from a transverse rectus abdominis musculocutaneous flap for breast reconstruction, our patient presented with flulike symptoms and progressed rapidly to multiorgan failure. Though initially no nidus for infection was evident, the abdominal donor site was surgically debrided and found to contain group A Streptococcus. Following aggressive rehydration and antibiotic therapy, the patient gradually made a full recovery. In this case report, we review the presentation and epidemiology of STSS and compare it to the more common staphylococcal toxic shock syndrome. In addition, we discuss the management and outcomes of STSS, with an emphasis on raising clinical suspicion for this rare but dangerous entity.

Changes in shoulder muscle activity pattern on surface electromyography after breast cancer surgery.

PubMed

Yang, Eun Joo; Kwon, YoungOk

2018-02-01

Alterations in muscle activation and restricted shoulder mobility, which are common in breast cancer patients, have been found to affect upper limb function. The purpose of this study was to determine muscle activity patterns, and to compare the prevalence of abnormal patterns among the type of breast surgery. In total, 274 breast cancer patients were recruited after surgery. Type of breast surgery was divided into mastectomy without reconstruction (Mastectomy), reconstruction with tissue expander/implant (TEI), latissimus dorsi (LD) flap, or transverse rectus abdominis flap (TRAM). Activities of shoulder muscles were measured using surface electromyography. Experimental analysis was conducted using a Gaussian filter smoothing method with regression. Patients demonstrated different patterns of muscle activation, such as normal, lower muscle electrical activity, and tightness. After adjusting for BMI and breast surgery, the odds of lower muscle electrical activity and tightness in the TRAM are 40.2% and 38.4% less than in the Mastectomy only group. The prevalence of abnormal patterns was significantly greater in the ALND than SLNB in all except TRAM. Alterations in muscle activity patterns differed by breast surgery and reconstruction type. For breast cancer patients with ALND, TRAM may be the best choice for maintaining upper limb function. © 2017 Wiley Periodicals, Inc.

Reconstruction of a traumatic plantar foot defect with a novel free flap: The medial triceps brachii free flap.

PubMed

Leclère, Franck Marie; Casoli, Vincent

2015-01-01

Lower extremity defects may account for 14.6% of the approximately 117 million visits to emergency departments in the U. S. in 2007. In this article, we present a reconstruction of a traumatic plantar foot defect with a medial triceps brachii (MTB) free flap. A 53-year-old man sustained an accidental gunshot wound to the right foot. The patient was admitted after the failure of a sural flap procedure performed in another hospital. He presented with a soft-tissue defect with calcaneal exposition and osteomyelitis. The defect was reconstructed with a MTB free flap anastomosed to his dorsalis pedis vessels. Flap raising time was 52 min. There were no intraoperative complications. The total flap surface was 38.5 cm². The pedicle length was 3 cm. The diameters of the artery and vein of the flap pedicle were 1.1 mm and 1.4 mm, respectively. Ischemia time was 28 min. His donor site healed uneventfully without any morbidity, and the scar was well concealed. The flaps survived and there was no partial flap necrosis. A split-thickness skin graft was performed 12 days postoperatively. Two months later, he had a completely healed wound with no contour abnormality. The total follow-up was 24 months. The patient was able to walk normally. MTB free flap appears to be an excellent option for plantar foot defects in patients with preserved vascularization of the foot. Due to the anatomical shape of the flap, the position of its pedicle, and the moldability of the muscle, we predict that the use of the MTB free flap will grow and develop rapidly for reconstruction of ankle and foot defects.

Rotational Flap to Enhance Buccal Gingival Thickness and Implant Emergence Profile in the Esthetic Zone: Two Cases Reports

PubMed Central

AL-Juboori, Mohammed Jasim

2017-01-01

Objective: Many techniques have been developed to enhance the gingival thickness, gingival level and emergence profile around the implant in the esthetic zone. Introduction: In this study, a buccal rotational flap was used to improve the implant site in the esthetic zone and increase gingival tissue thickness. Methods: Two cases involved the use of a rotational flap during second-stage implant surgery, one case involved the use of a temporary crown with a healing abutment, and another case involved the use of a healing abutment. Result: The cases were followed up until the final crown was placed. The implant site was improved in 2 cases; the gingival thickness increased, the gingival level was enhanced and the emergence profile was developed. Conclusion: Many factors affect the results of a rotational flap; some factors are surgical, while others are prosthetic, biological and anatomical. PMID:28839477

[Muscle-sparing latissimus dorsi flap. Vascular anatomy and indications in breast reconstruction].

PubMed

Mojallal, A; Saint-Cyr, M; Wong, C; Veber, M; Braye, F; Rohrich, R

2010-04-01

The muscle-sparing latissimus dorsi flap pedicled on descending branch presents distinct advantages in breast reconstruction, specially when there is a transversely oriented skin paddle, including reduced donor site morbidity, sparing muscle function and greater freedom of orientation of the skin paddle. This study reports the anatomical basis, surgical technique, advantages and complications of this technique. Four clinical cases illustrate surgical indications in breast reconstructive surgery. An anatomical cadaveric study underwent to University of Texas Southwestern Medical Center, Dallas. The goal was performed to determine the location of the bifurcation of the thoracodorsal artery and the course of its descending branch compare to the anterior side of latissimus dorsi muscle. Four clinical cases illustrated indications of muscle-sparing latissimus dorsi flap pedicled on descending branch in breast reconstruction. These cases showed advantages and complications of the technique, and impact on donor site. Fifteen descending branch muscle-sparing latissimus dorsi flaps were harvested. All flaps had a bifurcation of the thoracodorsal artery. The average was located at 5,1cm from posterior axillary side (from 2,1 to 7,5 cm) and average of 2,2 cm from the anterior side of latissimus dorsi muscle (from 1,3 to 3,1cm). To 5, 10 and 15 cm from posterior axillary side, the descending branch was located at respectively an average of 2,0 cm (from 1,4 to 2,5), 2,4 cm (from 1,3 to 3,3), and 2,9 cm (from 2,0 to 3,8) behind the anterior side of latissimus dorsi muscle. The average length of descending branch was measured at 15,2 cm (from 13,2 to 19,0). None clinical cases paddle suffering was observed. Donor site morbidity was less than classical or extended adipomuscular technique. Latissimus dorsi muscle function is spared. The muscle-sparing latissimus dorsi flap, pedicled on descending branch, is versatile and reproducible. It results in minimal functional deficit of the donor site, absence of seroma, large freedom of orientation of the skin paddle, low rate of flap complications, and a cosmetically acceptable scar. There are a lot of indications in breast reconstruction. Copyright 2009 Elsevier Masson SAS. All rights reserved.

The free descending branch muscle-sparing latissimus dorsi flap: vascular anatomy and clinical applications.

PubMed

Colohan, Shannon; Wong, Corrine; Lakhiani, Chrisovalantis; Cheng, Angela; Maia, Munique; Arbique, Gary; Saint-Cyr, Michel

2012-12-01

Increasing focus on reducing morbidity from latissimus dorsi flaps has led to the evolution of muscle-sparing variants and perforator-based flaps. This study aimed to investigate the vascular anatomy of the muscle-sparing variant and to describe its application as a free flap based on the descending branch of the thoracodorsal artery. Twelve fresh cadavers underwent anatomical dissection and angiographic injection studies of the thoracodorsal arterial system. The musculocutaneous territories of the descending and transverse branches to the latissimus dorsi muscle were identified and assessed using three-dimensional reconstruction software of computed tomography imaging results. In the clinical study, five patients underwent reconstruction of a variety of defects using the free descending branch muscle-sparing latissimus dorsi flap. Three- and four-dimensional (computed tomography) angiography demonstrated perfusion of the latissimus dorsi muscle by the transverse and descending branches, with overlap of vascular territories via cross-linking vessels. The descending branch supplied a slightly greater cutaneous area overlying the muscle, although differences between both branches were not significant (p = 0.76). In the clinical study, the free muscle-sparing latissimus dorsi flap provided excellent coverage with no flap complications or seroma. The free muscle-sparing latissimus dorsi flap based on the descending branch of the thoracodorsal artery is a viable reconstructive option. Significant collateral flow between vessels allows for larger flap harvest than would be expected. The flap is technically simple to harvest, provides a large perfusion area, and is a reliable variant of the full latissimus dorsi flap. Therapeutic, V.

The Lateral Proximal Phalanx Flap for Contractures and Soft Tissue Defects in the Proximal Interphalangeal Joint

PubMed Central

Beltrán, Aldo G.; Romero, Camilo J.

2016-01-01

Background: The management of contractures and soft tissue defects in the proximal interphalangeal (PIP) finger joint remains a challenge. We report a transposition flap from the lateral skin of the proximal phalanx that is based on perforating branches of the digital arteries and can be used safely for both palmar and dorsal cover defects. Methods: We first completed an anatomic study, dissecting 20 fingers in fresh cadavers with arterial injections and made the new flap in patients with dorsal or palmar defects in PIP joints. Results: In cadavers, we can reveal 4 constant branches from each digital artery in the proximal phalanx, with the more distal just in the PIP joint constituting the flap pedicle. Between February 2010 and February 2015, we designed 33 flaps in 29 patients, 7 for dorsal and 26 for palmar defects, with no instances of flap necrosis and 4 distal epidermolysis. The patients were between 4 and 69 years with no major complications, and all of the skin defects in the PIP joint were resolved satisfactorily without any relevant sequelae at the donor site. Conclusions: This flap procedure is an easy, reliable, versatile, and safe technique, and could be an important tool for the management of difficult skin defects and contractures at the PIP joint level. PMID:28082850

Clinical utility of colour flow Doppler ultrasonography in planning anterolateral thigh flap harvest.

PubMed

Patel, Rajan S; Higgins, Kevin M; Enepekides, Danny J; Hamilton, Paul A

2010-10-01

The anatomic variability of cutaneous perforators contributes to the technical challenges of anterolateral thigh (ALT) free flap harvest. The objective of this study was to assess the accuracy and clinical utility of preoperative colour flow Doppler (CFD) ultrasonography in evaluating planned ALT flap donor sites. A prospective study of the infrainguinal vasculature (profunda femoris and lateral circumflex femoral arteries) in 16 consecutive patients scheduled for ALT free flap transfer for reconstruction of head and neck surgical defects was undertaken. All patients underwent CFD ultrasonography. The location of perforators and the thigh thickness determined by CFD ultrasonography were correlated with the actual intraoperative findings using a scatter plot and paired t-test. Two patients were diagnosed with bilateral silent infrainguinal claudication, which precluded safe use of the ALT donor site. In two other patients, the planned ALT donor site ipsilateral to the defect was not used because of silent infrainguinal claudication diagnosed by CFD ultrasonography. In the 14 patients who underwent ALT flap harvest, CFD ultrasonography identified 48 perforators, which coincided with 43 actual perforators found intraoperatively. CFD ultrasonography demonstrated a statistically significant correlation with the actual perforator locations (Spearman coefficient .76; p = .55). Although CFD ultrasonography tended to underestimate flap thickness, there was a statistically significant correlation (Spearman coefficient .94; p ≤ .0001) with the actual flap thickness. CFD ultrasonography has clinical utility in facilitating decision making and planning ALT flap harvest.

Design and creation of an experimental program of advanced training in reconstructive microsurgery.

PubMed

Lorenzo, Andrés R; Alvarez, Angel; Garcia-Barreiro, Juan; Centeno, Alberto; Lopez, Eduardo; Martelo, Francisco

2006-01-01

In this study, we design an experimental protocol for the purpose of enhancing performance in training in microsurgery. It is based on five free tissue transfer exercises in rat (epigastric cutaneous flap, saphenous fasciocutaneous flap, epigastric neurovascular flap, saphenous muscular flap, and hindlimb replantation), which simulate the principal clinical procedures of reconstructive microsurgery. The first part of the study consists of an anatomical review of the flaps of 5 rats and in the second part we have carried out the free transfer of flaps on 25 rats divided into 5 groups. To differentiate between them, we have created a mathematical function, referred to as difficulty in a microsurgical exercise, which has enabled us to establish a scale of progression for training, ranging form the easiest to the most difficult. As a conclusion, we believe that this protocol is a useful instrument as it allows for a more precise assessment of microsurgical capacity due to enhanced accuracy in the reproduction of global procedures and the fact that the quantification of progress in training is based on clinical monitoring after 7 days. (c) 2006 Wiley-Liss, Inc. Microsurgery, 2006.

Versatility of the Angularis Oris Axial Pattern Flap for Facial Reconstruction.

PubMed

Losinski, Sara L; Stanley, Bryden J; Schallberger, Sandra P; Nelson, Laura L; Towle Millard, Heather A M

2015-11-01

To describe the versatility of the axial pattern flap based on the cutaneous perforating branch of the angularis oris artery for reconstruction of large facial defects in dogs, including complications and clinical outcomes. Retrospective clinical case series. Client-owned dogs (n = 8). Facial flaps (n = 9) based at the commissure of the lip with a caudodorsal orientation were utilized, with established anatomical borders. Flaps were elevated deep to the panniculus carnosus in a caudal to rostral direction, preserving the angularis oris artery, its cutaneous perforator, and surrounding cutaneous vasculature. Flaps were rotated dorsally or ventrally to cover the defect. Primary closure of the donor site was by direct apposition in all cases. Angularis oris axial pattern flaps were most commonly used to close large defects of the nasomaxillary area rostral to the eyes (6 dogs), followed by orbital (2) and intermandibular (1) defects. Defects occurred because of tumor resection (6 dogs), trauma (2), and a chronic, non-healing wounding (1). All flaps healed with acceptable functional and cosmetic outcomes without major complications. Followup ranged from 10 days to 16 months. Minor postoperative complications included flap edema (8 dogs), partial incisional dehiscence (3), distal tip necrosis (2), and oroantral fistula recurrence (1). Angularis oris axial pattern flaps provided hirsute, full-thickness skin coverage of a variety of large facial defects with minor complications, and should be considered when restructuring large defects of the rostral face or chin. © Copyright 2015 by The American College of Veterinary Surgeons.

[Pedicle flaps based on the sphenopalatine artery: anatomical and surgical study].

PubMed

Gras-Cabrerizo, Juan R; Gras-Albert, Juan R; Monjas-Canovas, Irene; García-Garrigós, Elena; Montserrat-Gili, Joan R; Sánchez del Campo, Francisco; Kolanczak, Katarzyna; Massegur-Solench, Humbert

2014-01-01

Local pedicle flaps based on the sphenopalatine artery make it possible to reconstruct large defects of the skull base (SB). From January 2008 to January 2013, 64 lesions with involvement of SB were analysed. These lesions were treated using endoscopic endonasal approach and required a pedicle flap based on the sphenopalatine artery. In addition, measurements and flexibility of the flaps were examined in 4 cadaveric nasal cavities. Surgical group. Sixty-four nasoseptal flaps (NSF) were used, in 4 cases associated with a middle turbinate flap (MTF), and in 1 case supplemented with an inferior turbinate flap (ITF). Five cerebrospinal fluid fistulas (8%) were noted. Among patients with initial lesions, 7% presented an anosmia. Cadaveric group. The length of the NSF varied between 5.2 cm and 7.7 cm and the width ranged from 3 cm to 4.5 cm. The ITF provided an anterior-posterior distance between 4.2 cm and 5 cm, with a width between 1.2 cm and 2.8 cm. The mean length of MTFs varied between 3.5 cm and 4.2 cm, with a width between 1.4 cm and 1.9 cm. The most versatile local flap for the reconstruction of skull base defects is the NSF, and flaps pedicled to the posterolateral nasal artery offer an excellent alternative. Copyright © 2013 Elsevier España, S.L. y Sociedad Española de Otorrinolaringología y Patología Cérvico-Facial. All rights reserved.

Subcostal Transverse Abdominis Plane Block for Acute Pain Management: A Review.

PubMed

Soliz, Jose M; Lipski, Ian; Hancher-Hodges, Shannon; Speer, Barbra Bryce; Popat, Keyuri

2017-10-01

The subcostal transverse abdominis plane (SCTAP) block is the deposition of local anesthetic in the transverse abdominis plane inferior and parallel to the costal margin. There is a growing consensus that the SCTAP block provides better analgesia for upper abdominal incisions than the traditional transverse abdominis plane block. In addition, when used as part of a four-quadrant transverse abdominis plane block, the SCTAP block may provide adequate analgesia for major abdominal surgery. The purpose of this review is to discuss the SCTAP block, including its indications, technique, local anesthetic solutions, and outcomes.

Lumbar artery perforators: an anatomical study based on computed tomographic angiography imaging.

PubMed

Sommeling, Casper Emile; Colebunders, Britt; Pardon, Heleen E; Stillaert, Filip B; Blondeel, Phillip N; van Landuyt, Koenraad

2017-08-01

The free lumbar artery perforator flap has recently been introduced as a potentially valuable option for autologous breast reconstruction in a subset of patients. Up to date, few anatomical studies, exploring the lumbar region as a donor site for perforator- based flaps, have been conducted. An anatomical study of the position of the dominant lumbar artery perforator was performed, using the preoperative computed tomographic angiography images of 24 autologous breast reconstruction patients. In total, 61 dominant perforators were determined, 28 on the left and 33 on the right side. A radiologist defined the position of the perforator as coordinates in an xy-grid. Dominant perforators were shown to originate from the lumbar arteries at the level of lumbar vertebrae three or four. Remarkably, approximately 85% of these lumbar artery perforators enter the skin at 7-10 cm lateral from the midline (mean left 8.6 cm, right 8.2 cm). This study concludes a rather constant position of the dominant perforator. Therefore, preoperative-computed tomographic angiography is not always essential to find this perforator and Doppler ultrasound could be considered as an alternative, thereby carefully assessing all advantages and disadvantages inherent to either of these imaging methods.

Prevertebral corridor: posterior pathway for reconstruction of the ventral skull base.

PubMed

Durmaz, Abdullah; Fernandez-Miranda, Juan; Snyderman, Carl H; Rivera-Serrano, Carlos; Tosun, Fuat

2011-05-01

Regional vascularized flaps, such as the pericranial and temporoparietal fascia flaps, are currently used for reconstruction of skull base defects after endoscopic endonasal surgery whenever local vascularized flaps, such as the nasoseptal flap, are not available. Two different transposition pathways, infratemporal transpterygoid and subfrontal, have been proposed for regional flaps. The objective of this study was to describe and assess the feasibility of the transposition of a vascularized pedicled flap from the occipital galeopericranium via the prevertebral space corridor into the nasopharynx. Ten heads were injected with colored silicone. An endoscopic endonasal anterior craniofacial resection and panclival approach were performed in each specimen. The occipital flap was harvested using a previously described technique. The prevertebral corridor, extending from the neck to the nasopharynx, was dissected superficial to the paraspinal muscles. Computed tomography-based image guidance was used to assess the relationship between the corridor and adjacent neurovascular structures. Length of the corridor and pedicle and area of the donor flap were measured. The flap was harvested and successfully transposed into the nasopharynx using the proposed corridor in all studied specimens (10 heads, 20 sides). All flaps provided complete coverage of the skull base defects. The average length of the pedicle was 70.5 (SD, 6.5) mm, and the average length and width of the flap were 99.9 (SD, 14.6) mm and 59.3 (SD, 10.9) mm, respectively. The average length of the prevertebral corridor was 49.7 (SD, 4.8) mm. The occipital flap has favorable anatomic characteristics for use in skull base reconstruction. Transposition of the flap via the prevertebral corridor is a suitable option for vascularized reconstruction of expanded endonasal skull base defects when other local or regional flaps are not available. Additional clinical studies are necessary to define its role in endoscopic endonasal surgery.

Double-barrelled wet colostomy formation after pelvic exenteration for locally advanced or recurrent rectal cancer.

PubMed

Bloemendaal, A L A; Kraus, R; Buchs, N C; Hamdy, F C; Hompes, R; Cogswell, L; Guy, R J

2016-11-01

In advanced pelvic cancer it may be necessary to perform a total pelvic exenteration. In such cases urinary tract reconstruction is usually achieved with the creation of an ileal conduit with a urinary stoma on the right side of the patient's abdomen and an end colostomy separately on the left. The potential morbidity from a second stoma may be avoided by the use of a double-barrelled wet colostomy (DBWC), as a single stoma. Another advantage is the possibility of using a vertical rectus abdominis muscle flap for perineal reconstruction. All patients undergoing formation of a DBWC were included. A DBWC was formed in 10 patients. One patient underwent formation of a double-barrelled wet ileostomy. In this technical note we present our early experience in 11 cases and a video of DBWC formation in a male patient. Colorectal Disease © 2016 The Association of Coloproctology of Great Britain and Ireland.

Breast Microsurgery in Plastic Surgery Literature: A 21-Year Analysis of Publication Trends

PubMed Central

Daly, Lauren Tracy; Mowlds, Donald; Brodsky, Merrick A.; Abrouk, Michael; Gandy, Jessica R.; Wirth, Garrett A.

2018-01-01

Introduction Microsurgical reconstruction of the breast represents an area of continual evolution, as new autologous flaps are introduced and principles are refined. This progression can be demonstrated by bibliometric analysis of the scientific literature. Methods The top 10 plastic surgery journals were determined by impact factor (IF). Each issue of every journal from 1993 to 2013 was accessed directly, and all articles discussing microsurgery on the female breast were classified by authors’ geographic location, study design, and level of evidence (LOE, I–V). The productivity index and productivity share of each geographic region was calculated based on number of articles published and IF. Results A total of 706 breast microsurgery articles were analyzed. There was a significant increase in microsurgical breast research (p < 0.01), with an average 33.6 ± 31.1 articles per year and a mean increase of 4.4 articles per year. Most research was of lower LOE, with level I constituting 0.14% and level II constituting 5.21% of all articles. United States contributed the most research with 336.4 articles, followed by Western Europe with 242.2. However, Western Europe experienced the greatest increase in productivity share, with + 0.50 ± 0.29 growth, while United States demonstrated the greatest decrease in productivity share with − 1.23 ± 0.31 growth. Among autologous flaps, transverse rectus abdominis muscle research had the greatest yearly publication volume until 2002, when overtaken by deep inferior epigastric perforator flap research. Conclusion Over the 21-year study period, the United States not only contributed the greatest volume of research on female breast microsurgery but also demonstrated the greatest decline in research productivity. Efforts should be made to increase the LOE in breast microsurgery research. PMID:26645157

[Applied anatomy study and clinical application of great saphenous veno-saphenous neurocutaneous vascular flap].

PubMed

Li, Zelong; Ding, Zihai; Wang, Peixin; Xie, Yibo; Zeng, Bo

2006-03-01

To provide the anatomic basis for defect repair of the knee, leg, foot and ankle with great saphenous veno-saphenous neurocutaneous vascular island flaps. The origin, diameter, branches, distribution and anastomoses of the saphenous artery and saphenous neurocutaneous vascular were observed on 20 sides of adult leg specimens and 4 fresh cadaver voluntary legs. Another 4 fresh cadaver voluntary legs were radiographed with a soft X-ray system after the intravenous injection of Vermilion and cross-sections under profound fascial, other hand, micro-anatomic examination was also performed in these 4 fresh cadaver legs. The soft tissue defects in lower extremity, upper extremity, heel or Hucou in hand were repaired with the proximal or distal pedicle flaps or free flaps in 18 patients (12 males and 6 females,aging from 7 to 53 years). The defect was caused by trauma, tumour, ulcer and scar. The locations were Hucou (1 case), upper leg (3 cases), lower extremity and heal (14 cases). Of then, 7 cases were complicated by bone exposure, 3 cases by tendon exposure and 1 case by steel espouse, the defect size were 4 cm x 4 cm to 7 cm x 13 cm. The flap sizes were 4 cm x 6 cm to 8 cm x 15 cm, which pedicle length was 8-11 cm with 2.5-4.0 cm fascia and 1-2 cm skin at width. Genus descending genicular artery began from 9.33 +/- 0.81 cm away from upper the condyles medialis, it branched saphenous artery accompanying saphenous nerve descendent. And saphenous artery reached the surface of the skin 7.21 +/- 0.82 cm away from lower the condyles medialis, and anastomosed with the branches of tibialis posterior artery, like "Y" or "T" pattern. The chain linking system of arteries were found accompanying along the great saphenous vein as saphenous nerve, and then a axis blood vessel was formed. The small artery of only 0.05-0.10 mm in diameter, distributed around the great saphenous vein within 5-8 mm and arranged parallelly along the vein like water wave in soft X-ray film. All proximal flaps, distal pedicle flaps and free flaps survived well. The appearance, sensation and function were satisfactory in 14 patients after a follow-up of 6-12 months. The great saphenous vein as well as saphenous neurocutaneous has a chain linking system vascular net. A flap with the vascular net can be transplanted by free, by reversed pedicle, or by direct pedicle to repair the wound of upper leg and foot. A superficial vein-superficial neurocutaneous vascular flap with abundance blood supply and without sacrificing a main artery is a favourite method in repair of soft tissue defects in foot and lower extremity.

A novel lobule rotation flap for the reconstruction of middle third auricular defects.

PubMed

Basu, Indraneil; Way, Benjamin; Al-Basri, Isam

2013-12-01

There are numerous techniques for the reconstruction of cutaneous defects of the pinna. Many of these distort the auricle, and several are challenging and time-consuming to perform. An illustrative case is presented to demonstrate a novel lobule rotational flap, which can be used to cover cutaneous defects of the middle third of the pinna. Postoperative photography illustrates that this simple one-stage technique causes minimal anatomical distortion and allows the final scar to be concealed within the inner helical rim. Small local flaps can be raised from the lobule to cover challenging defects of the middle third of the pinna. In selected patients, with abundant lobular tissue, this technique can be as effective as more complex reconstructive options. © 2013 The International Society of Dermatology.

[Discussion on the location of acupoints of the spleen meridian of foot-Taiyin in the abdominal region].

PubMed

Sui, Ming-He; Ma, Hui-Fang; Wang, Chao-Yang

2010-10-01

The four acupoints Fushe (SP 13), Fujie (SP 14), Daheng (SP 15) and Fuai (SP 16) (except SP 12 ) of the Spleen Meridian of Foot-Taiyin in the abdomen are all 4 cun lateral to the abdominal midline. The origin of "4-cun" distance and the related explanations have not been found in any books including textbooks and related Chinese national standards about acupuncture and moxibustion. In the graphical representations, these 4 acupoints are directly below the nipple, because the nipple is 4 cun from the chest midline. The authors of the present paper don't think that is right, because in locating the acupoint, the nearest body surface anatomical landmarks should be used first as the basis. The abdomen and the chest are two anatomic sites after all, locating the abdominal acupoints with the chest surface landmarks often results in larger deviation, because many people's bodies are not so symmetrical and standard, and the adult abdominal fat difference is very big. Therefore, it is highly recommended that the abdominal acupoints are located by using the abdominal anatomical landmarks, for example, the outer edge of rectus abdominis, the outer edge of abdomen ,etc.

Inter- and Intraspecific Variations in the Pectoral Muscles of Common Chimpanzees (Pan troglodytes), Bonobos (Pan paniscus), and Humans (Homo sapiens).

PubMed

Potau, J M; Arias-Martorell, J; Bello-Hellegouarch, G; Casado, A; Pastor, J F; de Paz, F; Diogo, R

2018-01-01

We have analyzed anatomic variations in the pectoralis major and pectoralis minor muscles of common chimpanzees (Pan troglodytes) and bonobos (Pan paniscus) and compared them to anatomic variations in these muscles in humans (Homo sapiens) . We have macroscopically dissected these muscles in six adult Pan troglodytes , five Pan paniscus of ages ranging from fetus to adult, and five adult Homo sapiens . Although Pan troglodytes are thought to lack a separate pectoralis abdominis muscle, we have identified this muscle in three of the Pan troglodytes ; none of the Pan paniscus , however, had this muscle. We have also found deep supernumerary fascicles in the pectoralis major of two Pan troglodytes and all five Pan paniscus . In all six Pan troglodytes , the pectoralis minor was inserted at the supraspinatus tendon, while, in Pan paniscus and Homo sapiens , it was inserted at the coracoid process of the scapula. Some of the anatomic features and variations of these muscles in common chimpanzees and bonobos are similar to those found in humans, therefore enhancing our knowledge of primate comparative anatomy and evolution and also shedding light on several clinical issues.

Inter- and Intraspecific Variations in the Pectoral Muscles of Common Chimpanzees (Pan troglodytes), Bonobos (Pan paniscus), and Humans (Homo sapiens)

PubMed Central

Arias-Martorell, J.; Bello-Hellegouarch, G.; Casado, A.; Pastor, J. F.; de Paz, F.; Diogo, R.

2018-01-01

We have analyzed anatomic variations in the pectoralis major and pectoralis minor muscles of common chimpanzees (Pan troglodytes) and bonobos (Pan paniscus) and compared them to anatomic variations in these muscles in humans (Homo sapiens). We have macroscopically dissected these muscles in six adult Pan troglodytes, five Pan paniscus of ages ranging from fetus to adult, and five adult Homo sapiens. Although Pan troglodytes are thought to lack a separate pectoralis abdominis muscle, we have identified this muscle in three of the Pan troglodytes; none of the Pan paniscus, however, had this muscle. We have also found deep supernumerary fascicles in the pectoralis major of two Pan troglodytes and all five Pan paniscus. In all six Pan troglodytes, the pectoralis minor was inserted at the supraspinatus tendon, while, in Pan paniscus and Homo sapiens, it was inserted at the coracoid process of the scapula. Some of the anatomic features and variations of these muscles in common chimpanzees and bonobos are similar to those found in humans, therefore enhancing our knowledge of primate comparative anatomy and evolution and also shedding light on several clinical issues. PMID:29581990

Expanded Transposition Flap Technique for Total and Subtotal Resurfacing of the Face and Neck

PubMed Central

Spence, Robert J.

2007-01-01

Background: The reconstruction of major burn and other deformities resulting from significant soft tissue deficits of the face and neck is a continuing challenge for surgeons who wish to reliably restore facial function and aesthetic appearance. A primary problem is deficiency of well-matched donor skin. Other problems include the unique characteristics of facial skin, the fine anatomic nuances, and the unique functional demands placed on the face. This article describes an expanded shoulder transposition flap that can provide a large amount of both flap and full-thickness skin graft for total and subtotal reconstruction of the face. Methods: An expanded shoulder transposition flap has been used since 1986 for head and neck resurfacing 58 times in 41 patients ranging in age from 2 to 62 years. The details of the technique and the results of the flap including complications are described. Results: The flap proved remarkably reliable and reproducible in resurfacing the peripheral facial aesthetic units. The pedicle skin is often used for grafting of the central face with its finer features. The donor site of the flap is closed primarily. Conclusions: Twenty years' experience with expanded transposition flaps has shown it to be reliable and versatile in the reconstruction of major soft tissue deficits of the face and neck. It is a technique that provides economy of tissue, versatility, and is well within the skill, patience, and courage of most reconstructive surgeons. PMID:17534420

Early Reconstruction of Distal Leg and Foot in Acute High-Voltage Electrical Burn: Does Location of Pedicle in the Zone of Injury Affect the Outcome of Distally Based Sural Flap?

PubMed

Asʼadi, Kamran; Salehi, Seyed Hamid; Shoar, Saeed

2017-01-01

Distally based fasciocutaneous sural flap is popular in the reconstruction of distal leg and foot burns. However, utilization of this technique in high-voltage electrical injury has been challenging. The present study aimed to compare the outcome of early aggressive debridement and coverage of contact point of acute high-voltage electrical injury using distally based fasciocutaneous sural flap between high-risk and low-risk patients defined by the anatomic proximity of the flap pedicle to the zone of injury. A total of 51 patients with contact point of high-voltage electrical burn (HVEB) in distal leg and foot undergoing distally based fasciocutaneous sural flap were included in this prospective clinical study. In 28 patients, the flap pedicle was not involved in the contact point of high-voltage electrical injury (low risk/control group), whereas in 21 patients, it was located inside the zone of injury (high-risk/case group). Patients were followed up for a median of 21 months (range, 12-44 months). Wound dimensions to be covered were relatively similar between the 2 groups. Complications of flap survival (primary outcome) and other minor early and late complications (secondary outcome) did not significantly differ between the 2 groups (P > 0.05). Provided that early and completed debridements of contact points of HVEB were achieved, distally based sural flap is feasible and there is reliable coverage in HVEB even in patients with flap pedicle located in vicinity of the zone of injury.

Evolution of transversus abdominis plane infiltration techniques for postsurgical analgesia following abdominal surgeries.

PubMed

Gadsden, Jeffrey; Ayad, Sabry; Gonzales, Jeffrey J; Mehta, Jaideep; Boublik, Jan; Hutchins, Jacob

2015-01-01

Transversus abdominis plane (TAP) infiltration is a regional anesthesia technique that has been demonstrated to be effective for management of postsurgical pain after abdominal surgery. There are several different clinical variations in the approaches used for achieving analgesia via TAP infiltration, and methods for identification of the TAP have evolved considerably since the landmark-guided technique was first described in 2001. There are many factors that impact the analgesic outcomes following TAP infiltration, and the various nuances of this technique have led to debate regarding procedural classification of TAP infiltration. Based on our current understanding of fascial and neuronal anatomy of the anterior abdominal wall, as well as available evidence from studies assessing local anesthetic spread and cutaneous sensory block following TAP infiltration, it is clear that TAP infiltration techniques are appropriately classified as field blocks. While the objective of peripheral nerve block and TAP infiltration are similar in that both approaches block sensory response in order to achieve analgesia, the technical components of the two procedures are different. Unlike peripheral nerve block, which involves identification or stimulation of a specific nerve or nerve plexus, followed by administration of a local anesthetic in close proximity, TAP infiltration involves administration and spread of local anesthetic within an anatomical plane of the surgical site.

Preoperative color Doppler assessment in planning of gluteal perforator flaps.

PubMed

Isken, Tonguc; Alagoz, M Sahin; Onyedi, Murat; Izmirli, Hakki; Isil, Eda; Yurtseven, Nagehan

2009-02-01

Gluteal artery perforator flaps have gained popularity due to reliability, preservation of the muscle, versatility in flap design without restricting other flap options, and low donor-site morbidity in ambulatory patients and possibility of enabling future reconstruction in paraplegic patients. But the inconstant anatomy of the vascular plexus around the gluteal muscle makes it hard to predict how many perforators are present, what their volume of blood flow and size are, where they exit the overlying fascia, and what their course through the muscle will be. Without any prior investigations, the reconstructive surgeon could be surprised intraoperatively by previous surgical damage, scar formation, or anatomic variants.For these reasons, to confirm the presence and the location of gluteal perforators preoperatively we have used color Doppler ultrasonography. With the help of the color Doppler ultrasonography 26 patients, 21 men and 5 women, were operated between the years 2002 and 2007. The mean age of patients was 47.7 (age range: 7-77 years). All perforator vessels were marked preoperatively around the defect locations. The perforator based flap that will allow primary closure of the donor site and the defect without tension was planned choosing the perforator that showed the largest flow in color Doppler ultrasonography proximally. Perforators were found in the sites identified with color Doppler ultrasonography in all other flaps. In our study, 94.4% flap viability was ensured in 36 perforator-based gluteal area flaps. Mean flap elevation time was 31.9 minutes. We found that locating the perforators preoperatively helps to shorten the operation time without compromising a reliable viability of the perforator flaps, thus enabling the surgeon easier treatment of pressure sores.

Three-dimensional Reconstruction of Scar Contracture-bearing Axilla and Digital Webs Using the Square Flap Method.

PubMed

Huang, Chenyu; Ogawa, Rei

2014-05-01

Joint scar contractures are characterized by tight bands of soft tissue that bridge the 2 ends of the joint like a web. Classical treatment methods such as Z-plasties are mainly based on 2-dimensional designs. Our square flap method is an alternative surgical method that restores the span of the web in a stereometric fashion, thereby reconstructing joint function. In total, 20 Japanese patients with joint scar contractures on the axillary (n = 10) or first digital web (n = 10) underwent square flap surgery. The maximum range of motion and commissure length were measured before and after surgery. A theoretical stereometric geometrical model of the square flap was established to compare it to the classical single (60 degree), 4-flap (45 degree), and 5-flap (60 degree) Z-plasties in terms of theoretical web reconstruction efficacy. All cases achieved 100% contracture release. The maximum range of motion and web space improved after square flap surgery (P = 0.001). Stereometric geometrical modeling revealed that the standard square flap (α = 45 degree; β = 90 degree) yields a larger flap area, length/width ratio, and postsurgical commissure length than the Z-plasties. It can also be adapted by varying angles α and β, although certain angle thresholds must be met to obtain the stereometric advantages of this method. When used to treat joint scar contractures, the square flap method can fully span the web space in a stereometric manner, thus yielding a close-to-original shape and function. Compared with the classical Z-plasties, it also provides sufficient anatomical blood supply while imposing the least physiological tension on the adjacent skin.

Three-dimensional Reconstruction of Scar Contracture-bearing Axilla and Digital Webs Using the Square Flap Method

PubMed Central

Huang, Chenyu

2014-01-01

Background: Joint scar contractures are characterized by tight bands of soft tissue that bridge the 2 ends of the joint like a web. Classical treatment methods such as Z-plasties are mainly based on 2-dimensional designs. Our square flap method is an alternative surgical method that restores the span of the web in a stereometric fashion, thereby reconstructing joint function. Methods: In total, 20 Japanese patients with joint scar contractures on the axillary (n = 10) or first digital web (n = 10) underwent square flap surgery. The maximum range of motion and commissure length were measured before and after surgery. A theoretical stereometric geometrical model of the square flap was established to compare it to the classical single (60 degree), 4-flap (45 degree), and 5-flap (60 degree) Z-plasties in terms of theoretical web reconstruction efficacy. Results: All cases achieved 100% contracture release. The maximum range of motion and web space improved after square flap surgery (P = 0.001). Stereometric geometrical modeling revealed that the standard square flap (α = 45 degree; β = 90 degree) yields a larger flap area, length/width ratio, and postsurgical commissure length than the Z-plasties. It can also be adapted by varying angles α and β, although certain angle thresholds must be met to obtain the stereometric advantages of this method. Conclusions: When used to treat joint scar contractures, the square flap method can fully span the web space in a stereometric manner, thus yielding a close-to-original shape and function. Compared with the classical Z-plasties, it also provides sufficient anatomical blood supply while imposing the least physiological tension on the adjacent skin. PMID:25289342

Histologic change of arteriovenous malformations of the face and scalp after free flap transfer.

PubMed

Tark, K C; Chung, S

2000-07-01

In three patients with long-standing vascular malformations of the face and scalp, radial forearm free flaps were transferred after a near-total excision of the lesion. All patients had typical high-flow malformations with thrill and bruit. The onset and progression of the malformations were analyzed through clinical and histologic studies. After free flap transfer, the vascular malformations were followed up grossly and histologically for between 4 and 9 years. There was no recurrence of arteriovenous malformation after free flap transfer. The portion of the residual lesion adjacent to the transferred free flap disappeared, and the remaining discoloration also vanished grossly. Histologic comparison of immediate postoperative and 4-month postoperative specimens from the margin and residual lesion using Victoria blue staining showed that the typical preoperative findings for arteriovenous malformation-an intermingling of thick-walled vessels with abundant elastic fibers and thin-walled vessels without elastic fibers-had undergone change, resulting in the disappearance of the thick-walled vessels and leaving only homogeneous, thin-walled vasculature. The highly vascularized free flap, which does not contain abnormal fistulas, impacted the histologic change of the arteriovenous malformation by blocking the vicious cycle of ischemia and anatomic replacement of disfigured skin and subcutaneous tissues.

Demonstration of the Rat Ischemic Skin Wound Model

PubMed Central

Sherwood, Jacob; Wu, Mack; Gould, Lisa J.

2015-01-01

The propensity for chronic wounds in humans increases with ageing, disease conditions such as diabetes and impaired cardiovascular function, and unrelieved pressure due to immobility. Animal models have been developed that attempt to mimic these conditions for the purpose of furthering our understanding of the complexity of chronic wounds. The model described herein is a rat ischemic skin flap model that permits a prolonged reduction of blood flow resulting in wounds that become ischemic and resemble a chronic wound phenotype (reduced vascularization, increased inflammation and delayed wound closure). It consists of a bipedicled dorsal flap with 2 ischemic wounds placed centrally and 2 non-ischemic wounds lateral to the flap as controls. A novel addition to this ischemic skin flap model is the placement of a silicone sheet beneath the flap that functions as a barrier and a splint to prevent revascularization and reduce contraction as the wounds heal. Despite the debate of using rats for wound healing studies due to their quite distinct anatomic and physiologic differences compared to humans (i.e., the presence of a panniculus carnosus muscle, short life-span, increased number of hair follicles, and their ability to heal infected wounds) the modifications employed in this model make it a valuable alternative to previously developed ischemic skin flap models. PMID:25866964

Demonstration of the rat ischemic skin wound model.

PubMed

Trujillo, Andrea N; Kesl, Shannon L; Sherwood, Jacob; Wu, Mack; Gould, Lisa J

2015-04-01

The propensity for chronic wounds in humans increases with ageing, disease conditions such as diabetes and impaired cardiovascular function, and unrelieved pressure due to immobility. Animal models have been developed that attempt to mimic these conditions for the purpose of furthering our understanding of the complexity of chronic wounds. The model described herein is a rat ischemic skin flap model that permits a prolonged reduction of blood flow resulting in wounds that become ischemic and resemble a chronic wound phenotype (reduced vascularization, increased inflammation and delayed wound closure). It consists of a bipedicled dorsal flap with 2 ischemic wounds placed centrally and 2 non-ischemic wounds lateral to the flap as controls. A novel addition to this ischemic skin flap model is the placement of a silicone sheet beneath the flap that functions as a barrier and a splint to prevent revascularization and reduce contraction as the wounds heal. Despite the debate of using rats for wound healing studies due to their quite distinct anatomic and physiologic differences compared to humans (i.e., the presence of a panniculus carnosus muscle, short life-span, increased number of hair follicles, and their ability to heal infected wounds) the modifications employed in this model make it a valuable alternative to previously developed ischemic skin flap models.

[Applicability of Pedicled Coronoid Process and Temporal Muscle(Fascial)Combined(PCPTM)Flap for Reconstruction of Orbital Floor Defect Following Hemi-Maxillectomy for Advanced Maxillary Cancer - A Report of Two Cases].

PubMed

Karino, Masaaki; Kanno, Takahiro; Kaneko, Ichiro; Ide, Taichi; Yoshino, Aya; Sekine, Joji

2017-11-01

We usually perform surgery for resectable oral and maxillofacial carcinomas. Following complete cancer resection, reconstruction of soft and hard tissues using various types of local flaps and/or vascularized free flaps is usually performed. The maxilla is composed of various anatomical structures. In particular, reconstruction of the orbit is one of the most important and challenging procedures for prevention of functional and esthetic complications. Here we report 2 cases of orbital floor defect reconstruction following advanced maxillary cancer resection using a pedicled coronoid process and temporal muscle (fascial)combined(PCPTM)flap. Case 1: A 69-year-old Japanese man with squamous cell carcinoma of the left maxilla (cT4aN2bM0, Stage IV A). Case 2: An 86-year-old Japanese woman with recurrence of myoepithelial carcinoma of the left maxilla. In both cases, the orbital floor defect was reconstructed following hemi-maxillectomy using a PCPTM flap. Minor infection and/or partial necrosis were observed postoperatively, and a maxillofacial prosthesis was used in one case. A PCPTM flap was feasible for reconstruction of surgical defects of the orbital floor following maxillectomy for cancer.

Ad hoc posterior tibial vessels perforator propeller flaps for the reconstruction of lower third leg soft- tissue defects.

PubMed

Balakrishnan, Thalaivirithan Margabandu; Ramkumar, Jayagosh; Jaganmohan, Janardhanan

2017-01-01

Lower third leg soft tissue defects with anatomical and pathological constraints are posing formidable challenges to reconstructive surgeon. This retrospective study was conducted to assess the effectiveness of ad hoc posterior tibial vessels perforator-propeller flaps for the reconstruction of small and medium sized soft tissue defects in the lower third leg. 22 patients (16 were males and 6 were females) were involved in this study between period of January 2012 and December 2016.We followed the protocol of initial non delineating exploratory incision made to find out single best perforator in all patients. All the defects in leg reconstructed with adhoc posterior tibial vessel propeller flaps. All 22 flaps survived well. All in an average of 13 months follow up period, had pain free walking, with minimal scarring and acceptable aesthesis at the reconstruction sites with no need for any secondary procedure. With inability of preoperatively dopplering the perforators in the lower third leg region, the exploratory posterior nondelineating incision was used in all cases to secure the single best perforator for the propeller flaps. Thus adhoc posterior tibial vessel propeller flaps are dependable, easily adoptable for the reconstruction of soft tissue defects of the lower third leg region.

Ad hoc posterior tibial vessels perforator propeller flaps for the reconstruction of lower third leg soft- tissue defects

PubMed Central

Balakrishnan, Thalaivirithan Margabandu; Ramkumar, Jayagosh; Jaganmohan, Janardhanan

2017-01-01

Introduction: Lower third leg soft tissue defects with anatomical and pathological constraints are posing formidable challenges to reconstructive surgeon. Aim: This retrospective study was conducted to assess the effectiveness of ad hoc posterior tibial vessels perforator-propeller flaps for the reconstruction of small and medium sized soft tissue defects in the lower third leg. Patients and Methods: 22 patients (16 were males and 6 were females) were involved in this study between period of January 2012 and December 2016.We followed the protocol of initial non delineating exploratory incision made to find out single best perforator in all patients. All the defects in leg reconstructed with adhoc posterior tibial vessel propeller flaps. Results: All 22 flaps survived well. All in an average of 13 months follow up period, had pain free walking, with minimal scarring and acceptable aesthesis at the reconstruction sites with no need for any secondary procedure. Conclusion: With inability of preoperatively dopplering the perforators in the lower third leg region, the exploratory posterior nondelineating incision was used in all cases to secure the single best perforator for the propeller flaps. Thus adhoc posterior tibial vessel propeller flaps are dependable, easily adoptable for the reconstruction of soft tissue defects of the lower third leg region. PMID:29618863

Treatment of soft-tissue loss with nerve defect in the finger using the boomerang nerve flap.

PubMed

Chen, Chao; Tang, Peifu; Zhang, Xu

2013-01-01

This study reports simultaneous repair of soft-tissue loss and proper digital nerve defect in the finger using a boomerang nerve flap including nerve graft from the dorsal branch of the proper digital nerve. From July of 2007 to May of 2010, the flap was used in 17 fingers in 17 patients. The injured fingers included five index, seven long, and five ring fingers. The mean soft-tissue loss was 2.5 × 1.9 cm. The mean flap size was 2.8 × 2.1 cm. Proper digital nerve defects were reconstructed using nerve graft harvested from the dorsal branch of the adjacent finger's proper digital nerve. The average nerve graft length was 2.5 cm. The comparison group included 32 patients treated using a cross-finger flap and a secondary free nerve graft. In the study group, 15 flaps survived completely. Partial necrosis at the distal edge of the flap occurred in two cases. At a mean follow-up of 22 months, the average static two-point discrimination and Semmes-Weinstein monofilament test results on the pulp of the reconstructed finger were 7.5 mm and 3.86, respectively. In the comparison group, the results were 9.3 mm and 3.91, respectively. The study group presented better discriminatory sensation on the pulp and milder pain and cold intolerance in the reconstructed finger. The boomerang nerve flap is useful and reliable for reconstructing complicated finger damage involving soft-tissue loss and nerve defect, especially in difficult anatomical regions. Therapeutic, II.

[Neo-urethroclitoroplasty according to Petrovic].

PubMed

Trombetta, Carlo; Liguori, Giovanni; Benvenuto, Sara; Petrovic, Milos; Napoli, Renata; Umari, Paolo; Rizzo, Michele; Zordani, Alessio

2011-01-01

We present a refinement to our original technique in MtF gender reassignment surgery. Our goal was to construct a neoclitoris, which is wet and covered with urethral neoprepuce. Since 1995 more than 300 transgender MtF patients have been operated at our institution. Our refinement has been applied to 12 cases and showed both excellent functional and cosmetic results during midterm follow-up. During 2010 several sex reassignment surgeries have been performed using our new technique that includes: bilateral orchiectomy, removal of corpora cavernosa of the penis, formation of the neourethra with neomeatus, neovaginoplasty by inversion of penoscrotal skin flaps, construction of the neoclitoris with preservation of the neurovascular bundle and exterior vulva formation. The refinement consists in creating a neoclitoris embedded in urethral mucosa using urethral flaps. These flaps are in continuity with the previously spatulated urethra. The urethral plate is further incised distally in a Y fashion. The urethral flaps are sutured around the neoclitoris to form a neo-urethroclitoris covered by urethral neoprepuce, which resembles a real female clitoris. The neoclitoris is positioned in the anatomical position of the male suspensory ligament of the penis that is also the natural anatomical position of the female clitoris. With this method we are able to construct a clitoris with a normal sensitivity embedded in urethral mucosa that remains wet and hairless. It can be easily stimulated during sexual intercourse, as most of the patients reported great satisfaction and ability to reach orgasm. We want to emphasize how both the cosmetic results and functionality of the neovagina and neoclitoris are important in this type of surgery for the quality of life of our patients. We are still far from a perfect surgical solution, but we are further improving our technique and follow our aims step by step.

Color Doppler Sonographic and Cadaveric Study of the Arterial Vascularity of the Lateral Upper Arm Flap.

PubMed

Sun, Ruimei; Ding, Yu; Sun, Chuanzheng; Li, Xiaojiang; Wang, Jinde; Li, Lei; Yang, Jie; Ren, Yanxin; Zhong, Zhaoming

2016-04-01

To determine the importance of adequate preoperative assessment with color Doppler sonography to assist in the successful transfer of lateral upper arm flaps by studying the lateral upper arm flap with color Doppler sonography and analyzing the anatomic features of the radial collateral artery. A clinical case-control study was performed. The radial collateral artery was studied with color Doppler sonography in 15 healthy volunteers. The origins, courses, variations, and locations of the perforators of the radial collateral artery were recorded. The results and data from the color Doppler sonographic investigation were compared with an anatomic study that was performed on 22 adult cadaveric upper limb specimens. The volunteer group (14 of 15 volunteers) and the cadaveric group (19 of 22 upper arm specimens) clearly showed that the branch pattern of the arterial supply was as follows: brachial artery → deep brachial artery → radial collateral artery → posterior radial collateral artery → myocutaneous perforator. Variations in the origin of the radial collateral artery were identified in 1 volunteer bilaterally and in 3 upper arm specimens. The diameters of the artery and vein measured at the distal insertion of the deltoid and the origin of the deep brachial artery were not significantly different between the volunteer and cadaver groups (P > .05). Due to the difference in measuring methods, the length of the vascular pedicles was significantly different between the groups (P < .05). Color Doppler sonography can facilitate the preoperative assessment of the origin, course, variations, and locations of the radial collateral artery and therefore may increase the success rate of lateral upper arm flap transfer. © 2016 by the American Institute of Ultrasound in Medicine.

SURGICAL OUTCOMES AFTER INVERTED INTERNAL LIMITING MEMBRANE FLAP VERSUS CONVENTIONAL PEELING FOR VERY LARGE MACULAR HOLES.

PubMed

Narayanan, Raja; Singh, Sumit R; Taylor, Stanford; Berrocal, Maria H; Chhablani, Jay; Tyagi, Mudit; Ohno-Matsui, Kyoko; Pappuru, Rajeev R; Apte, Rajendra S

2018-04-23

To evaluate the anatomical and visual outcomes of inverted flap technique of peeling of internal limiting membrane (ILM) versus standard peeling of ILM for macular holes of basal diameter more than 800 μm. Patients with very large idiopathic macular holes more than 800 μm in basal diameter (ranging from 243 μm to 840 μm in minimum diameter) were retrospectively included in the study. In Group A, 18 eyes of 18 patients underwent ILM peeling using the inverted flap technique. In Group B, 18 eyes of 18 patients underwent conventional ILM peeling. The primary endpoint was the rate of hole closure at 6 months after surgery. The secondary outcome measure was the change in best-corrected visual acuity at 6 months after surgery. There were no significant differences in ocular characteristics of the study groups at baseline except for the age distribution. Mean macular hole diameter was 1,162.8 ± 206.0 μm and 1,229.6 ± 228.1 μm in Group A and Group B, respectively. The hole closure rate was 88.9% (16/18) in Group A and 77.8% (14/18) in Group B (P = 0.66). The mean gain in best-corrected visual acuity was higher in Group A than in Group B (P = 0.12) at 6 months, but this was not statistically significant. There were no severe ocular adverse events in either group. In this multicenter series, inverted ILM flap technique did not lead to significantly higher anatomical closure rates than conventional ILM peeling in large macular holes more than 800 μm in diameter.

Endoscopic Rectus Abdominis and Prepubic Aponeurosis Repairs for Treatment of Athletic Pubalgia.

PubMed

Matsuda, Dean K; Matsuda, Nicole A; Head, Rachel; Tivorsak, Tanya

2017-02-01

Review of the English orthopaedic literature reveals no prior report of endoscopic repair of rectus abdominis tears and/or prepubic aponeurosis detachment. This technical report describes endoscopic reattachment of an avulsed prepubic aponeurosis and endoscopic repair of a vertical rectus abdominis tear immediately after endoscopic pubic symphysectomy for coexistent recalcitrant osteitis pubis as a single-stage outpatient surgery. Endoscopic rectus abdominis repair and prepubic aponeurosis repair are feasible surgeries that complement endoscopic pubic symphysectomy for patients with concurrent osteitis pubis and expand the less invasive options for patients with athletic pubalgia.

[The effects of transversus abdominis plane block on analgesic and anesthetic consumption during total abdominal hysterectomy: a randomized controlled study].

PubMed

Karaman, Tugba; Ozsoy, Asker Zeki; Karaman, Serkan; Dogru, Serkan; Tapar, Hakan; Sahin, Aynur; Dogru, Hatice; Suren, Mustafa

A transversus abdominis plane block is a peripheral block method that has been used successfully for pain relief after total abdominal hysterectomy. However, the effects of the combination of the transversus abdominis plane block and general anesthesia on analgesic and anesthetic requirements remain unclear. This randomized placebo-controlled study is aimed to evaluate the effects of transversus abdominis plane block on analgesic and anesthetic consumption during total abdominal hysterectomy under general anesthesia. Sixty-six women undergoing total abdominal hysterectomy were randomized into two groups to receive general anesthesia alone (control group) or with transversus abdominis plane block using 20mL of 0.25% bupivacaine (transversus abdominis plane group). Intraoperative remifentanil and sevoflurane consumption were recorded. We also evaluated the postoperative pain, nausea, quality of recovery scores and rescue analgesic requirement during postoperative 24hours. The total remifentanil and sevoflurane consumption is significantly lower in transversus abdominis plane group; respectively mean (SD) 0.130 (0.25) vs. 0.094 (0.02) mcg.kg -1 .min -1 ; p<0.01 and 0.295 (0.05) vs. 0.243 (0.06) mL.min -1 ; p<0.01. In the postoperative period, pain scores were significantly reduced in transversus abdominis plane group soon after surgery; median (range) 6 (2-10) vs. 3 (0-5); p<0.001, at 2h (5 [3-9] vs. 2.5 [0-6]; p<0.001), at 6h (4 [2-7] vs. 3[0-6], p<0.001), at 12h (3.5 [1-6] vs. 2 [1-5]; p=0.003). The patients in the transversus abdominis plane group had significantly higher QoR-40 scores 190.5 (175-197) vs. 176.5 (141-187); p<0.001). Combining transversus abdominis plane block with general anesthesia can provide reduced opioid and anesthetic consumption and can improve postoperative pain and quality of recovery scores in patients undergoing total abdominal hysterectomy. Copyright © 2018 Sociedade Brasileira de Anestesiologia. Publicado por Elsevier Editora Ltda. All rights reserved.

Effect of surface stability on core muscle activity for dynamic resistance exercises.

PubMed

Willardson, Jeffrey M; Fontana, Fabio E; Bressel, Eadric

2009-03-01

To compare core muscle activity during resistance exercises performed on stable ground vs. the BOSU Balance Trainer. Twelve trained men performed the back squat, dead lift, overhead press, and curl lifts. The activity of the rectus abdominis, external oblique abdominis, transversus abdominis/internal oblique abdominis, and erector spinae muscles was assessed. Subjects performed each lift under three separate conditions including standing on stable ground with 50% of a 1-RM, standing on a BOSU Balance Trainer with 50% of a 1-RM, and standing on stable ground with 75% of a 1-RM. Significant differences were noted between the stable 75% of 1-RM and BOSU 50% of 1-RM conditions for the rectus abdominis during the overhead press and transversus abdominis/internal oblique abdominis during the overhead press and curl (P < .05). Conversely, there were no significant differences between the stable 75% of 1-RM and BOSU 50% of 1-RM conditions for the external obliques and erector spinae across all lifts examined. Furthermore, there were no significant differences between the BOSU 50% of 1-RM and stable 50% of 1-RM conditions across all muscles and lifts examined. The current study did not demonstrate any advantage in utilizing the BOSU Balance Trainer. Therefore, fitness trainers should be advised that each of the aforementioned lifts can be performed while standing on stable ground without losing the potential core muscle training benefits.

Aesthetic Penoscrotal Resurfacing: Creating Propeller Flaps from Gluteal Folds.

PubMed

Han, So-Eun; Kim, Eun-Ji; Sung, Hyun Hwan; Pyon, Jai-Kyong

2018-04-01

Reconstruction of extensive penoscrotal defects is a surgical challenge. Resurfacing defects in highly complex three-dimensional structures and restoring their function are an essential part of the reconstruction of penoscrotal regions. We describe a technique using internal pudendal artery perforator (IPAP) pedicled propeller flaps created from the gluteal fold. This could be a reliable surgical option that maintains a natural looking scrotal pouch with minimal donor site morbidity and optimal sexual activity. We retrospectively reviewed data for 10 consecutive patients who had undergone penoscrotal reconstruction using IPAP pedicled propeller flaps between January 2011 and March 2015. The IPAP was identified using a hand-held Doppler ultrasound device. This was the pivot around which the flap was internally rotated more than 90° in a tension-free manner. The long axis of the flap was centred on the gluteal fold to provide a better-orientated donor site scar. Complications and patient satisfaction with respect to size, colour match, scar appearance, and sexual activity were evaluated. Anatomic and aesthetic penoscrotal reconstruction was performed without any major complications in the follow-up period (mean, 19.7 mo). The mean width of the IPAP pedicled propeller flaps was 6.7cm, and the mean length was 11.7cm. Partial distal flap necrosis occurred in only one case, and healed spontaneously. All of the patients were satisfied with the cosmetic and functional results. On the basis of reliable perforators, donor site morbidity, flap thickness, and a better orientated scar, our technique using IPAP pedicled propeller flaps created from the gluteal fold could be a reasonable surgical option for extensive penoscrotal reconstruction. The creation of pedicled propeller flaps using an internal pudendal artery perforator could be a reliable surgical option for reconstruction of extensive penoscrotal defects. The approach yields functional and aesthetically acceptable surgical results. Copyright © 2016. Published by Elsevier B.V.

A Model of Free Tissue Transfer: The Rat Epigastric Free Flap

PubMed Central

Casal, Diogo; Pais, Diogo; Iria, Inês; Mota-Silva, Eduarda; Almeida, Maria-Angélica; Alves, Sara; Pen, Cláudia; Farinho, Ana; Mascarenhas-Lemos, Luís; Ferreira-Silva, José; Ferraz-Oliveira, Mário; Vassilenko, Valentina; Videira, Paula A.; Gory O'Neill, João

2017-01-01

Free tissue transfer has been increasingly used in clinical practice since the 1970s, allowing reconstruction of complex and otherwise untreatable defects resulting from tumor extirpation, trauma, infections, malformations or burns. Free flaps are particularly useful for reconstructing highly complex anatomical regions, like those of the head and neck, the hand, the foot and the perineum. Moreover, basic and translational research in the area of free tissue transfer is of great clinical potential. Notwithstanding, surgical trainees and researchers are frequently deterred from using microsurgical models of tissue transfer, due to lack of information regarding the technical aspects involved in the operative procedures. The aim of this paper is to present the steps required to transfer a fasciocutaneous epigastric free flap to the neck in the rat. This flap is based on the superficial epigastric artery and vein, which originates from and drain into the femoral artery and vein, respectively. On average the caliber of the superficial epigastric vein is 0.6 to 0.8 mm, contrasting with the 0.3 to 0.5 mm of the superficial epigastric artery. Histologically, the flap is a composite block of tissues, containing skin (epidermis and dermis), a layer of fat tissue (panniculus adiposus), a layer of striated muscle (panniculus carnosus), and a layer of loose areolar tissue. Succinctly, the epigastric flap is raised on its pedicle vessels that are then anastomosed to the external jugular vein and to the carotid artery on the ventral surface of the rat's neck. According to our experience, this model guarantees the complete survival of approximately 70 to 80% of epigastric flaps transferred to the neck region. The flap can be evaluated whenever needed by visual inspection. Hence, the authors believe this is a good experimental model for microsurgical research and training. PMID:28117814

A New Composite Eyeball-Periorbital Transplantation Model in Humans: An Anatomical Study in Preparation for Eyeball Transplantation.

PubMed

Siemionow, Maria; Bozkurt, Mehmet; Zor, Fatih; Kulahci, Yalcin; Uygur, Safak; Ozturk, Can; Djohan, Risal; Papay, Frank

2018-04-01

Vascularized composite allotransplantation offers a new hope for restoration of orbital content and perhaps vision. The aim of this study was to introduce a new composite eyeball-periorbital transplantation model in fresh cadavers in preparation for composite eyeball allotransplantation in humans. The composite eyeball-periorbital transplantation flap borders included the inferior border, outlined by the infraorbital rim; the medial border, created by the nasal dorsum; the lateral border, created by the lateral orbital rim; and the superior border, created by the superior part of the eyebrow. The pedicle of the flap included the facial artery, superficial temporal artery, and external jugular vein. The skin and subcutaneous tissues of the periorbital region were dissected and the bony tissue was reached. A coronal incision was performed and the frontal lobe of the brain was reached by means of frontal osteotomy. Ophthalmic and oculomotor nerves were also included in the flap. After a "box osteotomy" around the orbit, the dissection was completed. Methylene blue and indocyanine green injection (SPY Elite System) was performed to show the integrity of the vascular territories after facial flap harvest. Adequate venous return was observed within the flap after methylene blue dye injection. Laser-assisted indocyanine green angiography identified a well-defined vascular network within the entire composite eyeball-periorbital transplantation flap. For the first time, a novel composite eyeball-periorbital transplantation model in human cadavers was introduced. Good perfusion of the flap confirmed the feasibility of composite eyeball-periorbital transplantation in the clinical setting. Although harvesting of the flap is challenging, it introduces a new option for reconstruction of the periorbital region including the eyeball.

[Subcostal transversus abdominis plane block can improve analgesia after laparoscopic cholecystectomy].

PubMed

Vrsajkov, Vladimir; Mančić, Nedjica; Mihajlović, Dunja; Milićević, Suzana Tonković; Uvelin, Arsen; Vrsajkov, Jelena Pantić

After laparoscopic cholecystectomy, patients have moderate pain in the early postoperative period. Some studies shown beneficial effects of subcostal transversus abdominis plane block on reducing this pain. Our goal was to investigate influence of subcostal transversus abdominis plane block on postoperative pain scores and opioid consumption. We have randomized 76 patients undergoing laparoscopic cholecystectomy to receive either subcostal transversus abdominis plane block (n=38) or standard postoperative analgesia (n=38). First group received bilateral ultrasound guided subcostal transversus abdominis plane block with 20mL of 0.33% bupivacaine per side before operation and tramadol 1mg.kg -1 IV for pain breakthrough (≥6). Second group received after operation tramadol 1mg.kg -1 /6h as standard hospital analgesia protocol. Both groups received acetaminophen 1g/8h IV and metamizole 2.5g/12h. Pain at rest was recorded for each patient using NR scale (0-10) in period of 10min, 30min, 2h, 4h, 8h, 12h and 16h after the surgery. We obtained no difference between groups according age, weight, intraoperative fentanyl consumption and duration of surgery. Subcostal transversus abdominis plane block significantly reduced postoperative pain scores compared to standard analgesia in all periods after surgery. Tramadol consumption was significantly lower in the subcostal transversus abdominis plane (24.29±47.54g) than in the standard analgesia group (270.2±81.9g) (p=0.000). Our results show that subcostal transversus abdominis plane block can provide superior postoperative analgesia and reduction in opioid requirements after laparoscopic cholecystectomy. Copyright © 2017 Sociedade Brasileira de Anestesiologia. Publicado por Elsevier Editora Ltda. All rights reserved.

Definitive Surgical Treatment of Infected or Exposed Ventral Hernia Mesh

PubMed Central

Szczerba, Steven R.; Dumanian, Gregory A.

2003-01-01

Objective To discuss the difficulties in dealing with infected or exposed ventral hernia mesh, and to illustrate one solution using an autogenous abdominal wall reconstruction technique. Summary Background Data The definitive treatment for any infected prosthetic material in the body is removal and substitution. When ventral hernia mesh becomes exposed or infected, its removal requires a solution to prevent a subsequent hernia or evisceration. Methods Eleven patients with ventral hernia mesh that was exposed, nonincorporated, with chronic drainage, or associated with a spontaneous enterocutaneous fistula were referred by their initial surgeons after failed local wound care for definitive management. The patients were treated with radical en bloc excision of mesh and scarred fascia followed by immediate abdominal wall reconstruction using bilateral sliding rectus abdominis myofascial advancement flaps. Results Four of the 11 patients treated for infected mesh additionally required a bowel resection. Transverse defect size ranged from 8 to 18 cm (average 13 cm). Average procedure duration was 3 hours without bowel repair and 5 hours with bowel repair. Postoperative length of stay was 5 to 7 days without bowel repair and 7 to 9 days with bowel repair. Complications included hernia recurrence in one case and stitch abscesses in two cases. Follow-up ranges from 6 to 54 months (average 24 months). Conclusions Removal of infected mesh and autogenous flap reconstruction is a safe, reliable, and one-step surgical solution to the problem of infected abdominal wall mesh. PMID:12616130

Comparison of ultrasound guided transversus abdominis plane block versus local wound infiltration for post operative analgesia in patients undergoing gynaecological surgery under general anaesthesia.

PubMed

Ranjit, S; Shrestha, S K

2014-01-01

Transversus abdominis plane block has been recently developed as a part of multimodal post operative analgesic techniques. We compared the analgesic efficacy of this technique with local bupivacaine infiltration in patients undergoing gynaecological surgeries with pfannenstiel incision and lower midline incision under general anaesthesia. To evaluate the efficacy of ultrasound guided transversus abdominis plane block for postoperative analgesia. Patients were randomly allocated to three groups: control group (n=15), transversus abdominis plane block group (n=15), who received bilateral transversus abdominis plane blockwith 0.25% bupivacaine, and local infiltration group (n=15), who received local wound infiltration with 0.25% bupivacaine at the end of surgery. All patients received intramuscular diclofenac 12 hourly and intravenous tramadol SOS in the postoperative period. Visual analogue scores for pain were assessed at 1,2,4,8,12 and 24 hours postoperatively and these were compared between the three groups. Average tramadol consumption in 24 hours were also compared among the three groups. Data were subjected to univariate ANOVA test and chi-square test. Level of significance was set at 0.05. Visual analogue scores were significantly less in transversus abdominis plane block group and effect lasted up to 12 hours at rest postoperatively and 8 hours during cough and movement. Bilateral Transversus abdominis plane block was effective in reducing postoperative pain scores for 8 to 12 hours postoperatively. This block was also successful in reducing postoperative opioid requirement.

Use of Cyanoacrylate Glue Casting for Stabilization of Periocular Skin Grafts and Flaps.

PubMed

Jackson, Colette M; Nguyen, Michelle; Mancini, Ronald

To examine a novel technique for periocular skin graft and flap stabilization using cyanoacrylate glue applied to the host bed around the perimeter of the graft or flap to create an immobile cast in the immediate postoperative period to promote successful graft take and stable anatomic position. Retrospective review was performed of a single surgeon's patients who underwent periocular skin graft or flap between August 1, 2011, and February 29, 2016, in which cyanoacrylate glue was applied postoperatively for graft stabilization. Data examined included indication for procedure, location and size of graft, postoperative complications, and length of follow up postoperatively. Of 164 cases reviewed, 9 cases were identified in which cyanoacrylate glue was used as the sole means of graft or flap stabilization. Indications for surgery included repair of cicatricial ectropion (3 cases) and repair of Mohs defect status after excision of basal or squamous cell carcinoma (6 cases). All cases involved reformation of the lower eyelid. Five cases employed full-thickness skin grafts and 4 cases employed adjacent tissue rearrangement. Size of defect repaired ranged from 8 mm to 35 mm when largest diameter was measured. Complications included mild residual ectropion or mild punctal ectropion in 2 patients who was asymptomatic and did not require further surgery. No cases were complicated by hematoma, infection, or graft necrosis. Cyanoacrylate glue can be used to successfully stabilize skin grafts and flaps in the immediate postoperative period.

Neoadjuvant Radiotherapy: Changing the Treatment Sequence to Allow Immediate Free Autologous Breast Reconstruction.

PubMed

Hughes, Kimberley; Neoh, Derek

2018-06-16

 Locally advanced breast cancer (LABC) is traditionally treated with a multimodal approach of chemotherapy, surgery, and postmastectomy radiotherapy (PMRT). The advantages of immediate breast reconstruction (IBR) are well described and include improved aesthetic outcomes, fewer surgical procedures, shorter treatment period, and a higher quality of life. However, this sequence makes immediate free autologous reconstruction more challenging as PMRT can have deleterious and unpredictable effects on the flap. We have reversed this treatment sequence with neoadjuvant chemotherapy and radiotherapy, followed by mastectomy and immediate free autologous reconstruction. To our knowledge, this is the first series to assess the outcomes of neoadjuvant radiotherapy on immediate free microvascular breast reconstruction.  A review of patients with LABC who underwent immediate free autologous breast reconstruction post neoadjuvant chemoradiotherapy between 2013 and 2017 was conducted. All reconstructions were performed by a single reconstructive team. The primary end points were flap failure and surgical complications. Secondary end points were pathological response rate and disease recurrence.  A total of 40 women with an average age of 48.1 (36-61) and average body mass index of 25.6 (18-37) were included. The most common choice of flap was immediate deep inferior epigastric perforator (DIEP, 31), followed by transverse or diagonal upper gracilis (5), muscle-sparing transversus abdominis (3), and stacked DIEP (1). Our major complication rate was 12.5% and minor complication 15%. There were no cases of local recurrence and only three cases (7.5%) of distant disease progression.  From our experience, this treatment sequence allows patients to have an immediate gold standard reconstruction without an increase in surgical morbidity. It affords the benefits of IBR without concern in delaying adjuvant therapy and appears to be safe from an oncological perspective. Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

[Anatomy study on micro transverse flap pedicled with superfical palmar branch of radial artery from palmar wrist].

PubMed

Zhao, Min; Tian, Dehu; Shao, Xinzhong; Li, Dacun; Li, Jianfeng; Liu, Jingda; Zhao, Liang; Li, Hailei; Wang, Xiaolei; Zhang, Wentong; Wu, Jinying; Yuan, Zuoxiong

2013-07-01

To study the anatomical basis of micro transverse flap pedicled with the superfical palmar branch of radial artery from the palmar wrist for using this free flap to repair soft tissue defect of the finger. Thirty-eight fresh upper limb specimens (22 males and 16 females; aged 26-72 years with an average of 36 years; at left and right sides in 19 limbs respectively) were dissected and observed under operating microscope. Two specimens were made into casting mould of artery with bones, and 2 specimens were injected with red emulsion in radial artery. Thirty-four specimens were injected with 1% gentian violet solution in the superfical palmar branch of the radial artery. A transverse oval flap in the palmar wrist was designed, the axis of the flap was the distal palmar crease. The origin, distribution, and anastomosis of the superfical palmar branch of the radial artery were observed. The superficial palmar branch of the radial artery was constantly existed, it usually arises from the main trunk of the radial artery, 1.09-3.60 cm to proximal styloid process of radius. There were about 2-5 branches between the origin and the tubercle of scaphoid bone. The origin diameter was 1.00-3.00 mm, and the distal diameter at the styloid process of radius was 1.00-2.90 mm. The venous return of flap passed through 2 routes, and the innervations of the flap mainly from the palmar cutaneous branch of the median nerve. The area of the flap was 4 cm x 2 cm-6 cm x 2 cm. The origin and courses of the superficial palmar branch of the radial artery is constant, and its diameter is similar to that of the digital artery. A transverse oval flap pedicled with the superfical palmar branch of radial artery in the palmar wrist can be designed to repair defects of the finger.

Acute abdominal rhabdomyolysis after body building exercise: is there a "rectus abdominus syndrome?".

PubMed

Schmitt, H P; Bersch, W; Feustel, H P

1983-01-01

Report of a 19-year-old man who was admitted to the hospital after vigorous exercise with signs of the "acute abdomen" syndrome. Since intestinal reasons for the complaints were excluded, a myocardial infarction was considered. However, the excessively increased serum CK levels indicated a disorder of the voluntary muscles. A biopsy taken from the rectus abdominis revealed typical features of acute rhabdomyolysis, which was obviously restricted to the rectus abdominis. Together with a somewhat later observed autopsy case of a young male with acute abdominal rhabdomyolysis, also restricted to the rectus abdominis, this case gives rise to discuss, whether there exists a "rectus abdominis syndrome" analogous to the anterior tibial syndrome.

Unilateral dichotomy of nipple (intraareolar polythelia) and areola: report of a case and surgical correction.

PubMed

Arranz López, José L; García, Lourdes; Elena, Elvira; Benito, Pablo; De Juan, Ana

2006-01-01

An unusual case of intraareolar polythelia with two nipples is presented. The dichotomy affected not only the nipple, but also the areola. No other breast malformation existed. Surgical correction was performed by transposition flaps sutured to one another in the center of the areola. The anatomic and functional results were satisfactory.

Rectus abdominis overuse injury in a tennis athlete treated with traumeel.

PubMed

Natsis, Konstantinos; Lyrtzis, Christos; Papathanasiou, Efthymia; Anastasopoulos, Nikos

2012-01-01

Rectus abdominis injuries are common in tennis players at all levels of competition. Traumeel(®) injection can be used for treatment of muscle strains and hematomas. A 21-year-old female tennis athlete was injured on the non-dominant rectus abdominis during the cocking phase of the service motion. She suffered from pain and tenderness. One week later, during a serve, she experienced severe pain on the contralateral side of her abdomen. Conservative treatment was performed by the team physician with rest, ice therapy and analgesics for 20 days, but she had recurrent injuries. The ultrasonography and MRI showed hematoma of the rectus abdominis muscle. She was treated with 2 injections of Traumeel(®) on the 2(nd), 4(th), 6(th) post-traumatic day and received 1 injection on the 10(th) post-traumatic day. She also modified her serve technique. On the fourth post-treatment week the athlete had pain-free function and both the MRI appearance and the size of rectus abdominal muscle were normal. She returned to her sport activities. There is no recurrence of her injury 2 years later. Rectus abdominis hematoma must be diagnosed early. Traumeel(®) injections are effective, safe and well-tolerated for the treatment of overuse injury of the rectus abdominis following strain.

A flap based on the plantar digital artery arch branch to improve appearance of reconstructed fingers: Anatomical and clinical application.

PubMed

Tang, Lin-Feng; Ju, Ji-Hui; Liu, Yue-Fei; Lan, Bo; Hou, Rui-Xing

2018-02-01

To investigate blood supply features of the flap based on the plantar digital artery arch and arch branch artery, and the treatment of outcomes of reconstructed fingers by the plantar digital artery arch branch island flap. Eight fresh foot specimens were employed with red emulsion infusion and microdissection. The vascular organization was observed in the second toe, such as initiation site, the course, and the number of the plantar digital artery arch branch. There were 15 fingers of 13 patients (8 males and 5 females) with finger defects accompanied by toe transfer, using the plantar digital artery arch branch flap inserted in the neck of the second toe to correct the appearance defect caused by a narrow "neck" and a bulbous tip. The intact plantar digital arches were identified in all specimens. The plantar digital artery arch had 5 branches. The range of external diameter of the arch branch was 0.4-0.6 mm. All the plantar digital artery arch branch island flaps and the reconstructed fingers survived. These cases were conducted with a follow-up period for 3-18 months (average, 9 months). All the plantar digital artery arch branch island flaps and reconstructed fingers demonstrated a satisfactory appearance and favorable sense function. The reconstructed finger-tip characteristic was good, with no obvious scar hyperplasia. The range of flexion and extension of reconstructed fingers was favorable as well. The plantar digital artery arch and arch branch artery possess regular vasa vasorum and abundant vascularity. A flap based on the plantar digital artery arch branch is an ideal selection for plastic surgery of reconstructed fingers. Copyright © 2017 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

Computed Tomographic Angiographic Perforator Localization for Virtual Surgical Planning of Osteocutaneous Fibular Free Flaps in Head and Neck Reconstruction.

PubMed

Ettinger, Kyle S; Alexander, Amy E; Arce, Kevin

2018-04-10

Virtual surgical planning (VSP), computer-aided design and computer-aided modeling, and 3-dimensional printing are 3 distinct technologies that have become increasingly used in head and neck oncology and microvascular reconstruction. Although each of these technologies has long been used for treatment planning in other surgical disciplines, such as craniofacial surgery, trauma surgery, temporomandibular joint surgery, and orthognathic surgery, its widespread use in head and neck reconstructive surgery remains a much more recent event. In response to the growing trend of VSP being used for the planning of fibular free flaps in head and neck reconstruction, some surgeons have questioned the technology's implementation based on its inadequacy in addressing other reconstructive considerations beyond hard tissue anatomy. Detractors of VSP for head and neck reconstruction highlight its lack of capability in accounting for multiple reconstructive factors, such as recipient vessel selection, vascular pedicle reach, need for dead space obliteration, and skin paddle perforator location. It is with this premise in mind that the authors report on a straightforward technique for anatomically localizing peroneal artery perforators during VSP for osteocutaneous fibular free flaps in which bone and a soft tissue skin paddle are required for ablative reconstruction. The technique allows for anatomic perforator localization during the VSP session based solely on data existent at preoperative computed tomographic angiography (CTA); it does not require any modifications to preoperative clinical workflows. It is the authors' presumption that many surgeons in the field are unaware of this planning capability within the context of modern VSP for head and neck reconstruction. The primary purpose of this report is to introduce and further familiarize surgeons with the technique of CTA perforator localization as a method of improving intraoperative fidelity for VSP of osteocutaneous fibular free flaps. Copyright © 2018. Published by Elsevier Inc.

The Supraclavicular Artery Perforator Flap: A Comparative Study of Imaging Techniques Used in Preoperative Mapping.

PubMed

Sheriff, Hemin Oathman; Mahmood, Kawa Abdullah; Hamawandi, Nzar; Mirza, Aram Jamal; Hawas, Jawad; Moreno, Esther Granell; Clavero, Juan Antonio; Hankins, Christopher; Masia, Jaume

2018-05-18

 The supraclavicular artery flap is an excellent flap for head and neck reconstruction. The aim of this study is to assess imaging techniques to define the precise vascular boundaries of this flap.  Six imaging techniques were used for supraclavicular artery mapping in 65 cases; handheld Doppler, triplex ultrasound, computed tomography angiography, magnetic resonance angiography, digital subtraction angiography, and indocyanine green angiography. We checked the site of the perforators, the course of a supraclavicular artery, and anatomical mapping of the supraclavicular artery.  Handheld Doppler identified perforators' sites in 80% of the cases but showed no results for the course of the vessel. Triplex ultrasound identified the site of perforators in 52.9%, and partial mapping of the course of a supraclavicular artery in 64.7% of the cases. Computerized tomography angiography showed the site of perforators in 60%, and the course of supraclavicular artery completely in 45%, and partially in an additional 30%of the cases examined. Magnetic resonance angiography showed negative results for all parameters. Digital subtraction angiography showed the partial course of a supraclavicular artery in 62.5%, but showed no perforators. Indocyanine green angiography showed the site of perforators in 60% and a partial course of supraclavicular artery distal to perforators in 60%.Anatomical mapping of the vessel was possible with computerized tomography angiogram completely in 45%, and partially in 30%, and was also possible with indocyanine green angiography partially in 60%.  Computerized tomography angiography showed best results in the mapping of the supraclavicular artery, but with an inability to define the perforator perfusion territories, and also with risks of irradiation, while indocyanine green angiography is a good alternative as it could precisely map the superficial course of the artery and angiosomes, with no radiation exposure. Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Panorama of Reconstruction of Skull Base Defects: From Traditional Open to Endonasal Endoscopic Approaches, from Free Grafts to Microvascular Flaps

PubMed Central

Reyes, Camilo; Mason, Eric; Solares, C. Arturo

2014-01-01

Introduction A substantial body of literature has been devoted to the distinct characteristics and surgical options to repair the skull base. However, the skull base is an anatomically challenging location that requires a three-dimensional reconstruction approach. Furthermore, advances in endoscopic skull base surgery encompass a wide range of surgical pathology, from benign tumors to sinonasal cancer. This has resulted in the creation of wide defects that yield a new challenge in skull base reconstruction. Progress in technology and imaging has made this approach an internationally accepted method to repair these defects. Objectives Discuss historical developments and flaps available for skull base reconstruction. Data Synthesis Free grafts in skull base reconstruction are a viable option in small defects and low-flow leaks. Vascularized flaps pose a distinct advantage in large defects and high-flow leaks. When open techniques are used, free flap reconstruction techniques are often necessary to repair large entry wound defects. Conclusions Reconstruction of skull base defects requires a thorough knowledge of surgical anatomy, disease, and patient risk factors associated with high-flow cerebrospinal fluid leaks. Various reconstruction techniques are available, from free tissue grafting to vascularized flaps. Possible complications that can befall after these procedures need to be considered. Although endonasal techniques are being used with increasing frequency, open techniques are still necessary in selected cases. PMID:25992142

Revision of loop colostomy under regional anaesthesia and sedation.

PubMed

Ng, Oriana; Thong, Sze Ying; Chia, Claramae Shulyn; Teo, Melissa Ching Ching

2015-05-01

Patients presenting for emergency abdominal procedures often have medical issues that cause both general anaesthesia and central neuraxial blockade to pose significant risks. Regional anaesthetic techniques are often used adjunctively for abdominal procedures under general anaesthesia, but there is limited published data on procedures done under peripheral nerve or plexus blocks. We herein report the case of a patient with recent pulmonary embolism and supraventricular tachycardia who required colostomy refashioning. Ultrasonography-guided regional anaesthesia was administered using a combination of ilioinguinal-iliohypogastric, rectus sheath and transversus abdominis plane blocks. This was supplemented with propofol and dexmedetomidine sedation as well as intermittent fentanyl and ketamine boluses to cover for visceral stimulation. We discuss the anatomical rationale for the choice of blocks and compare the anaesthetic conduct with similar cases that were previously reported.

Perforator Peroneal Artery Flap for Tongue Reconstruction.

PubMed

Chauhan, Shubhra; Chavre, Sachin; Chandrashekar, Naveen Hedne; B S, Naveen

2017-03-01

Reconstruction has evolved long way from primary closure to flaps. As time evolved, better understanding of vascularity of flap has led to the development of innovative reconstructive techniques. These flaps can be raised from various parts of the body for reconstruction and have shown least donor site morbidity. We use one such peroneal artery perforator flap for tongue reconstruction with advantage of thin pliable flap, minimal donor site morbidity and hidden scar. Our patient 57yrs old lady underwent wide local excision with selective neck dissection. Perforators are marked about 10 and 15 cm inferiorly from the fibular head using hand held Doppler. Leg is positioned in such a way to give better exposure during dissection of the flap and flap is harvested under a tourniquet with pressure kept 350 mm Hg. The perforator is kept at the eccentric location, so as to gain length of the pedicle. Skin incison is placed over the peroneal muscle and deepened unto the deep facia, then the dissection is continued over the muscle and the perforator arising from the lateral septum. The proximal perforator about 10 cm from the fibular head is a constant perforator and bigger one, which is traced up to the peroneal vessel. We could get a 6 cm of pedicle length. Finally the flap is islanded on this perforator and the pedicle is ligated and flap harvested. Anastamosis was done to the ipsilateral side to facial vessels. The donor site is closed primarily and in the upper half one can harvest 5 cm width flap without requiring a skin graft along with a length of 8 to 12 cm. Various local and free flap has been used for reconstruction of partial tongue defects with its obvious donor site problems, like less pliable skin and not so adequate tissue from local flaps and sacrificing a important artery as in radial forearm flap serves as the work horse in reconstruction of partial tongue defects, Concept of super microsurgery was popularized by Japanese in 1980s and the concept of angiosome proposed by Taylor paved the way for development of new flaps. True perforator flaps are those where the source vessel is left undisturbed and overlying skin flap is raised. Yoshimura proposed cutaneous flap could be raised from peroneal artery (Br J Plast Surg 42:715-718, 1989). Wolff et al. (Plast Reconstr Surg 113:107-113, 2004) first used perforator based peroneal artery flap for oral reconstruction. Location of perforators vary, hence pre operative localisation can be done by ultrasound doppler, CT angio or MR angiography. Disadvantages over radial flap include varying anatomic location of perforators, need for imaging and difficult dissection of delicate vessels through muscles and hence a learning curve. Our patient had an arterial thrombus within few hours post-operatively which was successfully salvaged with immediate re-exploration and re-anastomosis of artery. Post-operative healing was uneventful and donor site was closed primarily without the need for graft. Perforator peroneal flap serves as a useful armamentarium for reconstruction of moderate size defects of tongue, buccal mucosa and floor of mouth with advantages of thin pliable flap, minimal donor site morbidity and hidden scar.

Postoperative analgesic efficacy of ultrasound-guided ilioinguinal-iliohypogastric nerve block compared with medial transverse abdominis plane block in inguinal hernia repair: A prospective, randomised trial.

PubMed

Bhatia, Nidhi; Sen, Indu Mohini; Mandal, Banashree; Batra, Ankita

2018-03-29

Analgesic efficacy of ultrasound-guided transverse abdominis plane block, administered a little more medially, just close to the origin of the transverse abdominis muscle has not yet been investigated in patients undergoing unilateral inguinal hernia repair. We hypothesised that medial transverse abdominis plane block would provide comparable postoperative analgesia to ilioinguinal-iliohypogastric nerve block in inguinal hernia repair patients. This prospective, randomised trial was conducted in 50 ASA I and II male patients≥18 years of age. Patients were randomised into two groups to receive either pre-incisional ipsilateral ultrasound-guided ilioinguinal-iliohypogastric nerve block or medial transverse abdominis plane block, with 0.3ml/kg of 0.25% bupivacaine. Our primary objective was postoperative 24-hour analgesic consumption and secondary outcomes included pain scores, time to first request for rescue analgesic and side effects, if any, in the postoperative period. There was no significant difference in the total postoperative analgesic consumption [group I: 66.04mg; group II: 68.33mg (P value 0.908)]. Time to first request for rescue analgesic was delayed, though statistically non-significant (P value 0.326), following medial transverse abdominis plane block, with excellent pain relief seen in 58.3% patients as opposed to 45.8% patients in ilioinguinal-iliohypogastric nerve block group. Medial transverse abdominis plane block being a novel, simple and easily performed procedure can serve as an useful alternative to ilioinguinal-iliohypogastric nerve block for providing postoperative pain relief in inguinal hernia repair patients. Copyright © 2018 Société française d'anesthésie et de réanimation (Sfar). Published by Elsevier Masson SAS. All rights reserved.

A randomised trial of the analgesic efficacy of ultrasound-guided transversus abdominis plane block after caesarean delivery under general anaesthesia.

PubMed

Tan, Terry T; Teoh, Wendy H L; Woo, David C M; Ocampo, Cecilia E; Shah, Mukesh K; Sia, Alex T H

2012-02-01

Previous studies examining the efficacy of transversus abdominis plane block after caesarean section have mostly been in parturients under spinal anaesthesia. We postulated that the advantage of performing transversus abdominis plane block after caesarean section might be even more obvious after general anaesthesia, resulting in reduced 24-h consumption of morphine. DESIGN, SETTING, PATIENTS AND INTERVENTIONS: In this single centre, randomised double-blind controlled trial, 40 women who underwent caesarean delivery under general anaesthesia were allocated randomly to receive a transversus abdominis plane block or no block. In those who received the block, 20 ml of levobupivacaine 2.5 mg ml was deposited bilaterally into the transversus abdominis plane under ultrasound guidance using a Sonosite Titan (SonoSite, Bothell, Washington, USA) 7-13 MHz linear transducer at the end of surgery when the patient was still anaesthetised. We recorded patient-controlled intravenous morphine use for 24 h, pain scores at rest and activity, sedation, nausea and vomiting, use of antiemetic medication and overall maternal satisfaction. The primary outcome was 24-h morphine consumption. Patients who received the transversus abdominis plane block used significantly less morphine in 24 h than those in the control group [12.3 (2.6) vs. 31.4 mg (3.1), P<0.001) and had higher satisfaction scores [16 (80%) vs. 5 (25%), P = 0.012). There were no differences between groups in the visual analogue pain scores, sedation level, nausea and vomiting or the use of antiemetic medication. Ultrasound-guided transversus abdominis plane block reduced morphine consumption following caesarean section under general anaesthesia, with increased maternal satisfaction.

Comparison of analgesic efficacy of four-quadrant transversus abdominis plane (TAP) block and continuous posterior TAP analgesia with epidural analgesia in patients undergoing laparoscopic colorectal surgery: an open-label, randomised, non-inferiority trial.

PubMed

Niraj, G; Kelkar, A; Hart, E; Horst, C; Malik, D; Yeow, C; Singh, B; Chaudhri, S

2014-04-01

Posterior transversus abdominis plane blocks have been reported to be an effective method of providing analgesia after lower abdominal surgery. We compared the efficacy of a novel technique of providing continuous transversus abdominis plane analgesia with epidural analgesia in patients on an enhanced recovery programme following laparoscopic colorectal surgery. A non-inferiority comparison was used. Adult patients undergoing elective laparoscopic colorectal surgery were randomly assigned to receive continuous transversus abdominis plane analgesia (n = 35) vs epidural analgesia (n = 35), in addition to a postoperative analgesic regimen comprising regular paracetamol, regular diclofenac and tramadol as required. Sixty-one patients completed the study. The transversus group received four-quadrant transversus abdominis plane blocks and bilateral posterior transversus abdominis plane catheters that were infused with levobupivacaine 0.25% for 48 h. The epidural group received an infusion of bupivacaine and fentanyl. The primary outcome measure was visual analogue scale pain score on coughing at 24 h after surgery. We found no significant difference in median (IQR [range]) visual analogue scores during coughing at 24 h between the transversus group 2.5 (1.0-3.0 [0-5.5]) and the epidural group 2.5 (1.0-5.0 [0-6.0]). The one-sided 97.5% CI was a 0.0 (∞-1.0) difference in means, establishing non-inferiority. There were no significant differences between the groups for tramadol consumption. Success rate was 28/30 (93%) in the transversus group vs 27/31 (87%) in the epidural group. Continuous transversus abdominis plane infusion was non-inferior to epidural infusion in providing analgesia after laparoscopic colorectal surgery. © 2013 The Association of Anaesthetists of Great Britain and Ireland.

Feasibility of preoperative planning using anatomical facsimile models for mandibular reconstruction.

PubMed

Toro, Corrado; Robiony, Massimo; Costa, Fabio; Zerman, Nicoletta; Politi, Massimo

2007-01-15

Functional and aesthetic mandibular reconstruction after ablative tumor surgery continues to be a challenge even after the introduction of microvascular bone transfer. Complex microvascular reconstruction of the resection site requires accurate preoperative planning. In the recent past, bone graft and fixation plates had to be reshaped during the operation by trial and error, often a time-consuming procedure. This paper outlines the possibilities and advantages of the clinical application of anatomical facsimile models in the preoperative planning of complex mandibular reconstructions after tumor resections. From 2003 to 2005, in the Department of Maxillofacial Surgery of the University of Udine, a protocol was applied with the preoperative realization of stereolithographic models for all the patients who underwent mandibular reconstruction with microvascular flaps. 24 stereolithographic models were realized prior to surgery before emimandibulectomy or segmental mandibulectomy. The titanium plates to be used for fixation were chosen and bent on the model preoperatively. The geometrical information of the virtual mandibular resections and of the stereolithographic models were used to choose the ideal flap and to contour the flap into an ideal neomandible when it was still pedicled before harvesting. Good functional and aesthetic results were achieved. The surgical time was decreased on average by about 1.5 hours compared to the same surgical kind of procedures performed, in the same institution by the same surgical team, without the aforesaid protocol of planning. Producing virtual and stereolithographic models, and using them for preoperative planning substantially reduces operative time and difficulty of the operation during microvascular reconstruction of the mandible.

A composite gluteofemoral flap for reconstruction of large pressure sores over the sacrococcygeal region.

PubMed

Xie, Yun; Zhuang, Yue-Hong; Xue, Lan; Zheng, He-Ping; Lin, Jian-Hua

2015-12-01

Gigantic pressure sores pose a daunting challenge for plastic surgeons. This paper presents a composite gluteofemoral flap for reconstruction of large pressure sores over the sacrococcygeal region. In this anatomical study, 30 embalmed cadaveric lower limbs were used for dissection to observe the musculocutaneous perforators of the inferior gluteal artery and the longitudinal nutritional vascular chain of the posterior femoral cutaneous nerve. In this clinical study, eight patients underwent surgical harvest of the composite gluteofemoral flap for coverage of grade IV sacrococcygeal pressure sores. The size of the pressure sores ranged between 16 × 9 cm and 22 × 10 cm. The inferior gluteal artery was present in 26 cases and absent in four cases. It gave off two to four musculocutaneous branches with a diameter larger than 0.5 mm to the gluteus maximus. A direct cutaneous branch was given off at the inferior margin of the gluteus maximus, serving as a nutritional artery for the posterior femoral cutaneous nerve. The size of the flap harvested ranged between 22 × 9 cm and 32 × 10 cm. Flaps in seven patients survived uneventfully and developed epidermal necrosis at the distal margin in one case. An average 2-year follow-up revealed no recurrence of pressure sores. The composite gluteofemoral flap, being robust in blood supply, simple in surgical procedure, and large in donor territory, is an important addition to the armamentarium. Copyright © 2015 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

Rectus abdominis atrophy after ventral abdominal incisions: midline versus chevron.

PubMed

Vigneswaran, Y; Poli, E; Talamonti, M S; Haggerty, S P; Linn, J G; Ujiki, M B

2017-08-01

Although many outcomes have been compared between a midline and chevron incision, this is the first study to examine rectus abdominis atrophy after these two types of incisions. Patients undergoing open pancreaticobiliary surgery between 2007 and 2011 at our single institution were included in this study. Rectus abdominis muscle thickness was measured on both preoperative and follow-up computed tomography (CT) scans to calculate percent atrophy of the muscle after surgery. At average follow-up of 24.5 and 19.0 months, respectively, rectus abdominis atrophy was 18.9% greater in the chevron (n = 30) than in the midline (n = 180) group (21.8 vs. 2.9%, p < 0.0001). Half the patients with a chevron incision had >20% atrophy at follow-up compared with 10% with a midline incision [odds ratio (OR) 9.0, p < 0.0001]. No significant difference was observed in incisional hernia rates or wound infections between groups. In this study, chevron incisions resulted in seven times more atrophy of the rectus abdominis compared with midline incisions. The long-term effects of transecting the rectus abdominis and disrupting its innervation creates challenging abdominal wall pathology. Atrophy of the abdominal wall can not be readily fixed with an operation, and this significant side effect of a transverse incision should be factored into the surgeon's decision-making process when choosing a transverse over a midline incision.

An anatomical comparison of Blair and facelift incisions for parotid surgery.

PubMed

Nouraei, S A R; Al-Yaghchi, C; Ahmed, J; Kirkpatrick, N; Mansuri, S; Singh, A; Grant, W E

2006-12-01

The rhytidectomy approach for parotidectomy allows the incision to be hidden, and post-operative scarring minimised. Furthermore, separate elevation of the Superficial Musculo-Aponeurotic System (SMAS) reduces the incidence of Frey's syndrome, and provides vascularized soft tissue for contour reconstruction. The technique has gained popularity particularly with plastic surgeons, but concerns persist that with this approach, particularly with lesions located anteriorly, access to the gland may be inadequate, and facial nerve identification may be compromised. We undertook an anatomical study to quantitatively compare the surgical access achieved using the facelift approach with the conventional Blair incision, by comparing the distances between the parotid edge and the retracted flaps. Despite reduced tissue elasticity due to formaldehyde fixation, it proved possible to demonstrate all regions of the parotid gland to the operating surgeon with either approach. There were no significant differences in the distance between the parotid edge and the retracted skin flaps (P > 0.1; paired t-test). The facelift approach provides at least equal access to all regions of the parotid gland when compared to a Blair's incision. It is a superior approach aesthetically and its more widespread use in parotid surgery is advocated.

Osseointegrated Implants and Prosthetic Reconstruction Following Skull Base Surgery.

PubMed

Hu, Shirley; Arnaoutakis, Demetri; Kadakia, Sameep; Vest, Allison; Sawhney, Raja; Ducic, Yadranko

2017-11-01

Rehabilitation following ablative skull base surgery remains a challenging task, given the complexity of the anatomical region, despite the recent advances in reconstructive surgery. Remnant defects following resection of skull base tumors are often not amenable to primary closure. As such, numerous techniques have been described for reconstruction, including local rotational muscle flaps, pedicled flaps with skin paddle, or even free tissue transfer. However, not all patients are appropriate surgical candidates and therefore may instead benefit from nonsurgical options for functional and aesthetic restoration. Osseointegrated implants and biocompatible prostheses provide a viable alternative for such a patient population. The purpose of this review serves to highlight current options for prosthetic rehabilitation of skull base defects and describe their indications, advantages, and disadvantages.

Locoregional and Microvascular Free Tissue Reconstruction of the Lateral Skull Base.

PubMed

Arnaoutakis, Demetri; Kadakia, Sameep; Abraham, Manoj; Lee, Thomas; Ducic, Yadranko

2017-11-01

The goals of reconstruction following any oncologic extirpation are preservation of function, restoration of cosmesis, and avoidance of morbidity. Anatomically, the lateral skull base is complex and conceptually intricate due to its three-dimensional morphology. The temporal bone articulates with five other cranial bones and forms many sutures and foramina through which pass critical neural and vascular structures. Remnant defects following resection of lateral skull base tumors are often not amenable to primary closure. As such, numerous techniques have been described for reconstruction including local rotational muscle flaps, pedicled flaps with skin paddle, or free tissue transfer. In this review, the advantages and disadvantages of each reconstructive method will be discussed as well as their potential complications.

Reconstruction of totally degloved fingers: a novel application of the bilobed spiraled innervated radial artery superficial palmar branch perforator flap design provides for primary donor-site closure.

PubMed

Chi, Zhenglin; Yang, Peng; Song, Dajiang; Li, Zan; Tang, Liang; Gao, Weiyang; Song, Yonghuan; Chu, Tingang

2017-05-01

To investigate the results of resurfacing completely degloved digits using bilobed innervated radial artery superficial palmar branch (RASPB) perforator flap in a spiral fashion. A detailed anatomic study on 30 adult fresh frozen cadavers preinjected with silicone rubber compound to demarcate arterial anatomy documented locations, numbers, and diameters of arteries and skin perforators with surrounding nerves. The flap-raising procedure was performed using four fresh cadaver specimen. We reviewed the reconstruction of 12 digits by using a bilobed spiraled innervated RASPB free perforator flap after non-replantable degloving injury. Two skin paddles were marked out using standard points of reference. At least two separate cutaneous perforator vessels were identified using a hand-held Doppler and were dissected back to the RASPB in retrograde fashion. The skin paddles were then divided between the two cutaneous perforators to provide two separate paddles with a common vascular supply. The skin paddles were stacked in a spiral fashion on the flap inset, effectively increasing the width of the flap to cover the totally degloved finger while still allowing closure of the primary donor-site. The RASPB was present within the flap in all cadavers. The direct perforator and the musculocutaneous perforator were available in 93.33 and 76.67 %, respectively, with neither of them in 6.67 % of the cases. The constantly present two perforators allowed the design of a new bilobed spiraled innervated radial artery superficial palmar branch perforator flap. We used the proposed flap to reconstruct completely degloved digits in 12 patients (mean age 28.6 years; range 17-35 years). With our proposed flap, no flap failure or re-exploration occurred and the donor site was closed primarily in all cases. All the flaps survived uneventfully. Total active motion ranged from 92° to 140° and 111° to 155° in the cases with and without metacarpophalangeal joint involvement, respectively. The static 2 point discrimination test varied from 6 to 11 mm. All the patients were satisfied with the overall results. The bilobed flap is large enough to cover totally degloved finger defects and contain direct skin perforators, provides a bespoke cover for complex soft tissue defects of completely degloved digits while also improving morbidity and cosmesis of the donor site. Level IV, retrospective series.

Does the Latissimus dorsi insert on the iliac crest in man? Anatomic and ontogenic study.

PubMed

Ben Hadj Yahia, Sihem; Vacher, Christian

2011-11-01

The Latissimus dorsi muscle is usually considered as inserted on the iliac crest, but it is separated from it by the thoracolumbar fascia. In our experience based on the harvesting of pedicled Latissimus dorsi flaps to cover cervicofacial loss of substances, we have found that in some cases, the muscular fibers of the anterior border of the muscle are directly inserted on the iliac crest. In these cases, the harvesting of the flap could be more distal. To determine whether this direct muscular insertion is frequent or not, we performed dissections on 30 fresh cadavers of the lower insertion of the Latissimus dorsi muscle, and 6 dissections of human fetuses to study the ontogeny of these insertions. The Latissimus dorsi muscle presented direct muscular insertions on the iliac crest in 13.33% of cases. The fetal dissections showed that before 30 weeks of development, the anterior part of the muscle was directly inserted on the iliac crest, and after it was separated from it by the thoracolumbar fascia. Although the harvesting of the Latissimus dorsi in continuity with the thoracolumbar fascia has been described in pedicled flaps, it is usually considered that it is impossible to harvest Latissimus dorsi musculocutaneous flaps in contact with the iliac crest, because there are no perforating vessels from the thoracolumbar fascia to the skin. According to our results, in some cases, it could be possible to harvest a pedicled musculo-cutaneous LD flap more distal that it is usually described.

The effects of running in place in a limited area with abdominal drawing-in maneuvers on abdominal muscle thickness in chronic low back pain patients.

PubMed

Gong, Wontae

2016-11-21

Based on previous studies indicating that core stabilization exercises accompanied by abdominal drawing-in maneuvers increase the thickness of the transversus abdominis muscle. The purpose of this study was to compare the measurements of abdominal muscle thicknesses during running in place in a limited area with the abdominal drawing-in maneuver. The study classified the subjects into two experimental groups: the training group (M = 2, F = 13), and the control group (M = 2, F = 13). The training group performed three sets of running in place in a limited area with abdominal drawing-in maneuvers each time, three times a week for six weeks. The abdominal muscle thicknesses of the subjects were measured using ultrasonography. Comparing the training group's abdominal muscle thickness before and after this study, there was a statistical significance in all of the external obliquus abdominis, the internal obliquus abdominis, and the transversus abdominis. In particular, thicknesses of external obliquus abdominis and internal obliquus increased remarkably. Running in place in a limited area accompanied by abdominal drawing-in maneuvers increased the thickness of the deep abdominal muscles that are the basis of trunk stabilization.

A comparison of plasma levobupivacaine concentrations following transversus abdominis plane block and rectus sheath block.

PubMed

Yasumura, R; Kobayashi, Y; Ochiai, R

2016-05-01

Levobupivacaine is commonly used as the local anaesthetic of choice in peripheral nerve blocks, but its pharmacokinetics have not been fully investigated. We compared the changes in plasma concentrations of levobupivacaine following transversus abdominis plane block and rectus sheath block. Fifty woman undergoing laparoscopy were randomly allocated to receive either a transversus abdominis plane block or an rectus sheath block. In both groups, 2.5 mg.kg(-1) levobupivacaine was administered, and blood samples were obtained 15 min, 30 min, 60 min and 120 min after injection. The mean maximum plasma concentration (Cmax) and mean time to reach Cmax (Tmax) as determined by non-linear regression analysis were 1.05 μg.ml(-1) and 32.4 min in the transversus abdominis plane group and 0.95 μg.ml(-1) and 60.9 min in the rectus sheath group, respectively. The plasma concentration of levobupivacaine peaked earlier in the transversus abdominis plane group than in the rectus sheath group and the maximum plasma concentration depended on the dose administered but not the procedure. © 2016 The Association of Anaesthetists of Great Britain and Ireland.

Intraoperative use of indocyanine green angiography for selecting the more reliable perforator of the anterolateral thigh flap: A comparison study.

PubMed

La Padula, Simone; Hersant, Barbara; Meningaud, Jean Paul

2018-03-30

Anatomical variability of anterolateral thigh flap (ALT) perforators has been reported. The aim of this study is to assess if the use of intraoperative indocyanine green angiography (iICGA) can help surgeons to choose the ALT flap best perforator to be preserved. A retrospective study was conducted in 28 patients with open tibial fracture, following a road traffic crash, who had undergone ALT flap. Patients were classified into two groups: ICGA group (iICGA was used to select the more reliable perforator) and control group. The mean tissue loss size of the ICGA group (n = 13, 11 men and 2 women, mean age: 52 ± 6 years) was of 16.6 cm × 12.2 cm. The mean defect size of the control group (n = 15, 14 men and 1 women, mean age: 50 ± 5.52 years) was of 15.3 cm × 11.1 cm. Statistical analysis was performed to analyze and compare the results. ICGA allowed preserving only the most functional perforator, that provided the best ALT flap perfusion in 10 out of the 13 cases (77%). ICGA allowed a significant operative time reduction (160 ± 23 vs. 202 ± 48 minutes; P < .001). One case of distal necrosis was observed in the ICGA group (mean follow-up 12.3 months), while partial skin necrosis occurred in three cases of the control group (mean follow-up 13.1 months); P = .35. No additional coverage was required and a successful bone healing was observed in both groups. These findings suggest that iICGA is an effective method that allows to select the most reliable ALT flap perforators and to reduce operative time. © 2018 Wiley Periodicals, Inc.

Spectrum of MRI findings in clinical athletic pubalgia.

PubMed

Zajick, Donald C; Zoga, Adam C; Omar, Imran M; Meyers, William C

2008-03-01

Athletic pubalgia is a frequently encountered syndrome for clinicians who treat active patients participating in a wide variety of athletic endeavors worldwide. Pathologies associated with this clinical scenario span anatomically from the pubic symphysis to the hip and include a myriad of poorly understood and incompletely described musculoskeletal entities, many of which are centered about the pubic symphysis and its tendinous attachments. In this article, we discuss the relevant anatomy and pathophysiology for the most frequently encountered of these disorders, using magnetic resonance (MR) images as a guide. We describe an MR imaging protocol tailored to clinical athletic pubalgia. We then review reproducible MRI patterns of pathology about the pubic symphysis, the rectus abdominis/adductor aponeurosis and the inguinal ring, as well as a group of clinically confounding entities remote from the symphysis but visible by MRI.

Transverse Cervical Artery: Consistent Anatomical Landmarks and Clinical Experience with Its Use as a Recipient Artery in Complex Head and Neck Reconstruction.

PubMed

Tessler, Oren; Gilardino, Mirko S; Bartow, Matthew J; St Hilaire, Hugo; Womac, Daniel; Dionisopoulos, Tassos; Lessard, Lucie

2017-03-01

Many head and neck reconstructions occur in patients with extensive history of surgery or radiation treatment. This leads to complicated free flap reconstructions, especially in choosing recipient vessels in a "frozen neck." The transverse cervical artery is an optimal second-line recipient artery in head and neck reconstruction. Seventy-two neck sides in 36 cadavers were dissected, looking for the transverse cervical artery and transverse cervical vein. Anatomical location of these vessels, their diameter, and length were documented. A retrospective analysis on 19 patients who had head and neck reconstruction using the transverse cervical artery as a recipient artery was undertaken as well with regard to outcome of procedures, reason for surgery, previous operations, and use of vein grafts during surgery. The transverse cervical artery was present in 72 of 72 of cadaveric specimens, and was infraclavicular in two of 72 specimens. Transverse cervical artery length ranged from 4.0 to 7.0 cm, and the mean diameter was 2.65 mm. The transverse cervical vein was present in 61 of 72 cadaveric specimens, the length ranged from 4.0 to 7.0 cm, and the mean diameter was 2.90 mm. The transverse cervical artery averaged 33 mm from midline, and branched off the thyrocervical trunk at an average 17 mm superior to the clavicle. Transverse cervical artery stenosis was markedly less in comparison with external carotid artery stenosis. In a 20-year clinical follow-up study, the transverse cervical artery was the recipient artery in 19 patients. A vein graft was used in one patient, and no flap loss occurred in any of the 19 patients. The transverse cervical artery is a reliable and robust option as a recipient artery in free flap head and neck reconstruction.

Effects of neuromuscular joint facilitation on bridging exercises with respect to deep muscle changes.

PubMed

Zhou, Bin; Huang, QiuChen; Zheng, Tao; Huo, Ming; Maruyama, Hitoshi

2015-05-01

[Purpose] This study examined the effects of neuromuscular joint facilitation on bridging exercises by assessing the cross-sectional area of the multifidus muscle and thickness of the musculus transversus abdominis. [Subjects] Twelve healthy men. [Methods] Four exercises were evaluated: (a) supine resting, (b) bridging resistance exercise involving posterior pelvic tilting, (c) bridging resistance exercise involving anterior pelvic tilting, and (d) bridging resistance exercise involving neuromuscular joint facilitation. The cross-sectional area of the multifidus muscle and thickness of the musculus transversus abdominis were measured during each exercise. [Results] The cross-sectional area of the multifidus muscle and thickness of the musculus transversus abdominis were significantly greater in the neuromuscular joint facilitation group than the others. [Conclusion] Neuromuscular joint facilitation intervention improves the function of deep muscles such as the multifidus muscle and musculus transversus abdominis. Therefore, it can be recommended for application in clinical treatments such as that for back pain.

Blunt transection of rectus abdominis following seatbelt related trauma with associated small and large bowel injury.

PubMed

Patel, K; Doolin, R; Suggett, N

2013-01-01

Closed rupture of rectus abdominis following seatbelt related trauma is rare. We present the case of a 45 year old female who presented with closed rupture of the rectus abdominis in conjunction with damage to small bowel mesentery and infarction of small and large bowel following a high velocity road traffic accident. Multiple intestinal resections were required resulting in short bowel syndrome and abdominal wall reconstruction with a porcine collagen mesh. Post-operative complications included intra-abdominal sepsis and an enterocutaneous fistula. The presence of rupture of rectus abdominis muscle secondary to seatbelt injury should raise the suspicion of intra-abdominal injury. Our case highlights the need for suspicion, investigation and subsequent surgical management of intra-abdominal injury following identification of this rare consequence of seatbelt trauma. Copyright © 2013 The Authors. Published by Elsevier Ltd.. All rights reserved.

Functional Reconstruction with Latissimus Dorsi Flap following Resection of an Extensive Basal Cell Carcinoma in the Shoulder Region: A Case Report

PubMed Central

Paprottka, Felix J.; Klimas, Dalius; Hebebrand, Detlev

2018-01-01

Large and ulcerating skin tumors have become a rarity in the modern Western world. However, these conditions can cause serious life-threatening complications. The case of a 60-year-old male Caucasian patient is reported, who had suffered from an extensive basal cell carcinoma in the right shoulder region for several years. The patient kept the lesion secret from his friends and family and delayed presentation to health care services. After an episode of tumor-related heavy bleeding, the patient was referred to our clinic and received a radical surgical tumor resection—followed by defect coverage with a latissimus dorsi myocutaneous flap. An alternative treatment option that could be offered to the patient would have been a mutilating surgical procedure with an arm amputation. By using this plastic reconstructive surgical technique, the main function of the shoulder joint was conserved. The presented case demonstrates options for defect coverage of problematic wounds in anatomically complex body regions—like the shoulder—by using a functional reconstruction using myocutaneous flaps. PMID:29896564

Routine preoperative colour Doppler duplex ultrasound scanning in anterolateral thigh flaps.

PubMed

Lichte, Johanna; Teichmann, Jan; Loberg, Christina; Kloss-Brandstätter, Anita; Bartella, Alexander; Steiner, Timm; Modabber, Ali; Hölzle, Frank; Lethaus, Bernd

2016-10-01

The anterolateral thigh flap (ALT) is often used to reconstruct the head and neck and depends on one or more skin perforators, which often present with variable anatomy. The aim of this study was to localise and evaluate the precise position of these perforators preoperatively with colour Doppler duplex ultrasound scanning (US). We detected 74 perforators in 30 patients. The mean duration of examination with colour Doppler was 29 (range 13-51) minutes. Adequate perforators and their anatomical course could be detected preoperatively extremely accurately (p<0.001). The mean difference between the preoperatively marked, and the real, positions was 6.3 (range 0-16) mm. There was a highly significant correlation between the accuracy of the prediction and the body mass index of the patient (0.75; p<0.001). Neither the age nor the sex of the patient correlated with the accuracy of the prediction. Colour Doppler duplex US used preoperatively to localise perforators in ALT flaps is reliable and could be adopted as standard procedure. Copyright © 2016 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Quantifying muscle patterns and spine load during various forms of the push-up.

PubMed

Freeman, Stephanie; Karpowicz, Amy; Gray, John; McGill, Stuart

2006-03-01

This study was conducted to quantify the normalized amplitudes of the abdominal wall and back extensor musculature during a variety of push-up styles. We also sought to quantify their impact on spinal loading by calculating spinal compression and torque generation in the L4-5 area. Ten university-age participants, nine males and one female, in good to excellent condition, volunteered to participate in this study. All participants were requested to perform a maximum of 12 different push-up exercises, three trials per exercise. Surface electromyographic data (EMG) were collected bilaterally on rectus abdominis, external oblique, internal oblique, latissimus dorsi, and erector spinae muscles, and unilaterally (right side) on pectoralis major, triceps brachii, biceps brachii, and anterior deltoid muscles. Spine kinetics were obtained using an anatomically detailed model of the torso/spine. This study revealed that more dynamic push-ups (i.e., ballistic, with hand movement) required more muscle activation and higher spine load, whereas placing labile balls under the hands only resulted in modest increases in spine load. Right rectus abdominis (RA) activation was significantly higher than left RA activation during the left hand forward push-up and vice versa for the right hand forward push-up (P < 0.001). External oblique (EO) demonstrated the same switch in dominance during staggered hand push-ups (P < 0.01). The one-arm push-up resulted in the highest spine compression. Skilled participants showed greater synchronicity with peak muscle activation (plyometric type of contractions) during ballistic push-ups. These data will help guide exercise selection for individuals with differing training objectives and injury history.

Imaging of patent foramen ovale with 64-section multidetector CT.

PubMed

Saremi, Farhood; Channual, Stephanie; Raney, Aidan; Gurudevan, Swaminatha V; Narula, Jagat; Fowler, Steven; Abolhoda, Amir; Milliken, Jeffrey C

2008-11-01

To investigate the feasibility of 64-section multidetector computed tomography (CT) by using CT angiography (a) to demonstrate anatomic detail of the interatrial septum pertinent to the patent foramen ovale (PFO), and (b) to visually detect left-to-right PFO shunts and compare these findings in patients who also underwent transesophageal echocardiography (TEE). In this institutional review board-approved HIPAA-compliant study, electrocardiographically gated coronary CT angiograms in 264 patients (159 men, 105 women; mean age, 60 years) were reviewed for PFO morphologic features. The length and diameter of the opening of the PFO tunnel, presence of atrial septal aneurysm (ASA), and PFO shunts were evaluated. A left-to-right shunt was assigned a grade according to length of contrast agent jet (grade 1, 1 cm to 2 cm; grade 3, >2 cm). In addition, 23 patients who underwent both modalities were compared (Student t test and linear regression analysis). A difference with P < .05 was significant. A flap valve, seen in 101 (38.3%) patients, was patent at the entry into the right atrium (PFO) in 62 patients (61.4% of patients with flap valve, 23.5% of total patients). A left-to-right shunt was detected in 44 (16.7% of total) patients (grade 1, 61.4%; grade 2, 34.1%; grade 3, 4.5%). No shunt was seen in patients without a flap valve. Mean length of PFO tunnel was 7.1 mm in 44 patients with a shunt and 12.1 mm in 57 patients with a flap valve without a shunt (P < .0001). In patients with a tunnel length of 6 mm or shorter, 92.6% of the shunts were seen. ASA was seen in 11 (4.2%) patients; of these patients, a shunt was seen in seven (63.6%). In 23 patients who underwent CT angiography and TEE, both modalities showed a PFO shunt in seven. Multidetector CT provides detailed anatomic information about size, morphologic features, and shunt grade of the PFO. Shorter tunnel length and septal aneurysms are frequently associated with left-to-right shunts in patients with PFO. (c) RSNA, 2008.

Comparison of abdominal muscle activity and peak expiratory flow between forced vital capacity and fast expiration exercise.

PubMed

Ishida, Hiroshi; Suehiro, Tadanobu; Watanabe, Susumu

2017-04-01

[Purpose] The purpose of this investigation was to compare the activities of the abdominal muscles and peak expiratory flow between forced vital capacity and fast expiration exercise. [Subjects and Methods] Fifteen healthy male participated in this study. Peak expiratory flow and electromyographic activities of the rectus abdominis, external oblique, and internal oblique/transversus abdominis muscles were measured during forced vital capacity and fast expiration exercise and then peak amplitude and its appearance time were obtained. [Results] Peak expiratory flow values were significantly higher during fast expiration exercise than during forced vital capacity. The internal oblique/transversus abdominis muscles showed significantly higher peak amplitude during fast expiration exercise than during forced vital capacity. However, there were no significant differences between forced vital capacity and fast expiration exercise in the rectus abdominis and external oblique muscles. There was no difference in the appearance time of the peak amplitude between forced vital capacity and fast expiration exercise in any muscle. [Conclusion] Fast expiration exercise might be beneficial for increasing expiratory speed and neuromuscular activation of the internal oblique/transversus abdominis muscles compared to forced vital capacity. These findings could be considered when recommending a variation of expiratory muscle strength training as part of pulmonary rehabilitation programs.

Use of the medial femoral condyle vascularized bone flap in traumatic avascular necrosis of the navicular: a case report.

PubMed

Holm, Janson; Vangelisti, Garrett; Remmers, Jared

2012-01-01

The medial femoral condyle vascularized bone flap has a high success rate in published literature regarding its use in nonunions and avascular necrosis of the upper and lower extremities. It is reported to have minimal donor site morbidity and the ability to provide structural support and torsional strength to load-bearing areas. The flap has found particular success in the treatment of scaphoid nonunions. The tarsal navicular, similar to the scaphoid, is largely articular cancellous bone with little surface area for vascular inflow. These anatomic features make the navicular prone to nonunion and avascular necrosis in traumatic scenarios. We describe a case of nonunion and avascular necrosis of the tarsal navicular occurring as sequelae of a high-impact midfoot injury sustained in an automobile accident. After an initial attempt at open reduction and internal fixation with midfoot bridge plating, subsidence and nonunion resulted. An attempt at arthrodesis of the talonavicular and naviculocuneiform joints was then undertaken. This too failed, leading to the development of additional collapse and avascular necrosis. The site was treated with a medial femoral condyle vascularized bone flap. In this single case, the patient returned to pain-free ambulation and reported excellent outcomes and functional capacity. Although we present a successful case, a larger case series is necessary to establish the use of this flap as a reliable option for the treatment of nonunion and avascular necrosis of the tarsal navicular. Copyright © 2012 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.

The anatomy of the musculocutaneous latissimus dorsi flap for neophalloplasty.

PubMed

Dennis, M; Granger, A; Ortiz, A; Terrell, M; Loukos, M; Schober, J

2018-03-01

In transgender surgery, the ideal neophallus is one that: (a) is constructed using a reproducible procedure, (b) possesses tactile and erogenous sensation, (c) is large and rigid enough (naturally, or using a prosthesis) to permit penetrative intercourse, (d) leaves acceptable donor site morbidity, (e) results in esthetically satisfactory appearance, and (f) allows for voiding while standing. The musculocutaneous latissimus dorsi (MLD) flap has favorable results in the area of neophalloplasty. Among its advantages are acceptable donor site appearance, stiffness sufficient for intercourse, and esthetically satisfactory genital appearance. The anatomy of the MLD flap supports the creation of a neophallus for transsexual anatomy revision. Herein, we give an overview of the advantages and disadvantages of the procedure, and the anatomical details and surgical steps involved. Novel illustrations were created from standard surgical text descriptions to clarify this topic for surgical training and patient understanding and decision making. A review of the relevant literature regarding the anatomy, procedure development, and outcomes is presented. The MLD flap uses part of the latissimus dorsi muscle with branches of the thoracodorsal vessels and nerve to construct a neophallus. A thin strip of muscle around the pedicle is harvested, resulting in a slightly curvilinear scar. The blood supply is connected to the femoral artery and saphenous vein or the deep inferior epigastric artery and vein, while the nerve is connected to the ilioinguinal nerve or the obturator nerve. The MLD flap for neophalloplasty is a reliable graft with a well concealed scar and low donor site morbidity. Clin. Anat. 31:152-159, 2018. © 2017 Wiley Periodicals, Inc. © 2017 Wiley Periodicals, Inc.

Multiple Free Internal Limiting Membrane Flap Insertion in the Treatment of Macular Hole-Associated Retinal Detachment in High Myopia.

PubMed

Chen, San-Ni; Hsieh, Yi-Ting; Yang, Chung-May

2018-06-06

The aim of this paper was to evaluate the efficacy of multiple free internal limiting membrane (ILM) flap insertion in the management of macular hole-associated retinal detachment in high myopia. Eyes receiving operation for macular hole-associated retinal detachment were retrospectively recruited. Those in the study group received ILM peeling and multiple free ILM flap insertion, while those in the control group received ILM peeling only. Postoperative anatomical outcomes and best-corrected visual acuity were compared between the 2 groups. Twenty-seven eyes of 27 patients were recruited in this study (13 in the study group, 14 in the control group). After the operation, the retina was reattached in all cases in both groups. The macular hole closure rate was 100% in the study group but only 42.9% in the control group (adjusted p < 0.001). The eyes in the study group had better visual improvement (logMAR -0.58 ± 0.43) than those in the control group (logMAR -0.31 ± 0.50) with borderline significance (adjusted p = 0.078). For macular hole-associated retinal detachment in highly myopic eyes, the multiple free ILM flap insertion technique offers an effective way to close macular holes. Whether this result also means better visual outcome remains to be seen. © 2018 S. Karger AG, Basel.

A Novel Augmented Reality-Based Navigation System in Perforator Flap Transplantation - A Feasibility Study.

PubMed

Jiang, Taoran; Zhu, Ming; Zan, Tao; Gu, Bin; Li, Qingfeng

2017-08-01

In perforator flap transplantation, dissection of the perforator is an important but difficult procedure because of the high variability in vascular anatomy. Preoperative imaging techniques could provide substantial information about vascular anatomy; however, it cannot provide direct guidance for surgeons during the operation. In this study, a navigation system (NS) was established to overlie a vascular map on surgical sites to further provide a direct guide for perforator flap transplantation. The NS was established based on computed tomographic angiography and augmented reality techniques. A virtual vascular map was reconstructed according to computed tomographic angiography data and projected onto real patient images using ARToolKit software. Additionally, a screw-fixation marker holder was created to facilitate registration. With the use of a tracking and display system, we conducted the NS on an animal model and measured the system error on a rapid prototyping model. The NS assistance allowed for correct identification, as well as a safe and precise dissection of the perforator. The mean value of the system error was determined to be 3.474 ± 1.546 mm. Augmented reality-based NS can provide precise navigation information by directly displaying a 3-dimensional individual anatomical virtual model onto the operative field in real time. It will allow rapid identification and safe dissection of a perforator in free flap transplantation surgery.

Muscle mass and composition of the hip, thigh and abdominal muscles in women with and without hip osteoarthritis.

PubMed

Fukumoto, Yoshihiro; Ikezoe, Tome; Tateuchi, Hiroshige; Tsukagoshi, Rui; Akiyama, Haruhiko; So, Kazutaka; Kuroda, Yutaka; Yoneyama, Tomohide; Ichihashi, Noriaki

2012-09-01

The objective of this study was to compare muscle mass and composition between individuals with and without hip osteoarthritis. Twenty-four women with hip osteoarthritis (OA group) and 16 healthy women (healthy group) participated in this study. Muscle thickness (MT) and echo intensity (EI) were measured as indices of muscle mass and composition, respectively, using ultrasound imaging. Seven muscles were examined: gluteus maximus, gluteus medius, quadriceps femoris, rectus abdominis, external oblique, internal oblique and transversus abdominis. MT of only quadriceps femoris in the OA group was significantly thinner than that in the healthy group. EIs of gluteus medius, quadriceps femoris and rectus abdominis were significantly higher in the OA group than those in the healthy group. Thus, actual contractile tissue of gluteus medius and rectus abdominis substantially decreased, although muscle mass was similar, whereas both quantitative and qualitative changes occurred in quadriceps femoris in patients with hip OA. Copyright © 2012 World Federation for Ultrasound in Medicine & Biology. Published by Elsevier Inc. All rights reserved.

[Use of free vascularized fibular graft flap in the treatment of large bone defects after limb injury].

PubMed

Bumbasirević, Marko Z; Lesić, Aleksandar R; Atkinson, Henry Dushan Edward; Tulić, Goran C

2013-01-01

Free vascularized fibular graft is of the greatest importance in the orthopaedics and trauma. Bone, skeletal defects due to the trauma, infections and congenital anomalies could be successfully solved by the free vascularized fibular grafts. In this article the main anatomical data of fibular graft, surgical techniques, indications for the FVFG in the treatment of trauma caused bone defects or its complications -sequels are described.

Mastering Lymphatic Microsurgery: A New Training Model in Living Tissue.

PubMed

Campisi, Corrado Cesare; Jiga, Lucian P; Ryan, Melissa; di Summa, Pietro G; Campisi, Corradino; Ionac, Mihai

2017-09-01

Advanced microsurgical techniques have emerged as a promising approach for the treatment of lymphedema, but achieving international standards is limited by a scarcity of adequate training models. The purpose of this report is to describe our in vivo porcine training model for microsurgery. Five female common-breed pigs (Sus scrofa domesticus) weighing 20 to 28 kg were placed under general anesthesia, and blue patent violet dye was injected to highlight lymphatic structures and prepare the pigs for anatomical exploration and microsurgery. The number and type of patent anastomoses achieved and lymph node flaps created and any anatomical differences between porcine and human vessels were noted, in light of evaluating the use of pigs as a training model for microsurgery in living tissue. Multiple lymphatic-venous anastomoses were created at the site of a single incision made at the subinguinal region, running medial and parallel to the saphenous vessels. Ten multiple lymphatic-venous anastomoses were created in total, and all were demonstrated to be patent. Four lymph node flaps were prepared for lymph node transfer. The superficial lymphatic collector system in the caudal limb of the pig was identified and described with particular reference to the superficial, medial (dominant), and lateral branches along the saphenous vein and its accessory. The authors present a safe and adaptable in vivo experimental microsurgical porcine model that provides the opportunity to practice several advanced lymphatic microsurgical techniques in the same animal. The ideal lymph node transfer training model can be developed from this anatomical detail, giving the opportunity to use it for artery-to-artery anastomoses, vein-to-vein anastomoses, and lymphatic-to-lymphatic anastomoses.

Effects of age and inactivity due to prolonged bed rest on atrophy of trunk muscles.

PubMed

Ikezoe, Tome; Mori, Natsuko; Nakamura, Masatoshi; Ichihashi, Noriaki

2012-01-01

This study investigated the effects of age and inactivity due to being chronically bedridden on atrophy of trunk muscles. The subjects comprised 33 young women (young group) and 41 elderly women who resided in nursing homes or chronic care institutions. The elderly subjects were divided into two groups: independent elderly group who were able to perform activities of daily living involving walking independently (n = 28) and dependent elderly group who were chronically bedridden (n = 13). The thickness of the following six trunk muscles was measured by B-mode ultrasound: the rectus abdominis, external oblique, internal oblique, transversus abdominis, thoracic erector spinae (longissimus) and lumbar multifidus muscles. All muscles except for the transversus abdominis and lumbar multifidus muscles were significantly thinner in the independent elderly group compared with those in the young group. The thicknesses of all muscles in the dependent elderly group was significantly smaller than that in the young group, whereas there were no differences between the dependent elderly and independent elderly groups in the muscle thicknesses of the rectus abdominis and internal oblique muscles. In conclusion, our results suggest that: (1) age-related atrophy compared with young women was less in the deep antigravity trunk muscles than the superficial muscles in the independent elderly women; (2) atrophy associated with chronic bed rest was more marked in the antigravity muscles, such as the back and transversus abdominis.

Case Report: Late Reconstruction of the Land Mine-Injured Heel With an Osteomyocutaneous Composite Fibular Flap.

PubMed

Tuzun, Harun Yasin; Kurklu, Mustafa; Kulahci, Yalcin; Turkkan, Selim; Arsenishvili, Arsen

The heel comprises the epidermis, minimal subcutaneous tissue, a dense septum, and the calcaneus. Injury to any of these structures can impair the ability to walk. The soft tissue or calcaneal bone can be injured by trauma. Injuries incurred in war are usually high-energy traumas caused by weapons such as rifles, rockets, and land mines. Such injuries can be life threatening and involve the loss of tissue, including skin, soft tissue, bone, and neurovascular tissue. Two main treatment protocols are used for such injuries with large tissue defects: amputation and reconstruction. We describe a reconstruction with an osteomyocutaneous fibular flap for a heel injury. At the 2-year follow-up point, the patient had 30% loss of ankle range of motion. The visual analog scale score had dramatically decreased from 8 to 1, and the patient was satisfied with the result. In conclusion, patients with significant problems such as infection, pain, and anatomic deterioration of the calcaneus can be successfully treated using an osteomyocutaneous fibular flap in a single surgery. Copyright © 2017 The American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.

[Surgical coverage technics of pressure sores and their outcomes].

PubMed

Bilkay, Ufuk; Helvaci, Evren; Tokat, Cenk; Ozek, Cüneyt; Akin, Yalçin

2006-04-01

We reviewed the outcome of 66 patients with 100 pressure sores between 1984 and 2002. In the current study, 100 pressure sores in 66 patients (45 male, 21 female; mean age 39.4; range 13 to 80 years) who underwent surgical repair of pressure sores reconstructed using myocutaneous or fasciocutaneous flaps, skin grafts, excision and closure. The risk factors for pressure sores included acute trauma-induced spinal cord injury in 40 (61%) patients with paraplegia and in 5 (7%) patients with quadriplegia; congenital spina bifida and multiple sclerosis in 7 (11%) patients and prolonged immobilization in 14 (21 patients) patients. We achieved an overall pressure sore recurrence rate of 22% and overall patient recurrence of 24% in a-3-year follow-up. The recurrence rates according to anatomic sites; 23% (10 of 43) for the ischial pressure sore, sacral 21% (8 of 37), and trochanteric 20% (4 of 20). Fasciocutaneous and myocutaneous flap reconstructions were the most durable, as they were associated with 17% (6 of 34) and 12% recurrence rates (5 of 39). To reduce the recurrence rates the authors advocate the use of myocutaneous and fasciocutaneous flaps instead of skin grafts or direct closure for the coverage of pressure sores.

Retroauricular skin: a flaps bank for ear reconstruction.

PubMed

Cordova, A; D'Arpa, S; Pirrello, R; Giambona, C; Moschella, F

2008-01-01

The retroauricular skin has always been given much attention by the reconstructive surgeon for ear and face reconstruction because it is richly vascularised, as many anatomical investigations show, it is hidden behind the ear, its skin is very similar to that of ear and face. All these reasons make it an ideal donor site for ear reconstruction. The authors propose their own algorithm for reconstruction of every kind of anterior defects of the auricle with different Retroauricular Island Flaps (RIFs) based on the location and size of the defect developed over a 16 years single institution's experience with a series of 216 consecutive cases. 216 patients have undergone ear reconstruction with RIFs from 1999 to 2006. In 52 a Superior Pedicle RIF (SP-RIF) was used for defects of the upper half of the auricle. In 68 cases a Perforator RIF (P-RIF) was used for conchal reconstruction. In 96 cases an Inferior Pedicle RIF (IP-RIF) was used for reconstruction of nonmarginal and superficial marginal defects of the auricle. No flap failure was recorded. Excellent morphological reconstruction was obtained with these flaps with no sequealae at the donor site in terms of form and function. Only in the case of P-RIFs the sulcus becomes flat in its central part, but this has never affected the possibility of wearing spectacles. The SP-RIFs may sometimes show some signs of venous stasis that invariably resolve in the first two postoperative days. The retroauricular skin may be considered a flaps bank for ear reconstruction. It offers in fact a great variety of island flaps that are suitable for every kind of loss of substance of the ear, have a safe vascularisation, skin of similar colour and texture, are easy to harvest under local anaesthesia on an outpatient basis and cause no relevant morbidity at the donor site. Location and size of the defects lead the choice between the different types of RIFs.

Scapular flap for maxillectomy defect reconstruction and preliminary results using three-dimensional modeling.

PubMed

Modest, Mara C; Moore, Eric J; Abel, Kathryn M Van; Janus, Jeffrey R; Sims, John R; Price, Daniel L; Olsen, Kerry D

2017-01-01

Discuss current techniques utilizing the scapular tip and subscapular system for free tissue reconstruction of maxillary defects and highlight the impact of medical modeling on these techniques with a case series. Case review series at an academic hospital of patients undergoing maxillectomy + thoracodorsal scapula composite free flap (TSCF) reconstruction. Three-dimensional (3D) models were used in the last five cases. 3D modeling, surgical, functional, and aesthetic outcomes were reviewed. Nine patients underwent TSCF reconstruction for maxillectomy defects (median age = 43 years; range, 19-66 years). Five patients (55%) had a total maxillectomy (TM) ± orbital exenteration, whereas four patients (44%) underwent subtotal palatal maxillectomy. For TM, the contralateral scapula tip was positioned with its natural concavity recreating facial contour. The laterally based vascular pedicle was ideally positioned for facial vessel anastomosis. For subtotal-palatal defect, an ipsilateral flap was harvested, but inset with the convex surface facing superiorly. Once 3D models were available from our anatomic modeling lab, they were used for intraoperative planning of the last five patients. Use of the model intraoperatively improved efficiency and allowed for better contouring/plating of the TSCF. At last follow-up, all patients had good functional outcomes. Aesthetic outcomes were more successful in patients where 3D-modeling was used (100% vs. 50%). There were no flap failures. Median follow-up >1 month was 5.2 months (range, 1-32.7 months). Reconstruction of maxillectomy defects is complex. Successful aesthetic and functional outcomes are critical to patient satisfaction. The TSCF is a versatile flap. Based on defect type, choosing laterality is crucial for proper vessel orientation and outcomes. The use of internally produced 3D models has helped refine intraoperative contouring and flap inset, leading to more successful outcomes. 4. Laryngoscope, 127:E8-E14, 2017. © 2016 The American Laryngological, Rhinological and Otological Society, Inc.

A retrospective study: Multivariate logistic regression analysis of the outcomes after pressure sores reconstruction with fasciocutaneous, myocutaneous, and perforator flaps.

PubMed

Chiu, Yu-Jen; Liao, Wen-Chieh; Wang, Tien-Hsiang; Shih, Yu-Chung; Ma, Hsu; Lin, Chih-Hsun; Wu, Szu-Hsien; Perng, Cherng-Kang

2017-08-01

Despite significant advances in medical care and surgical techniques, pressure sore reconstruction is still prone to elevated rates of complication and recurrence. We conducted a retrospective study to investigate not only complication and recurrence rates following pressure sore reconstruction but also preoperative risk stratification. This study included 181 ulcers underwent flap operations between January 2002 and December 2013 were included in the study. We performed a multivariable logistic regression model, which offers a regression-based method accounting for the within-patient correlation of the success or failure of each flap. The overall complication and recurrence rates for all flaps were 46.4% and 16.0%, respectively, with a mean follow-up period of 55.4 ± 38.0 months. No statistically significant differences of complication and recurrence rates were observed among three different reconstruction methods. In subsequent analysis, albumin ≤3.0 g/dl and paraplegia were significantly associated with higher postoperative complication. The anatomic factor, ischial wound location, significantly trended toward the development of ulcer recurrence. In the fasciocutaneous group, paraplegia had significant correlation to higher complication and recurrence rates. In the musculocutaneous flap group, variables had no significant correlation to complication and recurrence rates. In the free-style perforator group, ischial wound location and malnourished status correlated with significantly higher complication rates; ischial wound location also correlated with significantly higher recurrence rate. Ultimately, our review of a noteworthy cohort with lengthy follow-up helped identify and confirm certain risk factors that can facilitate a more informed and thoughtful pre- and postoperative decision-making process for patients with pressure ulcers. Copyright © 2017 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

Osteomyocutaneous fibular flap harvesting: Computer-assisted planning of perforator vessels using Computed Tomographic Angiography scan and cutting guide.

PubMed

Battaglia, Salvatore; Maiolo, Vincenzo; Savastio, Gabriella; Zompatori, Maurizio; Contedini, Federico; Antoniazzi, Elisa; Cipriani, Riccardo; Marchetti, Claudio; Tarsitano, Achille

2017-10-01

Mandibular reconstruction performed after virtual planning has become more common during recent years. The gold standard for extensive mandibular reconstruction is of course a fibular free flap. In designing an osteomyocutaneous fibula flap, poor planning, aberrant anatomy and/or inadequate perforator vessels are the most frequent causes of complications and may force the surgeon to modify the flap design, explore the contralateral leg or harvest an additional microvascular flap. The goal of our study was to pre-operatively evaluate the vascular anatomy of the fibula and localize the cutaneous perforator vessels, so to create the fibular cutting guide based on the position of the cutaneous perforator and safely harvest the reconstructive flap. Twenty consecutive patients who were candidates for mandibular reconstruction using a fibular microvascular free flap were enrolled in this study between January 2016 and August 2016. The patients were preoperatively assessed with a Computed Tomographic scan of head and neck and with a Computed Tomographic Angiography (CTA) scan of the lower limbs to evaluate the vascular anatomy of the fibula. Virtual planning was carried out for all patients. The fibular cutting guide was based on the position of the perforator cutaneous vessels, which were used to harvest the cutaneous part of the flap. Preoperative CT measurements were performed in order to identify the cutaneous perforators on the patients' skin. Intraoperative checking was performed to evaluate the accuracy of the perforators' position and the reproducibility of the virtual planning. In 5 patients out of 20 (25%), anatomical anomalies were discovered, without clinical evidence. The perforator vessels were localized in all patients. The average difference between the CTA and the intraoperative perforator localization was 1 mm (range 0-2 mm). Fibular cutting guide was positioned and fitted the anatomy of the patients in all treated patients. This allowed us to perform the planned segmentation of the fibula, obtaining the correct number of segments. In all cases, flap insetting was carried out and skin paddle was positioned as preoperatively planned. Neither donor site complications nor flap complications occurred. Preoperative evaluation of the legs using CTA, in patients who undergo an osteomyocutaneous fibular free flap for mandibular reconstruction, is a valuable approach to reduce altered-anatomy related complications and to improve the accuracy and outcomes of the reconstruction, especially in reconstructions of complex defects. In these cases, a soft tissue-based cutting guide can be planned based on the perforator vessels of the skin paddle, minimizing the harvesting risks of vascular lesions. Further studies and longer follow-ups are needed to evaluate the long-term outcomes and advantages of this procedure. Copyright © 2017 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.

Sports Hernia: Diagnosis, Management and Operative Treatment

PubMed Central

Emblom, Benton A.

2017-01-01

Objectives: Athletic Pubalgia, also known as sports hernia or core muscle injury, causes significant dysfunction in athletes. Increased recognition of this specific injury distinct from inguinal hernia pathology has led to better management of this debilitating condition. We hypothesize that patients who undergo our technique of athletic pubalgia repair will recover and return to high-level athletics. Methods: Using our billing and clinical database, patients who underwent sports hernia repair by single surgeon at a single institution were contacted for Harris hip score, functional outcome, and return to play data. Results: Of 101 patients who met criteria, 43 were contacted. 93% of patients were able to return to play at an average of 4.38 mo. Normal activities were rated at 95.5% and athletic function was rated at 88.9%. Negative predictors were female sex, multiple operations, and prior inguinal hernia repair. Overall complication rate was 4.6%, and reoperation rate was 4.6%. Conclusion: Our method of adductor to rectus abdominis turn up flap is a safe procedure with high return to play success. Patients who had previously undergone inguinal hernia repair or other hip/pelvic related surgery had a worse outcome.

Nonexpansive immediate breast reconstruction using human acellular tissue matrix graft (AlloDerm).

PubMed

Salzberg, C Andrew

2006-07-01

Immediate breast reconstruction has become a standard of care following mastectomy for cancer, largely due to improved esthetic and psychologic outcomes achieved with this technique. However, the current historical standards--transverse rectus abdominis myocutaneous flap reconstruction and expander--implant surgery-still have limitations as regards patient morbidity, short-term body-image improvements, and even cost. To address these shortcomings, we employ a novel concept of human tissue replacement to enhance breast shape and provide total coverage, enabling immediate mound reconstruction without the need for breast expansion prior to permanent implant placement. AlloDerm (human acellular tissue matrix) is a human-derived graft tissue with extensive experience in various settings of skin and soft tissue replacement surgery. This report describes the success using acellular tissue matrix to provide total coverage over the prosthesis in immediate reconstruction, with limited muscle dissection. In this population, 49 patients (76 breasts) successfully underwent the acellular tissue matrix-based immediate reconstruction, resulting in durable breast reconstruction with good symmetry. These findings may predict that acellular tissue matrix-supplemented immediate breast reconstruction will become a new technique for the immediate reconstruction of the postmastectomy breast.

Refinements in pectus carinatum correction: the pectoralis muscle split technique.

PubMed

Schwabegger, Anton H; Jeschke, Johannes; Schuetz, Tanja; Del Frari, Barbara

2008-04-01

The standard approach for correction of pectus carinatum deformity includes elevation of the pectoralis major and rectus abdominis muscle from the sternum and adjacent ribs. A postoperative restriction of shoulder activity for several weeks is necessary to allow stable healing of the elevated muscles. To reduce postoperative immobilization, we present a modified approach to the parasternal ribs using a pectoralis muscle split technique. At each level of rib cartilage resection, the pectoralis muscle is split along the direction of its fibers instead of elevating the entire muscle as performed with the standard technique. From July 2000 to May 2007, we successfully used this technique in 33 patients with pectus carinatum deformity. After the muscle split approach, patients returned to full unrestricted shoulder activity as early as 3 weeks postoperatively, compared to 6 weeks in patients treated with muscle flap elevation. Postoperative pain was reduced and the patients were discharged earlier from the hospital than following the conventional approach. The muscle split technique is a modified surgical approach to the parasternal ribs in patients with pectus carinatum deformity. It helps to maintain pectoralis muscle vascularization and function and can reduce postoperative pain, hospitalization, and rehabilitation period.

Quadratus Lumborum Block Versus Transversus Abdominis Plane Block for Postoperative Pain After Cesarean Delivery: A Randomized Controlled Trial.

PubMed

Blanco, Rafael; Ansari, Tarek; Riad, Waleed; Shetty, Nanda

Effective postoperative analgesia after cesarean delivery enhances early recovery, ambulation, and breastfeeding. In a previous study, we established the effectiveness of the quadratus lumborum block in providing pain relief after cesarean delivery compared with patient-controlled analgesia (morphine). In the current study, we hypothesized that this method would be equal to or better than the transversus abdominis plane block with regard to pain relief and its duration of action after cesarean delivery. Between April 2015 and August 2015, we randomized 76 patients scheduled for elective cesarean delivery under spinal anesthesia to receive the quadratus lumborum block or the transversus abdominis plane block for postoperative pain relief. This trial was registered prospectively (NCT 02489851) [corrected]. Patients in the quadratus lumborum block group used significantly less morphine than the transversus abdominis plane block group (P < 0.05) at 12, 24, and 48 hours but not at 4 and 6 hours after cesarean delivery. This group also had significantly fewer morphine demands than the control group (P < 0.05) at 6, 12, 24, and 48 hours after cesarean delivery. No significant differences in visual analog scale results were shown between the 2 groups at rest or with movement. Calculated total pain relief at rest and with movement were similar (P < 0.001) in both groups. The quadratus lumborum block was more effective in reducing morphine consumption and demands than transversus abdominis plane blocks after cesarean section. This effect was observed up to 48 hours postoperatively.

Analgesic effect of ultrasound-guided transversus abdominis plane block after total abdominal hysterectomy: a randomized, double-blind, placebo-controlled trial.

PubMed

Røjskjaer, Jesper O; Gade, Erik; Kiel, Louise B; Lind, Morten N; Pedersen, Lars M; Kristensen, Billy B; Rasmussen, Yvonne H; Foss, Nicolai B

2015-03-01

To assess the effect of bilateral ultrasound-guided transversus abdominis plane block with ropivacaine compared with placebo as part of a multimodal analgesic regimen. A randomized, double-blind, placebo-controlled trial following the CONSORT criteria. Hvidovre University Hospital. Forty-six women scheduled for total abdominal hysterectomy. Women received either ropivacaine 0.75%, 20 mL (n = 24) or 0.9% saline, 20 mL (n = 24) in the transversus abdominis plane on each side. Primary outcome was the 24-h postoperative morphine consumption. Secondary outcomes were pain scores at rest and during coughing, postoperative nausea and vomiting at 1, 2, 4, 6, 8, and 24 h, and time to first mobilization. There was no difference in the mean 24-h postoperative morphine consumption between the two groups (p = 0.733). The ropivacaine group had significantly lower median pain scores at 1 h (p = 0.008) and 2 h (p = 0.027) postoperatively at rest and at 8 h (p = 0.028) during coughing. There was no significant difference in other secondary outcomes. There was no reduction in 24-h morphine consumption when using an ultrasound-guided transversus abdominis plane block in women undergoing total abdominal hysterectomy. As part of a multimodal regimen the transversus abdominis plane block showed some effect on pain scores at rest only in the early postoperative period. © 2014 Nordic Federation of Societies of Obstetrics and Gynecology.

Measurement of superficial and deep abdominal muscle thickness: an ultrasonography study.

PubMed

Tahan, Nahid; Khademi-Kalantari, Khosro; Mohseni-Bandpei, Mohammad Ali; Mikaili, Saeed; Baghban, Alireza Akbarzadeh; Jaberzadeh, Shapour

2016-08-23

Real-time ultrasound imaging is a valid method in the field of rehabilitation. The ultrasound imaging allows direct visualization for real-time study of the muscles as they contract over the time. Measuring of the size of each abdominal muscle in relation to the others provides useful information about the differences in structure, as well as data on trunk muscle activation patterns. The purpose of this study was to assess the size and symmetry of the abdominal muscles at rest in healthy adults and to provide a reference range of absolute abdominal muscle size in a relatively large population. A total 156 healthy subjects with the age range of 18-44 years were randomly recruited. The thickness of internal oblique, external oblique, transverse abdominis, and rectus abdominis muscles was measured at rest on both right and left sides using ultrasound. Independent t test was used to compare the mean thickness of each abdominal muscle between males and females. Differences on side-to-side thicknesses were assessed using paired t test. The association between abdominal muscle thicknesses with gender and anthropometric variables was examined using the Pearson correlation coefficient. A normal pattern of increasing order of mean abdominal muscle thickness was found in both genders at both right and left sides: transverse abdominis < external oblique < internal oblique < rectus abdominis. There was a significant difference on the size of transverse abdominis, internal oblique, and external oblique muscles between right and left sides in both genders. Males had significantly thicker abdominal muscles than females. Age was significantly correlated with the thickness of internal oblique, external oblique, and rectus abdominis muscles. Body mass index was also positively correlated with muscle thickness of rectus abdominis and external oblique. The results provide a normal reference range for the abdominal muscles in healthy subjects and may be used as an index to find out abnormalities and also to evaluate the effectiveness of different interventions.

Predictors of Clinical Outcome after Reconstruction of Complex Soft Tissue Defects Involving the Achilles Tendon with the Composite Anterolateral Thigh Flap with Vascularized Fascia Lata.

PubMed

Jandali, Zaher; Lam, Martin C; Merwart, Benedikt; Möhring, Bernd; Geil, Stephanie; Müller, Klaus; Ionac, Mihai; Jiga, Lucian P

2018-06-26

 The composite anterolateral thigh flap with vascularized fascia lata (ALT-FL flap) for covering complex soft tissue defects involving the Achilles tendon has shown promising results. The age and body mass index (BMI) are important predictors of clinical outcome after surgical treatment of Achilles tendon ruptures. In this study, we investigate whether these also influence the outcome of patients after Achilles tendon reconstruction using the ALT-FL flap.  Twenty patients (mean age: 55.9 ± 8.7 years) with complex tissue defects involving the Achilles tendon underwent reconstruction with the ALT-FL flap. Both the Achilles tendon Total Rupture Score (ATRS) and the American Orthopaedic Foot and Ankle Society (AOFAS) score were assessed preoperatively and 12 months postoperatively. In addition, postoperative magnetic resonance imaging (MRI) studies and measurements of the ankle range of motion were performed and results compared with existing literature.  All flaps survived and MRI studies confirmed complete anatomical integration of the fascia lata as "neotendon" at the recipient site. In our patient cohort, the age did not correlate with the outcome measurements, whereas the BMI showed significant negative correlation with the postoperative ATRS ( p  < 0.001) and AOFAS scores ( p  < 0.05). The ATRS and AOFAS scores of all patients improved significantly ( p  < 0.001). However, obese patients with a BMI of more than 30 kg/m 2 achieved significant lower ATRS ( p  < 0.001) and AOFAS scores ( p  < 0.01), as well as patients with peripheral artery disease (PAD) ( p  < 0.05). The mean ankle range of motion after ALT-FL flap reconstruction remained statistical insignificant compared with previous avascular or vascularized tendon repairs of the Achilles tendon.  The ALT-FL flap enables reconstruction of complex tissue defects involving the Achilles tendon with good functional results. However, the presence of an increased BMI or PAD, but not necessarily the age, proves to be a predictor of poor clinical outcome and therefore should be subject to scrutiny during patient selection. Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

[Expression of tumor necrosis factor-like weak inducer of apoptosis in patients with gastric cancer and its relationship with nutritional status].

PubMed

Lu, Hang; Sun, Yuanshui

2016-10-25

To investigate the expression of tumor necrosis factor-like weak inducer of apoptosis (TWEAK) in the serum and the rectus abdominis muscle in patients with gastric cancer and its relationship with the nutritional status. Method Clinical data of 102 patients with gastric cancer (gastric cancer group) and 53 patients with benign abdominal disease (control group) who were admitted to Zhejiang Province People's Hospital from January 2008 to October 2013 were analyzed retrospectively. Enzyme-linked immunosorbent assay(ELISA) was used to detect the serum expression of TWEAK. Reverse transcription polymerase chain reaction (RT-PCR) and Western blot were used to detect the mRNA and protein expression of TWEAK in the rectus abdominis muscle. Relationship between TWEAK expression and nutritional status of gastric cancer patients was examined. The relative expression level of TWEAK protein in serum of gastric cancer group and control group was 0.403±0.065 and 0.148±0.036 respectively. The relative expression of TWEAK mRNA in the rectus abdominis muscle tissue was 0.313±0.089 (gastric cancer group) and 0.118±0.005 (control group). The relative expression of TWEAK protein in the rectus abdominis muscle tissue was 0.197±0.064 (gastric cancer group) and 0.066±0.014 (control group), and the differences were statistically significant (both P=0.000). The high expression of TWEAK (high than median) in rectus abdominis muscle of gastric cancer patients was related to the percentage of more than 10% decline in body weight (P=0.000), the small percentage of ideal body weight at the time of admission (P=0.000), BMI<20 kg/m 2 (P=0.023), higher NRS2002 nutritional risk screening score (P=0.000), lower prognostic nutrition index (P=0.000) and serum albumin <35 g/L (P=0.000). The expression of TWEAK in serum and rectus abdominis muscle of gastric cancer patients up-regulates compared to non-tumor patients. The expression level of TWEAK in the rectus abdominis muscle of gastric cancer patients is closely related to poor nutritional status, suggesting that TWEAK may play a key role in the process of cachexia of gastric cancer patients.

[Application of 3D visualization technique in breast cancer surgery with immediate breast reconstruction using laparoscopically harvested pedicled latissimus dorsi muscle flap].

PubMed

Zhang, Pu-Sheng; Wang, Li-Kun; Luo, Yun-Feng; Shi, Fu-Jun; He, Lin-Yun; Zeng, Cheng-Bing; Zhang, Yu; Fang, Chi-Hua

2017-08-20

To study the value of 3D visualization technique in breast-preserving surgery for breast cancer with immediate breast reconstruction using laparoscopically harvested pedicled latissimus dorsi muscle flap. From January, 2015 to May, 2016, 30 patients with breast cancer underwent breast-preserving surgery with immediate breast reconstruction using pedicled latissimus dorsi muscle flap. The CT data of the arterial phase and venous phase were collected preoperatively and imported into the self-developed medical image 3D visualization system for image segmentation and 3D reconstruction. The 3D models were imported into the simulation surgery platform for virtual surgery to prepare for subsequent surgeries. The cosmetic outcomes of the patients were evaluated 6 months after the surgery. Another 18 patients with breast cancer who underwent laparoscopic latissimus dorsi muscle breast reconstruction without using 3D visualization technique from January to December, 2014 served as the control group. The data of the operative time, intraoperative blood loss and postoperative appearance of the breasts were analyzed. The reconstructed 3D model clearly displayed the anatomical structures of the breast, armpit, latissimus dorsi muscle and vessels and their anatomical relationship in all the 30 cases. Immediate breast reconstruction was performed successfully in all the cases with median operation time of 226 min (range, 210 to 420 min), a median blood loss of 95 mL (range, 73 to 132 mL). Evaluation of the appearance of the breast showed excellent results in 22 cases, good appearance in 6 cases and acceptable appearance in 2 cases. In the control group, the median operation time was 283 min (range, 256 to 313 min) and the median blood loss was 107 mL (range, 79 to 147 mL) with excellent appearance of the breasts in 10 cases, good appearance in 4 cases and acceptable appearance in 4 cases. 3D reconstruction technique can clearly display the morphology of the latissimus dorsi and the thoracic dorsal artery, allows calculation of the volume of the breast and the latissimus dorsi, and helps in defining the scope of resection of the latissimus dorsi to avoid injuries of the pedicled vessels. This technique also helps to shorten the operation time, reduce intraoperative bleeding, and improve the appearance of the reconstructed breast using pedicled latissimus dorsi muscle flap.

Posttraumatic thumb reconstruction.

PubMed

Muzaffar, Arshad R; Chao, James J; Friedrich, Jeffrey B; Freidrich, Jeffrey B

2005-10-01

After reading this article, the reader should be able to: 1. Discuss the critical anatomic features of the thumb as they affect on reconstructive decision making. 2. Define the goals of reconstruction. 3. Discuss an algorithm for thumb reconstruction according to the level of amputation. 4. Understand the role of prosthetics in thumb reconstruction. The function of the thumb is critical to overall hand function. Uniquely endowed with anatomic features that allow circumduction and opposition, the thumb enables activities of pinch, grasp, and fine manipulation that are essential in daily life. Destruction of the thumb secondary to trauma represents a much more significant loss than would result from loss of any other digit. Therefore, significant effort has been focused on thumb reconstruction. Numerous techniques have been described, ranging from simple osteoplastic techniques to complex microsurgical procedures. With an appreciation of the unique anatomic properties of the thumb, the hand surgeon is better able to understand the goals of thumb reconstruction and to develop an algorithm for thumb reconstruction. With such an understanding, an individualized reconstructive plan can be developed for each patient. A great many options are available for posttraumatic thumb reconstruction. Optimal results are obtained by pursuing an organized and logical approach to reconstruction based upon the level of tissue loss. Reconstruction methods depend on the location of the amputation and range from homodigital and heterodigital flaps to partial-toe transfer or a great-toe wrap-around flap to first-web-space deepening using Z-plasties, a dorsal rotation flap, or a distant flap, to distraction osteogenesis, lengthening of the thumb ray, spare parts from another injured digit in the acute setting for pollicization or heterotopic replantation, and microvascular toe transfer. Amputations in the distal third of the thumb are generally well-tolerated. The primary reconstructive issues are the restoration of a padded and sensate soft-tissue cover, as well as aesthetic considerations. First-web-space deepening will generally provide excellent results for amputations at the distal half of the middle third. In the proximal half of the middle third, lengthening of the thumb ray is generally required. Distraction lengthening of the first metacarpal is a useful and reliable technique that provides up to 3 cm of length without requiring complex microsurgical methods. Spare parts from another injured digit may be used in the acute setting for pollicization or heterotopic replantation. Microvascular toe transfer is an excellent option for elective reconstruction. However, other options also are available and may be more appropriate in some cases. Less ideal options include the various types of osteoplastic reconstruction. The reconstruction of posttraumatic thumb defects is a challenging and rewarding surgical endeavor. The value of a functioning thumb is immense, and its reconstruction is worthy of considerable effort. Despite the elegant reconstructive options available, the best results are obtained with replantation or revascularization whenever possible. Finally, the treatment plan always must be derived from a careful assessment of each patient's posttraumatic function and specific reconstructive needs.

[Functional and Anatomic Outcomes of Primary and Secondary Internal Limiting Membrane Transplantation in Large and Persistent Macular Holes].

PubMed

Hess, Jelka A; Michels, Stephan; Becker, Matthias D

2017-11-20

Background The gold standard therapy for full-thickness macular holes (FTMH) is vitrectomy (PPV) with peeling of the internal limiting membrane (ILM), gas tamponade of the vitreous cavity and postoperative face-down positioning. Nevertheless, eyes with large macular holes (> 400 µm) and surgical failures remain difficult to manage. Recently, ILM transplantation (ILM-TX) techniques were developed with acceptable results, advocating different mechanisms of hole closure: in such a setting, the ILM could serve as a scaffold for neuronal tissue in the pedicle ILM flap technique or the ILM could induce a contraction of the FTMH rims through shrinking of a folded ILM plug. Patients/Material and Methods This retrospective study evaluates the functional and anatomic outcomes following ILM-TX for large FTMH and failed FMTH surgery. Large holes (group 1) were treated by the pedicle flap and the plug technique. Persistent holes following vitrectomy and ILM peeling (group 2) were treated with the plug technique. All ILM-TX were performed under perfluorocarbon liquid (PFCL) with a subsequent silicone oil tamponade. Results In group 1 (6 eyes), three eyes had a free ILM graft and three eyes underwent a pedunculated ILM-TX. The mean best corrected visual acuity (BCVA, LogMar) before primary ILM-TX was 1.18 ± 0.54 with a mean initial hole size of 681 ± 106 µm and a photoreceptor defect (PRD) of 1829 ± 474 µm. Five of six eyes showed a postoperative anatomical macular hole closure (83%). The mean BCVA after a mean follow-up of 9.3 ± 5.1 months was 0.83 ± 0.31 after a free ILM graft and 0.95 ± 0.79 after a pedunculated ILM flap. The PRD reduced to 1781 ± 713 µm after a free ILM graft and 1148 ± 378 µm after a pedunculated ILM flap. In group 2 (7 eyes), all patients had failed initial macular hole surgery closure. Prior to free ILM-TX BCVA was 1.05 ± 0.41, the hole size was 433 ± 183 µm and PRD was 2012 ± 718 µm. After a mean of 9.6 ± 4.1 months following ILM-TX, in six of seven eyes the FTMH hole was closed (86%), BCVA improved to 0.53 ± 0.34 and the PRD shortened to 843 ± 291 µm. Conclusion In most cases, with large FTMH or holes after failed vitrectomy plus ILM peeling, ILM-TX allows a hole closure. Functional outcomes show stabilization and sometimes even a slight improvement. Georg Thieme Verlag KG Stuttgart · New York.

Large asymmetric hypertrophy of rectus abdominis muscle in professional tennis players.

PubMed

Sanchis-Moysi, Joaquin; Idoate, Fernando; Dorado, Cecilia; Alayón, Santiago; Calbet, Jose A L

2010-12-31

To determine the volume and degree of asymmetry of the musculus rectus abdominis (RA) in professional tennis players. The volume of the RA was determined using magnetic resonance imaging (MRI) in 8 professional male tennis players and 6 non-active male control subjects. Tennis players had 58% greater RA volume than controls (P = 0.01), due to hypertrophy of both the dominant (34% greater volume, P = 0.02) and non-dominant (82% greater volume, P = 0.01) sides, after accounting for age, the length of the RA muscle and body mass index (BMI) as covariates. In tennis players, there was a marked asymmetry in the development of the RA, which volume was 35% greater in the non-dominant compared to the dominant side (P<0.001). In contrast, no side-to-side difference in RA volume was observed in the controls (P = 0.75). The degree of side-to-side asymmetry increased linearly from the first lumbar disc to the pubic symphysis (r = 0.97, P<0.001). Professional tennis is associated with marked hypertrophy of the musculus rectus abdominis, which achieves a volume that is 58% greater than in non-active controls. Rectus abdominis hypertrophy is more marked in the non-dominant than in the dominant side, particularly in the more distal regions. Our study supports the concept that humans can differentially recruit both rectus abdominis but also the upper and lower regions of each muscle. It remains to be determined if this disequilibrium raises the risk of injury.

Responses of intra-abdominal pressure and abdominal muscle activity during dynamic trunk loading in man.

PubMed

Cresswell, A G

1993-01-01

The purpose of this study was to determine and compare interactions between the abdominal musculature and intra-abdominal pressure (IAP) during controlled dynamic and static trunk muscle loading. Myoelectric activity was recorded in six subjects from the rectus abdominis, obliquus externus, obliquus internus, transversus abdominis and erector spinae muscles using surface and intra-muscular fine-wire electrodes. The IAP was recorded intra-gastrically. Trunk flexions and extensions were performed lying on one side on a swivel table. An adjustable brake provided different friction loading conditions, while adding weights to an unbraked swivel table afforded various levels of inertial loading. During trunk extensions at all friction loads, IAP was elevated (1.8-7.2 kPa) with concomitant activity in transversus abdominis and obliquus internus muscles--little or no activity was seen from rectus abdominis and obliquus externus muscles. For inertia loading during trunk extension, IAP levels were somewhat lower (1.8-5.6 kPa) and displayed a second peak when abdominal muscle activity occurred in the course of decelerating the movement. For single trunk flexions with friction loading, IAP was higher than that seen in extension conditions and increased with added resistance. For inertial loading during trunk flexion, IAP showed two peaks, the larger first peak matched peak forward acceleration and general abdominal muscle activation, while the second corresponded to peak deceleration and was accompanied by activity in transversus abdominis and erector spinae muscles. It was apparent that different loading strategies produced markedly different patterns of response in both trunk musculature and intra-abdominal pressure.

Four quadrant transversus abdominis plane block and continuous transversus abdominis plane analgesia: a 3-year prospective audit in 124 patients.

PubMed

Niraj, G; Kelkar, Aditi; Hart, Elaine; Kaushik, Vipul; Fleet, Danny; Jameson, John

2015-11-01

Transversus abdominis plane (TAP) blocks have been reported to be an effective method of providing analgesia after abdominal surgery. To perform a prospective audit on the effectiveness of a novel technique of providing continuous transversus abdominis plane (TAP) analgesia in patients undergoing emergency and elective abdominal surgery. Prospective single center audit over a 3-year period. University hospital. One hundred twenty-four American Society of Anesthesiologists I to IV adult patients presenting for elective as well as emergency abdominal surgery in whom epidural analgesia was contraindicated or refused. Four quadrant TAP blocks and continuous TAP analgesia. Numerical rating scale pain scores at rest and on coughing, nausea scores, satisfaction scores, complications, frequency of analgesia failure, therapeutic failure with continuous TAP analgesia and opioid consumption. One hundred twenty-four patients who received continuous TAP analgesia were audited. This included 34 patients for elective open surgery, 36 patients for emergency laparotomy, and 54 patients who underwent elective laparoscopic colorectal surgery. Surgical incision was within the dermatomal limit of the block in 70% of the patients (88/124). Therapeutic failure with the technique was 10%. Frequency of analgesic failure over the 48-hour period was none in 39% and below 5 episodes in 57%. Four quadrant transversus abdominis plane blocks and continuous TAP analgesia is an effective technique for providing postoperative analgesia after abdominal surgery. It has the potential to be used as a sole analgesic technique when the surgical incision is within its dermatomal limit. Copyright © 2015 Elsevier Inc. All rights reserved.

The effects of aquatic trunk exercise on gait and muscle activity in stroke patients: a randomized controlled pilot study.

PubMed

Park, Byoung-Sun; Noh, Ji-Woong; Kim, Mee-Young; Lee, Lim-Kyu; Yang, Seung-Min; Lee, Won-Deok; Shin, Yong-Sub; Kim, Ju-Hyun; Lee, Jeong-Uk; Kwak, Taek-Yong; Lee, Tae-Hyun; Kim, Ju-Young; Park, Jaehong; Kim, Junghwan

2015-11-01

[Purpose] The purpose of this study was to investigate the relationship between muscle activity and gait function following aquatic trunk exercise in hemiplegic stroke patients. [Subjects and Methods] This study's participants included thirteen hemiplegic patients (ten males and three females). The aquatic therapy consisted of administering concentrative aquatic therapy for four weeks in a therapeutic pool. Gait parameters were measured using a gait analysis system adjusted to each subject's comfortable walking speed. Electromyographic signals were measured for the rectus abdominis, external abdominal oblique, transversus abdominis/internal-abdominal oblique, and erector spine of each patients. [Results] The pre- and post-training performances of the transversus abdominis/internal-abdominal oblique were compared statistically. There was no statistical difference between the patients' pre- and post-training values of maximal voluntary isometric contraction of the rectus abdominis, but the external abdominal oblique values tended to improve. Furthermore, gait factors improved significantly in terms of walking speeds, walking cycles, affected-side stance phases, affected-stride lengths, and stance-phase symmetry indices, respectively. [Conclusion] These results suggest that the trunk exercise during aquatic therapy may in part contribute to clinically relevant improvements in muscle activities and gait parameters.

The effects of aquatic trunk exercise on gait and muscle activity in stroke patients: a randomized controlled pilot study

PubMed Central

Park, Byoung-Sun; Noh, Ji-Woong; Kim, Mee-Young; Lee, Lim-Kyu; Yang, Seung-Min; Lee, Won-Deok; Shin, Yong-Sub; Kim, Ju-Hyun; Lee, Jeong-Uk; Kwak, Taek-Yong; Lee, Tae-Hyun; Kim, Ju-Young; Park, Jaehong; Kim, Junghwan

2015-01-01

[Purpose] The purpose of this study was to investigate the relationship between muscle activity and gait function following aquatic trunk exercise in hemiplegic stroke patients. [Subjects and Methods] This study’s participants included thirteen hemiplegic patients (ten males and three females). The aquatic therapy consisted of administering concentrative aquatic therapy for four weeks in a therapeutic pool. Gait parameters were measured using a gait analysis system adjusted to each subject’s comfortable walking speed. Electromyographic signals were measured for the rectus abdominis, external abdominal oblique, transversus abdominis/internal-abdominal oblique, and erector spine of each patients. [Results] The pre- and post-training performances of the transversus abdominis/internal-abdominal oblique were compared statistically. There was no statistical difference between the patients’ pre- and post-training values of maximal voluntary isometric contraction of the rectus abdominis, but the external abdominal oblique values tended to improve. Furthermore, gait factors improved significantly in terms of walking speeds, walking cycles, affected-side stance phases, affected-stride lengths, and stance-phase symmetry indices, respectively. [Conclusion] These results suggest that the trunk exercise during aquatic therapy may in part contribute to clinically relevant improvements in muscle activities and gait parameters. PMID:26696736

A pilot study on the influence of exercising on unstable training machine on balance control and trunk muscles activity.

PubMed

Domeika, Aurelijus; Aleknaite-Dambrauskiene, Ieva; Poskaitis, Vytautas; Zaveckas, Vidmantas; Grigas, Vytautas; Zvironiene, Ausra

2018-05-16

The main position of the working population is becoming sitting. Immobile prolonged sedentary time may cause negative effects including reduced intervertebral discs nutrition. Main ways of mitigating them are regular position changes and exercising. To evaluate influence of the short term training on unstable training machine on balance control and trunk muscles activity in patients with lower back pain. Participants (n=16) experiencing lower back pain were trained on an unstable sculling machine "Rehabili". Their balance tested by (Biodex Balance System) and rectus abdominis, externus oblique, transverse abdominis, multifidus and erector spine muscles activity (measured by surface electromyography) while sitting and standing with usual and aligned body postures both before and after six weeks of training (three 15 minutes sessions per week) were compared in between. Balance control improved after the training program. Besides, more symmetrical activation of both sides rectus and transversus abdominis muscles, as well as increased transversus abdominis muscle activation of 19% (p< 0.05), were observed. Six weeks short sessions training on unstable training machine improved balance control and increased trunk muscles activity especially in aligned body posture when standing or sitting on unstable surface.

Core Muscle Activation in Suspension Training Exercises.

PubMed

Cugliari, Giovanni; Boccia, Gennaro

2017-02-01

A quantitative observational laboratory study was conducted to characterize and classify core training exercises executed in a suspension modality on the base of muscle activation. In a prospective single-group repeated measures design, seventeen active male participants performed four suspension exercises typically associated with core training (roll-out, bodysaw, pike and knee-tuck). Surface electromyographic signals were recorded from lower and upper parts of rectus abdominis, external oblique, internal oblique, lower and upper parts of erector spinae muscles using concentric bipolar electrodes. The average rectified values of electromyographic signals were normalized with respect to individual maximum voluntary isometric contraction of each muscle. Roll-out exercise showed the highest activation of rectus abdominis and oblique muscles compared to the other exercises. The rectus abdominis and external oblique reached an activation higher than 60% of the maximal voluntary contraction (or very close to that threshold, 55%) in roll-out and bodysaw exercises. Findings from this study allow the selection of suspension core training exercises on the basis of quantitative information about the activation of muscles of interest. Roll-out and bodysaw exercises can be considered as suitable for strength training of rectus abdominis and external oblique muscles.

Current trends in breast reconstruction: survey of American Society of Plastic Surgeons 2010.

PubMed

Gurunluoglu, Raffi; Gurunluoglu, Aslin; Williams, Susan A; Tebockhorst, Seth

2013-01-01

We conducted a retrospective survey of American Society of Plastic Surgeons to ascertain the current trends in breast reconstruction (BR). Surveys were sent to 2250 active American Society of Plastic Surgeons members by e-mail with a cover letter including the link using Survey Monkey for the year 2010. In all, 489 surveys (a response rate of 21.7%) were returned. Three hundred fifty-eight surveys from respondents performing BR in their practices were included in the study. The survey included questions on surgeon demographics, practice characteristics, BR after mastectomy, number of BR per year, type and timing of BR, use of acellular dermal matrix, reconstructive choices in the setting of previous irradiation and in patients requiring postmastectomy radiation therapy, timing of contralateral breast surgery, fat grafting, techniques used for nipple-areola reconstruction, the complications, and physician satisfaction and physician reported patient satisfaction. Returned responses were tabulated and assessed. After prophylactic mastectomy, 16% of BRs were performed. In all, 81.2% of plastic surgeons predominantly performed immediate BR. In patients requiring postmastectomy radiation therapy, 81% did not perform immediate BR. Regardless of practice setting and laterality of reconstruction, 82.7% of respondents predominantly performed implant-based BR. Half of the plastic surgeons performing prosthetic BR used acellular dermal matrix. Only 14% of plastic surgeons predominantly performed autologous BR. Surgeons in solo, plastic surgery group practices, and multispecialty group practices preferred implant-based BR for both unilateral and bilateral cases more frequently than those in academic practices (P < 0.05). Overall, plastic surgeons in academic settings preferred autologous BR more frequently than those in other practice locations (P < 0.05). Of total respondents, 64.8% did not perform microsurgical BR at all; 28% reported performing deep inferior epigastric perforator flap BR. Pedicled transverse rectus abdominis myocutaneous flap was the most often used option for unilateral autologous reconstruction, whereas deep inferior epigastric perforator flap was the most commonly used technique for bilateral BR. The overall complication rate reported by respondents was 11%. The survey provides an insight to the current trends in BR practice with respect to surgeon and practice setting characteristics. Although not necessarily the correct best practices, the survey does demonstrate a likely portrayal of what is being practiced in the United States in the area of BR.

Minimizing complications associated with coronal approach by application of various modifications in surgical technique for treating facial trauma: A prospective study.

PubMed

Kumar, V Santosh; Rao, N Koteswara; Mohan, Kodali Rama; Krishna, Leela; Prasad, B Srinivasa; Ranganadh, N; Lakshmi, Vijaya

2016-01-01

Coronal incision is a popular and versatile surgical approach to the anterior cranial vault and upper and middle third facial skeleton. The flap itself permits widespread exposure of the fractures in this region. The bicoronal flap was first described by Hartley and Kenyon (neurosurgeons) to gain access to the anterior cranium in 1907. It extension as an access flap to the upper and lateral aspect of the face was pioneered by Tessier (1971). Esthetically, it is pleasing as the surgical scar is hidden within the hair. To evaluate the versatility of coronal incision using various modifications advocated in incision, exposure to fractured site, and closure of flap in treating the upper and middle third facial fractures. A total of ten patients diagnosed with upper and middle third facial fractures requiring open reduction and internal fixation/correction of contour defect were selected after preoperative clinical and radiographic (computed tomography scan) evaluation. All the cases were operated by coronal approach to gain the access to the fracture/defect site for reduction/correction of the defect. Advantages and complication are evaluated. Excellent access and anatomical reduction by this approach with least number of complications; if it is performed with healthy knowledge of anatomy of the scalp and temporal region. Certain minimal complications have also been noted using various modifications used in the procedure. Despite of prolonged surgical time for the exposure, it is very advantages in treating upper and middle third facial fractures due to wide access and discreet scar (minimal).

A Spine Loading Model of Women in the Military

DTIC Science & Technology

1996-10-01

latissimuss dorsi, posterior abdominal internal obliques, rectus abdomini and the abdominal external obliques (5,19). MVC exertions consisting of...Women tend to possess greater hip breadth and narrower abdominal depth than men (9). The sacroiliac joint is positioned several centimeters anteriorly...internal obliques, external obliques, rectus abdomini, and psoas major. The sizes and area centriods are also quantified for the vertebral body and the

The Applicability of the Army Physical Fitness Test in the Contemporary Operating Environment

DTIC Science & Technology

2008-06-13

abdominis, external obliques, internal obliques, latissimus dorsi, lumbar paraspinals, and rectus femoris during performance of different abdominal ...by asserting the need to train soldiers in the most stressful, painful , realistic environment possible in order to prepare them for combat. Both of...In Medicine & Science in Sports & Exercise, researchers specifically identify usage of the rectus abdominis, external oblique, internal oblique

Athletic pubalgia and the "sports hernia": MR imaging findings.

PubMed

Zoga, Adam C; Kavanagh, Eoin C; Omar, Imran M; Morrison, William B; Koulouris, George; Lopez, Hector; Chaabra, Avneesh; Domesek, John; Meyers, William C

2008-06-01

To retrospectively determine the sensitivity and specificity of magnetic resonance (MR) imaging findings in patients with clinical athletic pubalgia, with either surgical or physical examination findings as the reference standard. Institutional review board approval was granted for this HIPAA-compliant study, and informed consent was waived. MR imaging studies in 141 patients (134 male patients, seven female patients; mean age, 30.1 years; range, 17-71 years) who had been referred to a subspecialist because of groin pain were reviewed for findings including hernia, pubic bone marrow edema, secondary cleft sign, and rectus abdominis and adductor tendon injury. MR imaging findings were compared with surgical findings for 102 patients, physical examination findings for all 141 patients, and MR imaging findings in an asymptomatic control group of 25 men (mean age, 29.8 years; range, 18-39 years). Sensitivity and specificity of MR imaging for rectus abdominis and adductor tendon injury were determined by using a chi(2) analysis, and significance of the findings was analyzed with an unpaired Student t test. Disease patterns seen at MR imaging were compared with those reported in the surgical and sports medicine literature. One hundred thirty-eight (98%) of 141 patients had findings at MR imaging that could cause groin pain. Compared with surgery, MR imaging had a sensitivity and specificity, respectively, of 68% and 100% for rectus abdominis tendon injury and 86% and 89% for adductor tendon injury. Injury in each of these structures was significantly more common in the patient group than in the control group (P < .001). Only two patients had hernias at surgery. At MR imaging, injury or disease could be fit into distinct groups, including osteitis pubis, adductor compartment injury, rectus abdominis tendon injury, and injury or disease remote from the pubic symphysis. Patients with injury involving the rectus abdominis insertion were most likely to go on to surgical pelvic floor repair. MR imaging depicts patterns of findings in patients with athletic pubalgia, including rectus abdominis insertional injury, thigh adductor injury, and articular diseases at the pubic symphysis (osteitis pubis). (c) RSNA, 2008.

Ultrasound guided transversus abdominis plane vs surgeon administered intraoperative regional field infiltration with bupivacaine for early postoperative pain control in children undergoing open pyeloplasty.

PubMed

Lorenzo, Armando J; Lynch, Johanne; Matava, Clyde; El-Beheiry, Hossam; Hayes, Jason

2014-07-01

Regional analgesic techniques are commonly used in pediatric urology. Ultrasound guided transversus abdominis plane block has recently gained popularity. However, there is a paucity of information supporting a benefit over regional field infiltration. We present a parallel group, randomized, controlled trial evaluating ultrasound guided transversus abdominis plane block superiority over surgeon delivered regional field infiltration for children undergoing open pyeloplasty at a tertiary referral center. Following ethics board approval and registration, children 0 to 6 years old were recruited and randomized to undergo perioperative transversus abdominis plane block or regional field infiltration for early post-pyeloplasty pain control. General anesthetic delivery, surgical technique and postoperative analgesics were standardized. A blinded assessor regularly captured pain scores in the recovery room using the FLACC (Face, Legs, Activity, Cry, Consolability) scale. The primary outcome was the need for rescue morphine administration based on a FLACC score of 3 or higher. Two pediatric urologists performed 57 pyeloplasties during a 2.5-year period, enrolling 32 children (16 in each group, balanced for age and weight). There were statistically significant differences in the number of children requiring rescue morphine administration (13 of 16 receiving transversus abdominis plane block and 6 of 16 receiving regional field infiltration, p = 0.011), mean ± SD total morphine consumption (0.066 ± 0.051 vs 0.028 ± 0.040 mg/kg, p = 0.021) and mean ± SD pain scores (5 ± 5 vs 2 ± 3, p = 0.043) in the recovery room, in favor of surgeon administered regional field infiltration. No local anesthetic specific adverse events were noted. Ultrasound guided transversus abdominis plane block is not superior to regional field infiltration with bupivacaine as a strategy to minimize early opioid requirements following open pyeloplasty in children. Instead, our data suggest that surgeon delivered regional field infiltration provides better pain control. Copyright © 2014 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.

Pharmacokinetics of bupivacaine after bilateral ultrasound-guided transversus abdominis plane block following cesarean delivery under spinal anesthesia.

PubMed

Trabelsi, B; Charfi, R; Bennasr, L; Marzouk, S Ben; Eljebari, H; Jebabli, N; Sassi, M Ben; Trabelsi, S; Maghrebi, H

2017-11-01

Transversus abdominis plane block is an effective method of post-cesarean analgesia. There are no data available about plasma bupivacaine levels after this block in adults. This study aimed to assess bupivacaine pharmacokinetic parameters after ultrasound-guided transversus abdominis plane blocks following cesarean delivery under spinal anesthesia. A prospective observational study in parturients undergoing elective cesarean delivery under hyperbaric bupivacaine spinal anesthesia was conducted. After surgery, patients received bilateral transversus abdominis plane block (50mg bupivacaine each side). Venous blood samples were collected immediately before performing the block and at 10, 20, 30, 45, 60, 90, 120, 180, 240, 720 and 1440minutes. High performance liquid chromatography was used to measure total plasma bupivacaine concentrations. Mean bupivacaine area under the curve (AUC) was calculated from 0 to 24hours. Data were collected from 17 parturients. Mean age and body mass index were 31±6y and 30±4kg/m 2 respectively. Mean plasma bupivacaine concentration before the block was 171ng/mL. Mean peak concentration was 802.36ng/mL (range 231.8 to 3504.5ng/mL). Mean time to peak concentration was 30min and mean area-under-the-curve (0-24h) was 4505.4h.ng/mL. Mean elimination half-life was 8.75h. Three subjects had concentrations above the quoted toxic threshold and mild symptoms suggestive of neurotoxicity were reported by two subjects, but no treatment was required. Single-dose bilateral transversus abdominis plane block using 100mg of bupivacaine, after spinal anesthesia for cesarean delivery, can result in toxic plasma bupivacaine concentrations. Copyright © 2017 Elsevier Ltd. All rights reserved.

Do various baseline characteristics of transversus abdominis and lumbar multifidus predict clinical outcomes in nonspecific low back pain? A systematic review.

PubMed

Wong, Arnold Y L; Parent, Eric C; Funabashi, Martha; Stanton, Tasha R; Kawchuk, Gregory N

2013-12-01

Although individual reports suggest that baseline morphometry or activity of transversus abdominis or lumbar multifidus predict clinical outcome of low back pain (LBP), a related systematic review is unavailable. Therefore, this review summarized evidence regarding the predictive value of these muscular characteristics. Candidate publications were identified from 6 electronic medical databases. After review, 5 cohort studies were included. Although this review intended to encompass studies using different muscle assessment methods, all included studies coincidentally used ultrasound imaging. No research investigated the relation between static morphometry and clinical outcomes. Evidence synthesis showed limited evidence supporting poor baseline transversus abdominis contraction thickness ratio as a treatment effect modifier favoring motor control exercise. Limited evidence supported that high baseline transversus abdominis lateral slide was associated with higher pain intensity after various exercise interventions at 1-year follow-up. However, there was limited evidence for the absence of relation between the contraction thickness ratio of transversus abdominis or anticipatory onset of lateral abdominal muscles at baseline and the short- or long-term LBP intensity after exercise interventions. There was conflicting evidence for a relation between baseline percent thickness change of lumbar multifidus during contraction and the clinical outcomes of patients after various conservative treatments. Given study heterogeneity, the small number of included studies and the inability of conventional greyscale B-mode ultrasound imaging to measure muscle activity, our findings should be interpreted with caution. Further large-scale prospective studies that use appropriate technology (ie, electromyography to assess muscle activity) should be conducted to investigate the predictive value of morphometry or activity of these muscles with respect to LBP-related outcomes measures. Copyright © 2013 International Association for the Study of Pain. Published by Elsevier B.V. All rights reserved.

Evaluation of three-dimensional printing for internal fixation of unstable pelvic fracture from minimal invasive para-rectus abdominis approach: a preliminary report.

PubMed

Zeng, Canjun; Xiao, Jidong; Wu, Zhanglin; Huang, Wenhua

2015-01-01

The aim of this study is to evaluate the efficacy and feasibility of three-dimensional printing (3D printing) assisted internal fixation of unstable pelvic fracture from minimal invasive para-rectus abdominis approach. A total of 38 patients with unstable pelvic fractures were analyzed retrospectively from August 2012 to February 2014. All cases were treated operatively with internal fixation assisted by three-dimensional printing from minimal invasive para-rectus abdominis approach. Both preoperative CT and three-dimensional reconstruction were performed. Pelvic model was created by 3D printing. Data including the best entry points, plate position and direction and length of screw were obtained from simulated operation based on 3D printing pelvic model. The diaplasis and internal fixation were performed by minimal invasive para-rectus abdominis approach according to the optimized dada in real surgical procedure. Matta and Majeed score were used to evaluate currative effects after operation. According to the Matta standard, the outcome of the diaplasis achieved 97.37% with excellent and good. Majeed assessment showed 94.4% with excellent and good. The imageological examination showed consistency of internal fixation and simulated operation. The mean operation time was 110 minutes, mean intraoperative blood loss 320 ml, and mean incision length 6.5 cm. All patients have achieved clinical healing, with mean healing time of 8 weeks. Three-dimensional printing assisted internal fixation of unstable pelvic fracture from minimal invasive para-rectus abdominis approach is feasible and effective. This method has the advantages of trauma minimally, bleeding less, healing rapidly and satisfactory reduction, and worthwhile for spreading in clinical practice.

Soccer Attenuates the Asymmetry of Rectus Abdominis Muscle Observed in Non-Athletes

PubMed Central

Idoate, Fernando; Calbet, Jose A. L.; Izquierdo, Mikel; Sanchis-Moysi, Joaquin

2011-01-01

Purpose To determine the volume and degree of asymmetry of the rectus abdominis muscle (RA) in professional soccer players. Methods The volume of the RA was determined using magnetic resonance imaging (MRI) in 15 professional male soccer players and 6 non-active male control subjects. Results Soccer players had 26% greater RA volume than controls (P<0.05), due to hypertrophy of both the dominant (28% greater volume, P<0.05) and non-dominant (25% greater volume, P<0.01) sides, after adjusting for age, length of the RA muscle and body mass index (BMI) as covariates. Total volume of the dominant side was similar to the contralateral in soccer players (P = 0.42) and in controls (P = 0.75) (Dominant/non-dominant = 0.99, in both groups). Segmental analysis showed a progressive increase in the degree of side-to-side asymmetry from the first lumbar disc to the pubic symphysis in soccer players (r = 0.80, P<0.05) and in controls (r = 0.75, P<0.05). The slope of the relationship was lower in soccer players, although this trend was not statistically significant (P = 0.14). Conclusions Professional soccer is associated with marked hypertrophy of the rectus abdominis muscle, which achieves a volume that is 26% greater than in non-active controls. Soccer induces the hypertrophy of the non-dominant side in proximal regions and the dominant side in regions closer to pubic symphysis, which attenuates the pattern of asymmetry of rectus abdominis observed in non-active population. It remains to be determined whether the hypertrophy of rectus abdominis in soccer players modifies the risk of injury. PMID:21541351

Suprafascial versus traditional harvesting technique for free antero lateral thigh flap: A case-control study to assess the best functional and aesthetic result in extremity reconstruction.

PubMed

Maruccia, Michele; Fallico, Nefer; Cigna, Emanuele; Ciudad, Pedro; Nicoli, Fabio; Trignano, Emilio; Nacchiero, Eleonora; Giudice, Giuseppe; Ribuffo, Diego; Chen, Hung-Chi

2017-11-01

Clinical applications of ALT flap have currently extended to extremity (hand and foot) as well as oral cavity reconstruction. In these anatomical areas, the traditional harvesting technique presents a few disadvantages such as bulkiness of the recipient site and potential donor site morbidity including damage to the deep fascia and skin graft adhesions. The purpose of the present study was to compare the functional and aesthetic outcomes of upper and lower extremity reconstruction with either suprafascial or subfascial harvested anterolateral (ALT) flaps. Sixty patients who underwent hand or foot reconstruction with an ALT flap between January 2013 and January 2015 were included in the study (34 flaps elevated on a subfascial plane and 26 on a suprafascial plane). Group 1 (subfascial harvested ALT flap) was composed of 23 male and 11 female patients with an average age of 53.4 years (range, 36-72 years). Group 2 (suprafascial harvested ALT flap) was composed of 18 male and 8 female patients with an average age of 48.7 years (range, 32-69 years). Surgical indication was tumor resection for 20 patients in group 1 and 16 patients in group 2, chronic ulcer for 8 patients in group 1 and 6 patients in group 2, and trauma for 6 patients in group 1 and 4 patients in group 2. Complications were documented. Aesthetic outcomes were considered in terms of bulkiness of the recipient site, subsequent request for a debulking procedure, and donor site morbidity. Donor site scars were evaluated for cosmesis using a modified Hollander Wound Evaluation Scale (HWES). Skin grafts outcomes were assessed according to the modified Vancouver Scar Scale (VSS). Functional outcome at the recipient site was measured using the Enneking functional outcome score (ESS). Total range of motion (ROM) was recorded. All flaps were successfully elevated with at least one viable perforator with both approaches. The survival rates of suprafascial and subfascial harvested ALT flaps were 96.2 and 97% respectively (P = .85). The mean flap size was 110.4 ± 27.8 cm 2 in group 1 and 159.7 ± 44.4 cm 2 in group 2. The average flap thickness was 26.2± 5.2 mm in group 1 and 13.9 mm ± 4.1 in group 2. Complications included total flap loss (1 case in group 1 and 1 case in group 2), partial flap loss (2 cases in group 1 and 1 case in group 2), skin graft failure (3 cases in group 1), and muscle herniation at the donor site (1 case in group 1; P < .17). Secondary debulking procedures were needed for 20 flaps in the subfascial group and for one flap in the suprafascial group (P-value <.01). Donor site closure with skin grafts was necessary in 42 cases: 32 in group 1 and 10 in group 2. The suprafascial harvested ALT flap group reported a significant difference in terms of donor site morbidity. The HWES score of donor site scars was significantly lower in group 1 (mean 1.2 ± 0.54) than in group 2 (mean 2.4 ± 0.58), P < .01. Similarly, the VSS score for skin graft outcomes was lower in patients of group 1 (mean 4.5 ± 0.93) than in patients of group 2 (mean 6.7 ± 0.96), P < .01. There was also a significant lower score of postoperative ESS in patients of group 1 (mean 21.2 ± 3.4) when compared with patients of group 2 (mean 23.6 ± 2.7), P < .01. Total ROM improved on average 60° after surgery (P-value <.01). The suprafascial plane for elevating ALT flaps presented several advantages over the traditional subfascial approach in terms of functional and aesthetic outcomes, providing a thin flap allowing increased versatility to achieve better contour of flap, and minimizing the need for secondary debulking. © 2017 Wiley Periodicals, Inc.

Anatomical and functional outcomes of retinectomies in retinal detachments complicated by proliferative vitreoretinopathy.

PubMed

Adhi, Mohammad Idrees; Siyal, Nisar; Aziz, Sumbul

2017-01-01

To study anatomical and functional outcomes of retinectomies in rhegmatogenous retinal detachments complicated by proliferative vitreoretinopathy. This is a retrospective interventional consecutive case series of eyes with rhegmatogenous retinal detachments complicated by advanced proliferative vitreoretinopathy and managed by relaxing retinectomy over a period of seventeen years. Three-port pars plana vitrectomy included core vitrectomy and removal of all epi-retinal membranes. On failure to flatten, retina was cut and excised. Basal vitrectomy and removal of anterior flap of retina then followed. Silicone oil was used as temponade in majority of cases. The dependent variables were anatomical and functional outcomes. The statistical analysis was performed on SPSS 21. Series included 370 eyes of 337 patients. Mean follow up was 39 months. Scleral explant was used in 90(24.39%) cases. Two hundred and nine (56.49%) eyes were operated with trans conjunctival sutureless vitrectomy technique. Procedure was bilateral in 33 patients (09.79%). Retina attached in 311(84.05%) eyes after initial surgery. Final re-attachment after one or more surgeries was achieved in 344(92.97%) eyes. Two hundred and eleven (57.02%) cases achieved visual acuity of 6/60 or better. Relaxing retinectomies have good and encouraging anatomical and functional outcomes. This surgery can be effectively carried out with trans conjunctival sutureless vitrectomy technique.

Surface electromyography activity of the rectus abdominis, internal oblique, and external oblique muscles during forced expiration in healthy adults.

PubMed

Ito, Kenichi; Nonaka, Koji; Ogaya, Shinya; Ogi, Atsushi; Matsunaka, Chiaki; Horie, Jun

2016-06-01

We aimed to characterize rectus abdominis, internal oblique, and external oblique muscle activity in healthy adults under expiratory resistance using surface electromyography. We randomly assigned 42 healthy adult subjects to 3 groups: 30%, 20%, and 10% maximal expiratory intraoral pressure (PEmax). After measuring 100% PEmax and muscle activity during 100% PEmax, the activity and maximum voluntary contraction of each muscle during the assigned experimental condition were measured. At 100% PEmax, the external oblique (p<0.01) and internal oblique (p<0.01) showed significantly elevated activity compared with the rectus abdominis muscle. Furthermore, at 20% and 30% PEmax, the external oblique (p<0.05 and<0.01, respectively) and the internal oblique (p<0.05 and<0.01, respectively) showed significantly elevated activity compared with the rectus abdominis muscle. At 10% PEmax, no significant differences were observed in muscle activity. Although we observed no significant difference between 10% and 20% PEmax, activity during 30% PEmax was significantly greater than during 20% PEmax (external oblique: p<0.05; internal oblique: p<0.01). The abdominal oblique muscles are the most active during forced expiration. Moreover, 30% PEmax is the minimum intensity required to achieve significant, albeit very slight, muscle activity during expiratory resistance. Copyright © 2016 Elsevier Ltd. All rights reserved.

[Contribution of French surgeons to reconstructive microsurgery].

PubMed

Grinfeder, C; Pinsolle, V; Pelissier, P; Martin, D; Baudet, J

2005-02-01

The authors report the contribution of French surgeons and particularly the plastic surgeons to the reconstructive microsurgery since 1972. Different domains are reviewed: animal experimentation, anatomical studies, reimplantations, free tissular transfer, free bone transfer, strategic original concept of transfer, free toes transfer, microsurgical reconstruction of malformative hand, free lymphatic transfer, nervous microsurgery, flap prefabrication, allotransplantations and the future of microsurgery. Three societies have the place of honour: the French Society of Plastic Reconstructive and Aesthetic Surgery, the Group for Advancement of Microsurgery and the World Society for Reconstructive Microsurgery.

Effect of modified bridge exercise on trunk muscle activity in healthy adults: a cross sectional study.

PubMed

Yoon, Jeong-Oh; Kang, Min-Hyeok; Kim, Jun-Seok; Oh, Jae-Seop

This is a cross-sectional study. University research laboratory. Fifteen healthy adults (mean age: 27.47 years) volunteered for this study. The individuals performed standard bridge exercise and modified bridge exercises with right leg-lift (single-leg-lift bridge exercise, single-leg-lift bridge exercise on an unstable surface, and single-leg-lift hip abduction bridge exercise). During the bridge exercises, electromyography of the rectus abdominis, internal oblique, erector spinae, and multifidus muscles was recorded using a wireless surface electromyography system. Two-way repeated-measures analysis of variance (exercise by side) with post hoc pairwise comparisons using Bonferroni correction was used to compare the electromyography data collected from each muscle. Bilateral internal oblique muscle activities showed significantly greater during single-leg-lift bridge exercise (95% confidence interval: right internal oblique=-8.99 to -1.08, left internal oblique=-6.84 to -0.10), single-leg-lift bridge exercise on an unstable surface (95% confidence interval: right internal oblique=-7.32 to -1.78, left internal oblique=-5.34 to -0.99), and single-leg-lift hip abduction bridge exercise (95% confidence interval: right internal oblique=-17.13 to -0.89, left internal oblique=-8.56 to -0.60) compared with standard bridge exercise. Bilateral rectus abdominis showed greater electromyography activity during single-leg-lift bridge exercise on an unstable surface (95% confidence interval: right rectus abdominis=-9.33 to -1.13, left rectus abdominis=-4.80 to -0.64) and single-leg-lift hip abduction bridge exercise (95% confidence interval: right rectus abdominis=-14.12 to -1.84, left rectus abdominis=-6.68 to -0.16) compared with standard bridge exercise. In addition, the right rectus abdominis muscle activity was greater during single-leg-lift hip abduction bridge exercise compared with single-leg-lift bridge exercise on an unstable surface (95% confidence interval=-7.51 to -0.89). For erector spinae, muscle activity was greater in right side compared with left side during all exercises (95% confidence interval: standard bridge exercise=0.19-4.53, single-leg-lift bridge exercise=0.24-10.49, single-leg-lift bridge exercise on an unstable surface=0.74-8.55, single-leg-lift hip abduction bridge exercise=0.47-11.43). There was no significant interaction and main effect for multifidus. Adding hip abduction and unstable conditions to bridge exercises may be useful strategy to facilitate the co-activation of trunk muscles. Copyright © 2017 Associação Brasileira de Pesquisa e Pós-Graduação em Fisioterapia. Publicado por Elsevier Editora Ltda. All rights reserved.

Design and preliminary testing of a novel skin expander for total ear reconstruction in a rabbit model.

PubMed

Xiong, Wu; Yan, Yu; Hu, Feng; Liu, Can; Wang, Shaohua; Chen, Jia; Wang, Xueqi; Zhou, Jianda

2016-01-01

Ear reconstruction is one of the most complicated and challenging techniques in plastic surgery because of the histologic and anatomic properties of the ear. Success depends on fitting the auriform cartilage scaffold into the overlying skin, but current approaches can just give results that are not lifelike and can lead to complications. A novel double-capsule, double-valve plastic ear expander was designed and implanted subcutaneously on either side of the dorsum of six New Zealand white rabbits (two expanders per rabbit). The outer capsule was expanded by injecting approximately 120 mL of physiological saline, then withdrawing the liquid on two occasions. Next, the ear-shaped inner capsule was filled with high-hardness plaster, and the external capsule was emptied such that the expanded skin flap and external capsule responded to the negative pressure and closed over the ear-shaped inner capsule. As a result, the skin flap adopted an ear shape. The ear expander was left in place for 4 wk, removed with the help of a mini-incision, and stripped of its fibrous capsule. To simulate human ear reconstruction, the expander was replaced with an auriform silicone prosthesis, and the effects of auricular reconstruction were observed dynamically. All 12 skin flaps maintained abundant blood supply, created a clear outline of the ear framework, and produced a lifelike result. No complications were observed during the 4-wk observation period. The expanded skin flaps described here can mold to the desired contours and appear lifelike, as well as maintain abundant blood supply. This may provide a simpler approach to total ear reconstruction that reduces risk of complications. Copyright © 2016 Elsevier Inc. All rights reserved.

Total Composite Flap Facelift and the Deep-Plane Transition Zone: A Critical Consideration in SMAS-Release Midface Lifting

PubMed Central

Mani, Marc

2016-01-01

Background Recent anatomic studies suggest the superficial musculoaponeurotic system (SMAS) layer attenuates in the midface. This led the author to switch from a bilamellar high SMAS dissection to a “total composite flap” technique, preserving skin and SMAS/platysma as one layer in a critical “deep-plane transition zone” (DTZ) lateral to the zygomaticus major muscle. This allows traction on the SMAS to translate to the malar fat pad via a “cantilever bridge” effect, which is lost when skin is undermined in the DTZ. Objectives This paper attempts to answer the question of whether the composite flap or bilamellar technique better lifts the midface, comparing groups where the DTZ was undermined: (1) only at a sub-SMAS level; or (2) at both subcutaneous and sub-SMAS levels. Methods Thirty-five patients underwent bilamellar facelifts with skin and SMAS separated in the DTZ. Midfacial elevation was measured using size-matched preoperative and 18-month (average) postoperative photographs for the 70 hemi-midfaces. The same analysis was done for 35 patients undergoing total composite flap facelift, maintaining skin and SMAS as one layer in the DTZ. The two groups were compared. Results In the bilamellar group, the mean percentage of midfacial elevation at 18 months postoperative was 5.5% (range, 0.0%-17.8%). In the composite flap group, the percentage was 11.7% (range, 0.1%-32.3%). The difference was statistically significant. Conclusions Maintaining skin-SMAS attachments in the DTZ improves midface elevation during SMAS facelifting, exploiting a “cantilever bridge” effect of the skin transferring traction on the SMAS to the malar fat pad. Level of Evidence: 4 Therapeutic PMID:26931306

Morphology of the abdominal wall in the bat, Pteronotus parnellii (Microchiroptera: Mormoopidae): implications for biosonar vocalization.

PubMed

Lancaster, W C; Henson, O W

1995-01-01

We investigated the structure of the abdominal wall of Pteronotus parnellii and made comparisons with eight other species of Microchiroptera and one megachiropteran. Similar to other mammals, the abdominal wall of bats consists of the three flank muscles laterally and the m. rectus abdominis ventrally. In Microchiroptera, flank muscles are mostly confined to dorsal portions of the wall. The mm. transversus abdominis and obliquus internus abdominis form the bulk of the wall; the m. obliquus externus is poorly developed. Ventrolaterally, a large portion of the wall is a dense, bilaminar aponeurosis, composed of collagen, elastin, and fibroblasts. The thicker, superficial lamina derives from the mm. obliquus internus and transversus abdominis. The deep lamina is a continuation of the transversalis fascia. Collagen fibers of the two fused laminae are oriented orthogonally, resulting in a resilient, composite fabric. Fascicles of the flank muscles are oriented along the margins of the aponeurosis so that their forces appear to be concentrated onto the aponeurosis. We suggest that this system is adapted for the regulation and generation of intra-abdominal pressure. The abdominal wall of Pteropus, the one megachiropteran examined, lacks the derived aponeurosis and is similar to other mammals. We consider the abdominal wall of Microchiroptera to be analogous to the diaphragma, in that it functions in the regulation of pressure within body cavities and facilitates biosonar vocalization.

Exercise and Transversus Abdominis Muscle Atrophy after 60-d Bed Rest.

PubMed

Belavý, Daniel Ludovic; Gast, Ulf; Felsenberg, Dieter

2017-02-01

This study aimed to investigate atrophy in the deep abdominal muscles, spinal extensors, and the effect of high-load resistive exercise with and without whole-body vibration after 60 d of strict bed rest. Twenty-four subjects underwent 60 d of head-down tilt bed rest and performed either resistive vibration exercise (RVE), resistive exercise only (RE), or no exercise control (2nd Berlin BedRest Study). The thickness of the transversus abdominis, internal oblique, and erector spinae muscles and the area of the multifidus muscle were measured bilaterally via real-time ultrasound. Intention-to-treat analysis was implemented, and P values were adjusted by the false discovery rate method. At the end of the bed rest, transversus abdominis thickness was reduced by 18.3% in the inactive group (P = 0.00011) with no significant change in the RVE (-4.0%; P = 0.014 vs control) or RE (-5.0%; P = 0.10 vs control) groups. In the inactive subjects, internal oblique thickness reduced by 10.6% (P = 0.0025) and by 7% (P > 0.05) in each of the training groups. The lengthening of the lumbar spine was greatest on day 1 (+7.4%, P = 0.004) and day 2 (+6.3%, P = 0.004; day 54: +4.1%, P = 0.023). A 4.7% reduction of multifidus area was observed on day 1 of bed rest (P = 0.0049) and a 4.2% reduction of erector spinae thickness was observed on day 2 (P = 0.0011). Extensor atrophy and spinal lengthening was not affected by exercise. No significant difference was seen between RVE and RE. Bed rest leads to atrophy of the transversus abdominis and internal oblique muscles. The exercise program, which implemented lower-limb and back extension exercises against shoulder restraints, was able to reduce atrophy seen in transversus abdominis in bed rest.

Establishing Immediate Reliability of Sonographic Measurements of the Transversus Abdominis in Asymptomatic Adults Performing Upright Loaded Functional Tasks in a Clinical Context Without Delayed Recorded Measurement.

PubMed

McPherson, Sue; Watson, Todd; Pate, Lindsey

2016-08-01

This study examined the reliability of sonographic measurements of the transversus abdominis of adults without low back pain during upright loaded functional tasks in real time, without relying on delayed recorded images. A single-group repeated-measures reliability study was conducted on 12 healthy participants without low back pain. Six of these adults reported a prior history of abdominal drawing-in maneuver training without sonographic measurement. The participants performed 3 trials of neutral standing, a loaded forward reach, and a loaded box lift under rest and with abdominal drawing-in maneuver instructions; task order was randomized. Transversus abdominis thickness measurements were obtained by an experienced rater using B-mode sonography in real-time via electronic calipers twice on the same static image during all trials by a rater. The rater was masked to group assignment and on-screen measurement output and required to respond to trivia questions between repeated measurements. The participants included 6 male and 6 female adults with a mean age ± SD of 26.3 ± 3.7 years. Intra-rater intraclass correlation coefficients (2,3) were high and precise for the rater's first and second measurements for all tasks and instruction conditions for mean transversus abdominis thickness and percent change in thickness measurements (eg, ranges were 0.968-0.997 for intraclass correlation coefficients, 0.01-0.21 mm for standard errors of the measurement, and 0.01-0.58 mm for minimal detectable changes). Calipers cleared by the rater or a research assistant produced similar findings of excellent reliability and precision. High intra-rater reliability and precision of transversus abdominis thickness measurements were obtained by a physical therapist in real time from asymptomatic adults performing upright loaded functional tasks under rest and with abdominal drawing-in maneuver instructions.

Can angiogenesis induced by chronic electrical stimulation enhance latissimus dorsi muscle flap survival for application in cardiomyoplasty?

PubMed

Overgoor, Max L E; Carroll, Sean M; Papanicolau, George; Carroll, Camilla M A; Ustüner, Tuncay E T; Stremel, Richard W; Anderson, Gary L; Franken, Ralph J P M; Kon, Moshe; Barker, John H

2003-01-01

In cardiomyoplasty, the latissimus dorsi muscle is lifted on its primary neurovascular pedicle and wrapped around a failing heart. After 2 weeks, it is trained for 6 weeks using chronic electrical stimulation, which transforms the latissimus dorsi muscle into a fatigue-resistant muscle that can contract in synchrony with the beating heart without tiring. In over 600 cardiomyoplasty procedures performed clinically to date, the outcomes have varied. Given the data obtained in animal experiments, the authors believe these variable outcomes are attributable to distal latissimus dorsi muscle flap necrosis. The aim of the present study was to investigate whether the chronic electrical stimulation training used to transform the latissimus dorsi muscle into fatigue-resistant muscle could also be used to induce angiogenesis, increase perfusion, and thus protect the latissimus dorsi muscle flap from distal necrosis. After 14 days of chronic electrical stimulation (10 Hz, 330 microsec, 4 to 6 V continuous, 8 hours/day) of the right or left latissimus dorsi muscle (randomly selected) in 11 rats, both latissimus dorsi muscles were lifted on their thoracodorsal pedicles and returned to their anatomical beds. Four days later, the resulting amount of distal flap necrosis was measured. Also, at predetermined time intervals throughout the experiment, muscle surface blood perfusion was measured using scanning laser Doppler flowmetry. Finally, latissimus dorsi muscles were excised in four additional stimulated rats, to measure angiogenesis (capillary-to-fiber ratio), fiber type (oxidative or glycolytic), and fiber size using histologic specimens. The authors found that chronic electrical stimulation (1) significantly (p < 0.05) increased angiogenesis (mean capillary-to-fiber ratio) by 82 percent and blood perfusion by 36 percent; (2) did not reduce the amount of distal flap necrosis compared with nonchronic electrical stimulation controls (29 +/- 5.3 percent versus 26.6 +/- 5.1 percent); (3) completely transformed the normally mixed (oxidative and glycolytic) fiber type distribution into all oxidative fibers; and (4) reduced fiber size in the proximal and middle but not in the distal segments of the flap. Despite the significant increase in angiogenesis and blood perfusion, distal latissimus dorsi muscle flap necrosis did not decrease. This might be because of three reasons: first, the change in muscle metabolism from anaerobic to aerobic may have rendered the muscle fibers more susceptible to ischemia. Second, because of the larger diameter of the distal fibers in normal and stimulated latissimus dorsi muscle, the diffusion distance for oxygen to the center of the distal fibers is increased, making fiber survival more difficult. Third, even though angiogenesis was significantly increased in the flap, cutting all but the single vascular pedicle resulted in the newly formed capillaries not receiving enough blood to provide nourishment to the distal latissimus dorsi muscle. The authors' findings indicate that chronic electrical stimulation as tested in these experiments could not be used to prevent distal latissimus dorsi muscle flap ischemia and necrosis in cardiomyoplasty.

The Lumbar Artery Perforator Flap: 3-Dimensional Anatomical Study and Clinical Applications.

PubMed

Bissell, Mary Beth; Greenspun, David T; Levine, Josh; Rahal, William; Al-Dhamin, Ammar; AlKhawaji, Ali; Morris, Steven F

2016-10-01

The lumbar region is a potential donor site for perforator-based rotational or free flaps or as a recipient site for free flaps to obtain coverage for deficits in the sacral region. Because of the lack of consensus regarding the microvascular anatomy of this potential flap site, a robust investigation of the anatomy of this region is required. Three-dimensional reconstructions (n = 6) of the microvasculature of the lumbar region were generated using MIMICS software (Materialise, Belgium) for each of the four paired lumbar vessels. Diameter, course, and pedicle length were recorded for all lumbar artery (LA) perforators. Statistical analysis was performed using SigmaStat 4.0 and graphs were generated using GraphPad Prism 6 Software. Perforators arising from the first pair of LAs are reliably detected along the inferior margin of the 12th rib, extending inferiorly and laterally from the midline while perforators arising from the fourth pair of LA perforate the fascia along a horizontal plane connecting the posterior iliac crests. There are significantly more cutaneous perforators arising from the first (L1) and fourth (L4) pairs of LA than from the second (L2) and third (L3) (mean ± SD: L1, 5.5 ± 1.2; L2, 1.4 ± 0.7; L3, 1.3 ± 0.7; L4, 4.8 ± 1.0; P < 0.05). The average perforator diameter arising from L1 is greater than those arising from L4 (diameter ± SD: L1, 1.2 mm ± 0.2 >L4, 0.8 mm ± 0.2; P < 0.0001). L1 and L4 perforators have longer pedicle lengths than those arising from L2 and L3 (length ± SD: L1, 98.2 mm ± 57.8; L4, 106.1 mm ± 23.3 >L2, 67.5 mm ± 27.4; L3, 78.5 mm ± 30.3; P < 0.05). Perforators arising from the first and fourth LAs arise in a predictable fashion, have adequate pedicle lengths, and are of suitable diameter to support a perforator flap. We present a case to support the potential use of this flap for microvascular breast reconstruction.

INTERNAL LIMITING MEMBRANE PEELING VERSUS INVERTED FLAP TECHNIQUE FOR TREATMENT OF FULL-THICKNESS MACULAR HOLES: A COMPARATIVE STUDY IN A LARGE SERIES OF PATIENTS.

PubMed

Rizzo, Stanislao; Tartaro, Ruggero; Barca, Francesco; Caporossi, Tomaso; Bacherini, Daniela; Giansanti, Fabrizio

2017-12-08

The inverted flap (IF) technique has recently been introduced in macular hole (MH) surgery. The IF technique has shown an increase of the success rate in the case of large MHs and in MHs associated with high myopia. This study reports the anatomical and functional results in a large series of patients affected by MH treated using pars plana vitrectomy and gas tamponade combined with internal limiting membrane (ILM) peeling or IF. This is a retrospective, consecutive, nonrandomized comparative study of patients affected by idiopathic or myopic MH treated using small-gauge pars plana vitrectomy (25- or 23-gauge) between January 2011 and May 2016. The patients were divided into two groups according to the ILM removal technique (complete removal vs. IF). A subgroup analysis was performed according to the MH diameter (MH < 400 µm and MH ≥ 400 µm), axial length (AL < 26 mm and AL ≥ 26 mm), and the presence of chorioretinal atrophy in the macular area (present or absent). We included 620 eyes of 570 patients affected by an MH, 300 patients underwent pars plana vitrectomy and ILM peeling and 320 patients underwent pars plana vitrectomy and IF. Overall, 84.94% of the patients had complete anatomical success characterized by MH closure after the operation. In particular, among the patients who underwent only ILM peeling the closure rate was 78.75%; among the patients who underwent the IF technique, it was 91.93% (P = 0.001); and among the patients affected by full-thickness MH ≥400 µm, success was achieved in 95.6% of the cases in the IF group and in 78.6% in the ILM peeling group (P = 0.001); among the patients with an axial length ≥26 mm, success was achieved in 88.4% of the cases in the IF group and in 38.9% in the ILM peeling group (P = 0.001). Average preoperative best-corrected visual acuity was 0.77 (SD = 0.32) logarithm of the minimum angle of resolution (20/118 Snellen) in the peeling group and 0.74 (SD = 0.33) logarithm of the minimum angle of resolution (20/110 Snellen) in the IF group (P = 0.31). Mean postoperative best-corrected visual acuity was 0.52 (SD = 0.42) logarithm of the minimum angle of resolution (20/66 Snellen) in the peeling group and 0.43 (SD = 0.31) logarithm of the minimum angle of resolution (20/53 Snellen) in the IF group (P = 0.003). Vitrectomy associated with the inverted ILM flap technique seems to be effective surgery for idiopathic and myopic large MHs, improving both functional and anatomical outcomes.

The importance of a normal breathing pattern for an effective abdominal-hollowing maneuver in healthy people: an experimental study.

PubMed

Ha, Sung-min; Kwon, Oh-yun; Kim, Su-jung; Choung, Sung-dae

2014-02-01

A normal breathing pattern while performing the abdominal-hollowing (AH) maneuver or spinal-stabilization exercise is essential for the success of rehabilitation programs and exercises. In previous studies, subjects were given standardized instructions to control the influence of respiration during the AH maneuver. However, the effect of breathing pattern on abdominal-muscle thickness during the AH maneuver has not been investigated. To compare abdominal-muscle thickness in subjects performing the AH maneuver under normal and abnormal breathing-pattern conditions and to investigate the effect of breathing pattern on the preferential contraction ratio (PCR) of the transverse abdominis. Comparative, repeated-measures experimental study. University research laboratory. 16 healthy subjects (8 male, 8 female) from a university population. A real-time ultrasound scanner was used to measure abdominal-muscle thickness during normal and abnormal breathing patterns. A paired t test was used to assess the effect of breathing pattern on abdominal-muscle thickness and PCR. Muscle thickness in the transverse abdominis and internal oblique muscles was significantly greater under the normal breathing pattern than under the abnormal pattern (P < .05). The PCR of the transverse abdominis was significantly higher under the normal breathing pattern compared with the abnormal pattern (P < .05). The results indicate that a normal breathing pattern is essential for performance of an effective AH maneuver. Thus, clinicians should ensure that patients adopt a normal breathing pattern before performing the AH maneuver and monitor transverse abdominis activation during the maneuver.

Efficacy of ultrasound-guided transversus abdominis plane block in laparoscopic hysterectomy. Clinical trial.

PubMed

Guardabassi, D S; Lupi, S; Agejas, R; Allub, J M; García-Fornari, G

2017-05-01

Transversus abdominis plane block is a regional anaesthesia technique that has proven to be effective for postoperative pain reduction in different abdominal surgical procedures. This study evaluated its efficacy on post laparoscopic hysterectomy pain intensity and analgesic consumption. Randomized controlled trial which included 40 patients scheduled for laparoscopic hysterectomy, enrolled in 2 groups: transversus abdominis plane block+systemic analgesia (Group 1; n=20), versus systemic analgesia (Group 2; n=20). Opioid consumption within the first 24 postoperative hours, pain intensity scores at 60min, 2, 8 and 24h after surgery, adverse events related to systemic analgesia and time to hospital discharge were evaluated and registered. We found no differences between both groups in opioid consumption (10mg vs. 7mg; P=.2) and pain scores (NVS) within the first 24 postoperative hours, at 60min (3 vs. 5; P=.65), 120min (0 vs. 2; P=.15), 8 and 24h (0 vs. 0; P>.50) for the last 2 points in time analysed. Adverse events related to medication and time to hospital discharge showed similar results. Adding a transversus abdominis plane block technique to opioid PCA does not seem to improve postoperative pain management in laparoscopic hysterectomy. Patient preparation time and costs could be incremented and complications (although rare) related to the technique could appear. Copyright © 2017 Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor. Publicado por Elsevier España, S.L.U. All rights reserved.

Chondrocutaneous helix rim advancement flap: two classical and two new modifications for very large defects of the ear.

PubMed

Valesky, E M; Kaufmann, R; Meissner, M

2015-11-01

The plastic reconstruction of the ear after microscopically controlled tumor surgery is a particular challenge. The chondrocutaneous helix rim advancement flap (CHRAF) is perfectly suited for the repair of different defects of the helix and even defects beyond. Here, we describe two known and two new modifications of the CHRAF that enlarge the scope of application in tumor surgery of the ear. We demonstrate the different techniques and practical application of the repair and evaluate the benefits and limitations. The CHRAF and its modifications is an excellent method for repair of various defects of the helical region of the ear. The CHRAF and its modifications proves to be an good alternative to other methods of closure by preserving the anatomical contour and mechanical and acoustic functions in a single-staged procedure with excellent aesthetic results. The two new modifications we introduced here, enlarge the known armentarium for very large defects of the upper pole and the mid-helix of the ear. © 2014 European Academy of Dermatology and Venereology.

Simplicity and treatment of the typical cleft hand.

PubMed

Upton, J

2004-01-01

The typical cleft hand is now distinguished from symbrachydactyly. This review of the surgical treatment of 108 hands in 63 patients treated over a 28-year period concentrates upon the technical principles of surgical correction. The key to these reconstructions is a wide incision which extends from the ulnar side of the cleft around the malpositioned index finger to the thumb. This wide exposure provides clear identification of all anatomic structures within the palm. There are no tenuous flaps with narrow random pedicles. These difficult surgical corrections may often include index transposition, metacarpal and/or phalangeal osteotomies, joint releases, phalangeal ostectomies, preservation of the adductor pollicis muscle, first dorsal interosseous muscle release, syndactyly separation(s) and thumb duplication correction. Following reposition of all skeletal structures the dorsal and palmar full-thickness flaps are easily contoured to create a satisfactory first webspace. Outcomes data shows that although the pinch and grip remain weak, these hands are quite functional. It is important that the repositioned index ray not interfere with gripping and precision maneuvers between the mobile thumb and the ulnar two digits (ring and small) of the hand.

[Localization of perforators in the lower leg by digital antomy imaging methods].

PubMed

Wei, Peng; Ma, Liang-Liang; Fang, Ye-Dong; Xia, Wei-Zhi; Ding, Mao-Chao; Mei, Jin

2012-03-01

To offer both the accurate three-dimensional anatomical information and algorithmic morphology of perforators in the lower leg for perforator flaps design. The cadaver was injected with a modified lead oxide-gelatin mixture. Radiography was first performed and the images were analyzed using the software Photoshop and Scion Image. Then spiral CT scan was also performed and 3-dimensional images were reconstructed with MIMICS 10.01 software. There are (27 +/- 4) perforators whose outer diameter > or = 0.5 mm ( average, 0.8 +/- 0.2 mm). The average pedicle length within the superficial fascia is (37.3 +/- 18.6) mm. The average supplied area of each perforator is (49.5 +/- 25.5) cm2. The three-dimensional model displayed accurate morphology structure and three-dimensional distribution of the perforator-to- perforator and perforator-to-source artery. The 3D reconstruction model can clearly show the geometric, local details and three-dimensional distribution. It is a considerable method for the study of morphological characteristics of the individual perforators in human calf and preoperative planning of the perforator flap.

Translating Computer-Aided Design and Surgical Planning Into Successful Mandibular Reconstruction Using a Vascularized Iliac-Crest Flap.

PubMed

Zheng, Lei; Lv, Xiaoming; Zhang, Jie; Liu, Shuming; Zhang, Jianguo; Zhang, Yi

2018-04-01

This study evaluated the computer-aided approach to the reconstruction of mandibular defects using a vascularized iliac-crest flap. From December 2015 to October 2016, 14 patients (8 men and 6 women) 18 to 64 years old (median age, 29 yr) were treated at the Peking University School and Stomatology Hospital (Beijing, China). Biopsy specimens from all patients were subjected to histologic examination before segmental mandibulectomy. Computer-based surgical techniques, including virtual surgical planning, computer-aided design and manufacturing, rapid prototyping, and intraoperative navigation, were used to restore the anatomic continuity and configuration of the mandible using a vascularized iliac-crest flap. Two transverse dimensions and 1 anteroposterior (A-P) dimension were evaluated based on the virtual plan and postoperative computed tomogram. Lines from condylar head to condylar head and from gonial angle to gonial angle were defined as the transverse dimensions. A perpendicular line drawn from the mandibular midline to the center point on the condylar head to condylar head measurement was defined as the A-P dimension. Complications were evaluated during follow-up. The flap success rate was 92.9% (13 of 14), with 1 flap failure. After the operation, there were no other serious complications in 13 of the 14 patients, who exhibited a good mandibular configuration with good occlusion. Furthermore, the height of bone graft was sufficient for implants. Healing of the recipient and donor sites with no serious complication was uneventful. The average surgical errors in the A-P dimension and transverse dimensions were 1.8 ± 1.0 mm (range, 0.2 to 3.7 mm), 2.2 ± 1.1 mm (range, 0.9 to 5.0 mm), and 2.6 ± 1.6 mm (range, 0.3 to 7.2 mm), respectively. The use of these digital techniques was found to be a viable option for reconstruction of mandibular defects, but the results should be interpreted cautiously because of the small number of patients and the relatively short follow-up. Copyright © 2017. Published by Elsevier Inc.

Two-year quality of life after free flap reconstruction in tumor-site discrepancy among Taiwanese with moderately advanced oral squamous cell carcinoma.

PubMed

Chang, Kao-Ping; Lai, Chung-Sheng; Hsieh, Tung-Ying; Wu, Yi-Chia; Chang, Chih-Hau

2012-07-13

This study describes 2-year impact on quality of life (QOL) in relation to the anatomical discrepancy among T4a oral cancer patients after free flap reconstruction in Taiwan. Thirty-two patients who underwent tumor ablation with simultaneous microvascular free flap transfer at 2-year follow-up were recruited. They were divided into six subgroups, according to the resected area, consisting of: (1) buccal/retromolar trigone; (2) cheek; (3) commissure; (4) lip; (5) mandible; and (6) tongue. Functional disturbances and daily activity were analyzed using the Version-1 UW QOL Questionnaire with one more specific category: 'Drooling'. Kruskal-Wallis rank sums analysis was used to test differences in average QOL scores between these subgroups. Post-hoc analysis was applied to assess influence of dominant categories between subgroups. The category 'Pain' revealed the highest average score and reached significant statistical difference (P = 0.019) among all the categories, however, the category 'Employment' averaged the lowest score. Regarding 'Pain', there existed a statistical significance (P = 0.0032) between the commissure- and cheek-involved groups, which described the former showed poorer pain quality of life. The commissure-involved group had the lowest average score, which might imply the worst QOL in our study, especially for the categories 'Pain' and 'Drooling'. This present study of T4a patients was the first carried out in Taiwan implementing the QOL questionnaire, and its results may serve for future reference.

TRIDIMENSIONAL DOPPLER ASSESSMENT: A RELIABLE, NON-INVASIVE AND COST-EFFECTIVE METHOD FOR PREOPERATIVE PERFORATOR ASSESSMENT IN DIEP FLAP.

PubMed

Dražan, L; Lombardo, G A G

The preoperative perforator mapping is an important step in autologous breast reconstruction, making the flap raising safer, more predictable and time-saving. Although the Doppler exam has proven to be less accurate in locating perforators compared with colour duplex sonography and CTA, it will probably remain of importance in clinical practice. The aim of this paper is to share some advices on how to perform a Doppler exam in preoperative evaluation of a DIEAp flap, increasing its reliability in location of the perforators. The study was carried-out preoperatively on 26 consecutive patients. For the evaluation of the matching between Doppler Dot and operative finding was used a Cartesian coordinate systemResults: We have marked preoperatively 145 perforators in 26 patients for a total of 52 semi-abdomens. An average of 5.6 vessels per patient were marked. Of these, 80 (55.17%) were found between 0-1 cm, 36 (24.82%) between 1-2 cm and 5 (3.4%) of these more than 2 cm from each other. We had 24 (16.55%) false positives in which there was no correspondence between the signal and the intraoperative finding. Although the Doppler exam may not provide the same anatomic details as the other newer modalities, such as CTA and MRA, the HHD remains a very useful and important tool for autologous reconstruction. We recommend performing this exam in our standardized and reproducible method to improve the reliability..

Radio-anatomical analysis of the pericranial flap "money box approach" for ventral skull base reconstruction.

PubMed

Santamaría, Alfonso; Langdon, Cristóbal; López-Chacon, Mauricio; Cordero, Arturo; Enseñat, Joaquim; Carrau, Ricardo; Bernal-Sprekelsen, Manuel; Alobid, Isam

2017-11-01

To evaluate the versatility of the pericranial flap (PCF) to reconstruct the ventral skull base, using the frontal sinus as a gate for its passage into the sinonasal corridor "money box approach." Anatomic-radiological study and case series. Various approaches and their respective defects (cribriform, transtuberculum, clival, and craniovertebral junction) were completed in 10 injected specimens. The PCF was introduced into the nose through the uppermost portion of the frontal sinus (money box approach). Computed tomography (CT) scans (n = 50) were used to measure the dimensions of the PCF and the skull base defects. The vertical projection of the external ear canal was used as the reference point to standardize the incisions for the PCF. The surface area and maximum length of the PCF were 121.5 ± 19.4 cm 2 and 18.3 ± 1.3 cm, respectively. Using CT scans, we determined that to reconstruct defects secondary to transcribriform, transtuberculum, clival, and craniovertebral approaches, the PCF distal incision must be placed respectively at -3.7 ± 2.0 cm (angle -17.4 ± 8.5°), -0.2 ± 2.0 cm (angle -1.0 ± 9.3°), +5.5 ± 2.3 cm (angle +24.4 ± 9.7°), +8.4 ± 2.4 cm (angle +36.6 ± 11.5°), as related to the reference point. Skull base defects in our clinical cohort (n = 6) were completely reconstructed uneventfully with the PCF. The PCF renders enough surface area to reconstruct all possible defects in the ventral and median skull base. Using the uppermost frontal sinus as a gateway into the nose (money box approach) is feasible and simple. NA. Laryngoscope, 127:2482-2489, 2017. © 2017 The American Laryngological, Rhinological and Otological Society, Inc.

Calcaneocuboid joint instability: a novel operative technique for anatomic reconstruction.

PubMed

Lohrer, Heinz; Arentz, Sabine

2004-05-01

A case history of a 13-year-old female national top-level gymnast, suffering from calcaneocuboid joint instability, is presented. The procedure was done as an anatomic repair by capsular reefing, which was augmented using a local periosteal flap. Initially, the athlete twisted her ankle. Clinical investigation revealed no sign of a lateral ankle ligament injury, but following this initial examination, recurrent giving-way of the foot occurred. She additionally felt significant but diffuse pain on the lateral side of the foot during loading in training and competition. For 2 months she was unable to run and conservative treatment failed. Diagnosis of a calcaneocuboid instability was established 4 months after the initial lesion by clinical and x-ray stress examination of the calcaneocuboid joint. Open surgery was successfully performed. Early functional posttreatment was done and the patient returned to full high-level gymnastics ability 16 weeks after surgery. Two years later, a similar injury occurred to the opposite calcaneocuboid joint and the same operative procedure again led to full sports ability.

DOE Office of Scientific and Technical Information (OSTI.GOV)

Pairolero, P.C.; Arnold, P.G.

In this article, we review our experience during the past 9 years with 205 consecutive thoracic wall reconstructions. The 100 female and 105 male patients ranged in age from 12 to 85 years (mean, 53.4 years). One hundred fourteen patients had thoracic wall tumors, 56 had radiation necrosis, 56 had infected median sternotomy wounds, and 8 had costochondritis. Twenty-nine of these patients had combinations of the aforementioned conditions. One hundred seventy-eight patients underwent skeletal resection. A mean of 5.4 ribs were resected in 142 patients. Total or partial sternectomies were performed in 60. Skeletal defects were closed with prosthetic materialmore » in 66 patients and with autogenous ribs in 12. One hundred sixty-eight patients underwent 244 muscle flap procedures: 149 pectoralis major, 56 latissimus dorsi, 14 rectus abdominis, 13 serratus anterior, 8 external oblique, 2 trapezius, and 2 advancement of diaphragm. The omentum was transposed in 20 patients. The mean number of operations per patient was 1.9 (range, 1 to 8). The mean duration of hospitalization was 16.5 days. One perioperative death occurred (at 29 days). Four patients required tracheostomy. During a mean follow-up of 32.4 months, there were 49 late deaths, predominantly due to malignant disease. All 204 patients who were alive 30 days after operation had excellent surgical results at last follow-up examination or at the time of death due to causes unrelated to the reconstructive procedure.« less

Influence of exercise training on the oxidative capacity of rat abdominal muscles

NASA Technical Reports Server (NTRS)

Uribe, J. M.; Stump, C. S.; Tipton, C. M.; Fregosi, R. F.

1992-01-01

Our purpose was to determine if endurance exercise training would increase the oxidative capacity of the abdominal expiratory muscles of the rat. Accordingly, 9 male rats were subjected to an endurance training protocol (1 h/day, 6 days/week, 9 weeks) and 9 litter-mates served as controls. Citrate synthase (CS) activity was used as an index of oxidative capacity, and was determined in the following muscles: soleus, plantaris, costal diaphragm, crural diaphragm, and in all four abdominal muscles: rectus abdominis, transversus abdominis, external oblique, and internal oblique. Compared to their non-trained litter-mates, the trained rats had higher peak whole body oxygen consumption rates (+ 16%) and CS activities in plantaris (+34%) and soleus (+36%) muscles. Thus, the training program caused substantial systemic and locomotor muscle adaptations. The CS activity of costal diaphragm was 20% greater in the trained animals, but no difference was observed in crural diaphragm. The CS activity in the abdominal muscles was less than one-half of that in locomotor and diaphragm muscles, and there were no significant changes with training except in the rectus abdominis where a 26% increase was observed. The increase in rectus abdominis CS activity may reflect its role in postural support and/or locomotion, as none of the primary expiratory pumping muscles adapted to the training protocol. The relatively low levels of CS activity in the abdominal muscles suggests that they are not recruited frequently at rest, and the lack of an increase with training indicates that these muscles do not contribute significantly to the increased ventilatory activity accompanying exercise in the rat.

Normal postural responses preceding shoulder flexion: co-activation or asymmetric activation of transverse abdominis?

PubMed

Davarian, Sanaz; Maroufi, Nader; Ebrahimi, Esmaeil; Parnianpour, Mohammad; Farahmand, Farzam

2014-01-01

It is suggested that activation of the transverse abdominis muscle has a stabilizing effect on the lumbar spine by raising intra-abdominal pressure without added disc compression. However, its feedforward activity has remained a controversial issue. In addition, research regarding bilateral activation of trunk muscles during a unilateral arm movement is limited. The aim of this study was to evaluate bilateral anticipatory activity of trunk muscles during unilateral arm flexion. Eighteen healthy subjects (aged 25 ± 3.96 years) participated in this study and performed 10 trials of rapid arm flexion in response to a visual stimulus. The electromyographic activity of the right anterior deltoid (AD) and bilateral trunk muscles including the transverse abdominis/internal oblique (TA/IO), superficial lumbar multifidus (SLM) and lumbar erector spine (LES) was recorded. The onset latency and anticipatory activity of the recorded trunk muscles were calculated. The first muscle activated in anticipation of the right arm flexion was the left TA/IO. The right TA/IO activated significantly later than all other trunk muscles (P < 0.0005). In addition, anticipatory activity of the right TA/IO was significantly lower than all other trunk muscles (P < 0.0005). There was no significant difference in either onset latency or anticipatory activity among other trunk muscles (P > 0.05). Healthy subjects showed no bilateral anticipatory co-activation of TA/IO in unilateral arm elevation. Further investigations are required to delineate normal muscle activation pattern in healthy subjects prior to prescribing bilateral activation training of transverse abdominis for subjects with chronic low back pain.

The effect of bridge exercise method on the strength of rectus abdominis muscle and the muscle activity of paraspinal muscles while doing treadmill walking with high heels.

PubMed

Kang, Taewook; Lee, Jaeseok; Seo, Junghoon; Han, Dongwook

2017-04-01

[Purpose] The purpose of this research is to investigate the effect of the method of bridge exercise on the change of rectus abdominis muscle and the muscle activity of paraspinal muscles while doing treadmill walking with high heels. [Subjects and Methods] The subjects of this research are healthy female students consisting of 10 persons performing bridge exercises in a supine group, 10 persons performing bridge exercises in a prone group, and 10 persons in a control group while in S university in Busan. Bridge exercise in supine position is performed in hook lying position. Bridge exercise in prone position is plank exercise in prostrate position. To measure the strength of rectus abdominis muscle, maintaining times of the posture was used. To measure the muscle activity of paraspinal muscles, EMG (4D-MT & EMD-11, Relive, Korea) was used. [Results] The strength of rectus abdominis muscle of both bridge exercises in the supine group and bridge exercises in the prone group increases significantly after exercise. The muscle activity of paraspinal muscle such as thoracic parts and lumbar parts in bridge exercises in the prone group decreases statistically while walking on a treadmill with high heels. Muscle activity of thoracic parts paraspinal muscle and bridge exercises in the supine group decreased significantly. [Conclusion] According to this study, we noticed that bridge exercise in a prone position is desirable for women who prefer wearing high heels as a back pain prevention exercise method.

Skeletal muscle metastasis from breast cancer: management and literature review.

PubMed

Salemis, Nikolaos S

2015-01-01

Skeletal muscle metastasis from breast cancer is a very rare clinical entity. We describe an extremely rare case of breast cancer metastasis to the rectus abdominis muscle. Our patient, who had undergone a left modified radical mastectomy for breast cancer four years ago, presented with a painful abdominal mass. Computed tomography scans showed a rim-enhancing mass with central hypoatennuation within the sheath of the rectus abdominis muscle. A Fine needle aspiration biopsy was initially performed and the findings were suggestive of malignancy. The muscle lesion was then resected and the histopathological analysis showed metastasis of breast cancer. Through our review of the literature, we found that only two cases of rectus abdominis muscle metastasis from breast cancer have been reported so far. This case highlights the need to rule out muscle metastatic lesions in patients with history of breast cancer presenting with these clinical and imaging characteristics. Differentiation from primary sarcoma is of paramount importance. Skeletal muscle metastases usually indicate an advanced disease associated with poor prognosis. Treatment should be individualized depending on the patient's clinical condition.

Flapping before Flight: High Resolution, Three-Dimensional Skeletal Kinematics of Wings and Legs during Avian Development

PubMed Central

Heers, Ashley M.; Baier, David B.; Jackson, Brandon E.; Dial, Kenneth P.

2016-01-01

Some of the greatest transformations in vertebrate history involve developmental and evolutionary origins of avian flight. Flight is the most power-demanding mode of locomotion, and volant adult birds have many anatomical features that presumably help meet these demands. However, juvenile birds, like the first winged dinosaurs, lack many hallmarks of advanced flight capacity. Instead of large wings they have small “protowings”, and instead of robust, interlocking forelimb skeletons their limbs are more gracile and their joints less constrained. Such traits are often thought to preclude extinct theropods from powered flight, yet young birds with similarly rudimentary anatomies flap-run up slopes and even briefly fly, thereby challenging longstanding ideas on skeletal and feather function in the theropod-avian lineage. Though skeletons and feathers are the common link between extinct and extant theropods and figure prominently in discussions on flight performance (extant birds) and flight origins (extinct theropods), skeletal inter-workings are hidden from view and their functional relationship with aerodynamically active wings is not known. For the first time, we use X-ray Reconstruction of Moving Morphology to visualize skeletal movement in developing birds, and explore how development of the avian flight apparatus corresponds with ontogenetic trajectories in skeletal kinematics, aerodynamic performance, and the locomotor transition from pre-flight flapping behaviors to full flight capacity. Our findings reveal that developing chukars (Alectoris chukar) with rudimentary flight apparatuses acquire an “avian” flight stroke early in ontogeny, initially by using their wings and legs cooperatively and, as they acquire flight capacity, counteracting ontogenetic increases in aerodynamic output with greater skeletal channelization. In conjunction with previous work, juvenile birds thereby demonstrate that the initial function of developing wings is to enhance leg performance, and that aerodynamically active, flapping wings might better be viewed as adaptations or exaptations for enhancing leg performance. PMID:27100994

A retrospective investigation of abdominal visceral fat, body mass index (BMI), and active smoking as risk factors for donor site wound healing complications after free DIEP flap breast reconstructions.

PubMed

Timmermans, Floyd W; Westland, Pèdrou B; Hummelink, Stefan; Schreurs, Joep; Hameeteman, Marijn; Ulrich, Dietmar J O; Slater, Nicholas J

2018-06-01

The deep inferior epigastric artery perforator (DIEP) flap is one of the most common techniques for breast reconstruction. Body mass index (BMI) is considered as an important predictor of donor site healing complications such as wound dehiscence. The use of computed tomography (CT) proved to be a precise and objective method to assess visceral adipose tissue. It remains unclear whether quantification of visceral fat provides more accurate predictions of abdominal wound healing complications than BMI. A total of 97 patients with DIEP flap were retrospectively evaluated. Patients' abdominal visceral fat (AVF) was quantified on CT angiography (CTA). The patients were postoperatively assessed for abdominal wound healing complications. We analyzed for the correlations between AVF, BMI, and dehiscence and established a logistic regression model to assess the potential high-profile predictors in anatomic and patient characteristics such as weight, smoking, and diabetes. We included 97 patients, and of them, 24 patients (24.7%) had some degree of abdominal dehiscence. No significant differences were observed between the dehiscence group and the non-dehiscence group, except for smoking (p = 0.002). We found a significant correlation between AVF and BMI (R = 0.282, p = 0.005), but neither was significant in predicting donor site dehiscence. Smoking greatly increased the likelihood of developing wound dehiscence (OR = 11.4, p = < 0.001). AVF and BMI were not significant predictors of abdominal wound healing complications after DIEP flap reconstruction. This study established active smoking (OR = 11.4, p = < 0.001) as the significant risk factor that contributed to the development of abdominal wound dehiscence in patients with DIEP. Copyright © 2018 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

Reconstruction of supracrestal alveolar bone lost as a result of severe chronic periodontitis. Five-year outcome: case report.

PubMed

Kotschy, Peter; Laky, Markus

2006-10-01

This patient presented with generalized severe chronic periodontitis. Conventional periodontal therapy would have left her compromised esthetically and anatomically, with growing interdental "black triangles." This prompted the authors to try to reconstruct the maxillary alveolar bone that had been lost in the previous three decades because of untreated periodontitis. To maintain the level and quality of the gingival margin, open flap surgery was performed in the maxilla soon after scaling and root planing. To gain access to the roots and bone surfaces, a flap was raised by intrasulcular incisions and the modified and simplified papilla preservation technique. After debridement, the root surfaces were conditioned and enamel matrix proteins were applied. Bovine bone mineral was placed in the infrabony defects and supracrestally (buccally, lingually, and interdentally) to help regenerate the lost alveolar bone. In addition, the defects around the maxillary anterior teeth were covered with a membrane. To prevent shrinkage of the gingiva, suspensory sutures were placed on the right central incisor and both left incisors so that the anterior flap would be positioned approximately 3 mm coronally. After surgery, the patient was advised to apply 1% chlorhexidine gel twice a day and to avoid brushing the surgical site for 4 weeks. Professional maintenance care was administered twice a week for 2 months and the patient was instructed to maintain a liquid diet for 4 weeks. The treatment outcome was evaluated clinically and radiographically at regular intervals for 5 years postsurgically. Periodontal conditions were stable and fulfilled the patient's desire to eliminate the pockets without compromising esthetics, particularly in the maxillary anterior.

Two-year quality of life after free flap reconstruction in tumor-site discrepancy among Taiwanese with moderately advanced oral squamous cell carcinoma

PubMed Central

2012-01-01

Background This study describes 2-year impact on quality of life (QOL) in relation to the anatomical discrepancy among T4a oral cancer patients after free flap reconstruction in Taiwan. Methods Thirty-two patients who underwent tumor ablation with simultaneous microvascular free flap transfer at 2-year follow-up were recruited. They were divided into six subgroups, according to the resected area, consisting of: (1) buccal/retromolar trigone; (2) cheek; (3) commissure; (4) lip; (5) mandible; and (6) tongue. Functional disturbances and daily activity were analyzed using the Version-1 UW QOL Questionnaire with one more specific category: ‘Drooling’. Kruskal-Wallis rank sums analysis was used to test differences in average QOL scores between these subgroups. Post-hoc analysis was applied to assess influence of dominant categories between subgroups. Results The category ‘Pain’ revealed the highest average score and reached significant statistical difference (P = 0.019) among all the categories, however, the category ‘Employment’ averaged the lowest score. Regarding ‘Pain’, there existed a statistical significance (P = 0.0032) between the commissure- and cheek-involved groups, which described the former showed poorer pain quality of life. Conclusions The commissure-involved group had the lowest average score, which might imply the worst QOL in our study, especially for the categories ‘Pain’ and ‘Drooling’. This present study of T4a patients was the first carried out in Taiwan implementing the QOL questionnaire, and its results may serve for future reference. PMID:22789070

Full-mouth treatment of gingival recessions and noncarious cervical lesions with coronally advanced flap and xenogeneic collagen matrix: 
a 2-year case report.

PubMed

Martiniello, Nello; Stefanini, Martina; Zucchelli, Giovanni

In clinical practice it is common to observe adjacent multiple gingival recessions (MGRs) associated with noncarious cervical lesions (NCCLs). The aim of this 2-year case report was to describe the full-mouth treatment of a patient affected by MGRs and NCCLs, with a combined restorative-surgical approach using a coronally advanced flap (CAF) and a xenogeneic collagen matrix (CM). Before surgery, a composite restoration filled the deepest portion of the NCCL defects and was finished at the level of the maximum root coverage (MRC). The surgical technique adopted for the root coverage procedures was CAF for MGRs without vertical releasing incisions in the maxilla, and with one vertical releasing incision in the mandible. The CM was positioned at the level of the cementoenamel junction (CEJ), and sutured at the base of the anatomic de-epithelialized papillae. The flap was shifted coronally, providing complete coverage of the CM, and sutured coronal to the CEJ with a variable number of sling sutures. At 2 years, complete root coverage was achieved in all treated sites, and the patient reported complete resolution of dental hypersensitivity. In the questionnaire, the patient-reported outcome showed a high level of esthetic satisfaction (mean score: 9.6; range: 9 to 10), and the objective esthetic evaluation with the root coverage esthetic score (RES) system showed a very high result (mean: 9.4). The suggested combined restorative-surgical approach provided successful root coverage and a favorable esthetic outcome in the treatment of MGR associated with NCCLs.

Comparative effects of 12 weeks of equipment based and mat Pilates in patients with Chronic Low Back Pain on pain, function and transversus abdominis activation. A randomized controlled trial.

PubMed

Cruz-Díaz, David; Bergamin, M; Gobbo, S; Martínez-Amat, Antonio; Hita-Contreras, Fidel

2017-08-01

Pilates method has been recommended for patients with chronic low back pain (CLBP) and the activation of transversus abdominis has been deemed to play an important role in the improvement of these patients. Nevertheless, the evidence of the activation of TrA in Pilates practitioners remains unclear. To assess the effectiveness of 12 weeks of Pilates practice in disability, pain, kinesiophobia and transversus abdominis activation in patients with chronic nonspecific Low Back Pain. A randomized controlled trial was carried out. A single-blind randomized controlled trial with repeated measures at 6 and 12 weeks was carried out. A total of ninety eight patients with low back pain were included and randomly allocated to a Pilates Mat group (PMG) equipment based with apparatus Pilates (PAG) or control group (CG). Roland Morris Disability Questionnaire (RMDQ), visual analog scale (VAS) Tampa Scale of Kinesiophobia (TSK), and transversus abdominis (TrA) activation assessed by real time ultrasound measurement (US) were assessed as outcome measures. Improvement were observed in both intervention groups in all the included variables at 6 and 12 weeks (p<0.001). Faster enhancement was observed in the equipment based Pilates group (p=0.007). Equipment based and mat Pilates modalities are both effective in the improvement of TaA activation in patients with CLBP with associate improvement on pain, function and kinesiophobia. Significant differences were observed after 12 weeks of intervention in PMG and PAG with faster improvement in PAG suggesting that, feedback provided by equipment could help in the interiorization of Pilates principles. Copyright © 2017 Elsevier Ltd. All rights reserved.

Internal Oblique and Transversus Abdominis Muscle Fatigue Induced by Slumped Sitting Posture after 1 Hour of Sitting in Office Workers

PubMed Central

Waongenngarm, Pooriput; Rajaratnam, Bala S.; Janwantanakul, Prawit

2015-01-01

Background Prolonged sitting leads to low back discomfort and lumbopelvic muscle fatigue. This study examined the characteristics of body perceived discomfort and trunk muscle fatigue during 1 hour of sitting in three postures in office workers. Methods Thirty workers sat for 1 hour in one of three sitting postures (i.e., upright, slumped, and forward leaning postures). Body discomfort was assessed using the Body Perceived Discomfort scale at the beginning and after 1 hour of sitting. Electromyographic (EMG) signals were recorded from superficial lumbar multifidus, iliocostalis lumborum pars thoracis, internal oblique (IO)/transversus abdominis (TrA), and rectus abdominis muscles during 1 hour of sitting. The median frequency (MDF) of the EMG power spectrum was calculated. Results Regardless of the sitting posture, the Body Perceived Discomfort scores in the neck, shoulder, upper back, low back, and buttock significantly increased after 1 hour of sitting compared with baseline values (t(9) = −11.97 to −2.69, p < 0.05). The MDF value of the EMG signal of rectus abdominis, iliocostalis lumborum pars thoracis, and multifidus muscles was unchanged over time in all three sitting postures. Only the right and left IO/TrA in the slumped sitting posture was significantly associated with decreased MDF over time (p = 0.019 to 0.041). Conclusion Prolonged sitting led to increased body discomfort in the neck, shoulder, upper back, low back, and buttock. No sign of trunk muscle fatigue was detected over 1 hour of sitting in the upright and forward leaning postures. Prolonged slumped sitting may relate to IO/TrA muscle fatigue, which may compromise the stability of the spine, making it susceptible to injury. PMID:27014491

Liposomal Bupivacaine Use in Transversus Abdominis Plane Blocks Reduces Pain and Postoperative Intravenous Opioid Requirement After Colorectal Surgery.

PubMed

Stokes, Audrey L; Adhikary, Sanjib D; Quintili, Ashley; Puleo, Frances J; Choi, Christine S; Hollenbeak, Christopher S; Messaris, Evangelos

2017-02-01

Enhanced recovery protocols frequently use multimodal postoperative analgesia to improve postoperative outcomes in patients undergoing colorectal surgery. The purpose of this study was to evaluate liposomal bupivacaine use in transversus abdominis plane blocks on postoperative pain scores and opioid use after colorectal surgery. This was a retrospective cohort study comparing outcomes between patients receiving nonliposomal anesthetic (n = 104) and liposomal bupivacaine (n = 303) blocks. The study was conducted at a single tertiary care center. Patients included those identified within an institutional database as inpatients undergoing colorectal procedures between 2013 and 2015 who underwent transversus abdominis plane block for perioperative analgesia. The study measured postoperative pain scores and opioid requirements. Patients receiving liposomal bupivacaine had significantly lower pain scores for the first 24 to 36 postoperative hours. Pain scores were similar after 36 hours. The use of intravenous opioids among the liposomal bupivacaine group decreased by more than one third during the hospitalization (99.1 vs 64.5 mg; p = 0.040). The use of ketorolac was also decreased (49.0 vs 18.3 mg; p < 0.001). In subgroup analysis, the decrease in opioid use was observed between laparoscopic and robotic procedures but not with laparotomies. No significant differences were noted in the use of oral opioids, acetaminophen, or ibuprofen. Postoperative length of stay and total cost were decreased in the liposomal bupivacaine group but did not achieve statistical significance. The study was limited by its retrospective, single-center design and heterogeneity of block administration. Attenuated pain scores observed with liposomal bupivacaine use were associated with significantly lower intravenous opioid and ketorolac use, suggesting that liposomal bupivacaine-containing transversus abdominis plane blocks are well aligned with the opioid-reducing goals of many enhanced recovery protocols.

Transversus abdominis plane block reduces morphine consumption in the early postoperative period following microsurgical abdominal tissue breast reconstruction: a double-blind, placebo-controlled, randomized trial.

PubMed

Zhong, Toni; Ojha, M; Bagher, Shaghayegh; Butler, Kate; Srinivas, Coimbatore; McCluskey, Stuart A; Clarke, Hance; O'Neill, Anne C; Novak, Christine B; Hofer, Stefan O P

2014-11-01

The analgesic efficacy of the transversus abdominis plane peripheral nerve block following abdominal tissue breast reconstruction has not been studied in a randomized controlled trial. The authors conducted a double-blind, placebo-controlled, 1:1 allocation, two-arm parallel group, superiority design, randomized controlled trial in patients undergoing microsurgical abdominally based breast reconstruction. Intraoperatively, epidural catheters were inserted under direct vision through the triangle of Petit on both sides of the abdomen into the transversus abdominis plane just before rectus fascial closure. Patients received either bupivacaine (study group) or saline (placebo group) through the catheters for 2 postoperative days. All patients received hydromorphone by means of a patient-controlled analgesic pump. The primary outcome was the difference in the parenteral opioid consumption on each postoperative day between the groups. The secondary outcome measures included the following: total in-hospital opioid; antinausea medication; pain, nausea, and sedation scores; Quality of Recovery Score; time to ambulation; and hospital stay duration. Between September of 2011 and June of 2013, 93 patients were enrolled: 49 received bupivacaine and 44 received saline. There were 11 postoperative complications (13 percent); none were related to the catheter. Primary outcomes were completed by 85 of 93 patients (91.3 percent); the mean parenteral morphine consumption was significantly reduced on postoperative day 1 in the bupivacaine group (20.7±20.1 mg) compared with 30.0±19.1 mg in the control group (p=0.02). There were no significant differences in secondary outcomes. Following abdominally based breast reconstruction, transversus abdominis plane peripheral nerve block is safe and significantly reduces morphine consumption in the early postoperative period. Therapeutic, II.

The influence of simulated transversus abdominis muscle force on sacroiliac joint flexibility during asymmetric moment application to the pelvis.

PubMed

Gnat, Rafael; Spoor, Kees; Pool-Goudzwaard, Annelies

2015-10-01

The role of so-called local muscle system in motor control of the lower back and pelvis is a subject of ongoing debate. Prevailing beliefs in stabilizing function of this system were recently challenged. This study investigated the impact of in vitro simulated force of transversely oriented fibres of the transversus abdominis muscle (a part of the local system) on flexibility of the sacroiliac joint during asymmetric moment application to the pelvis. In 8 embalmed specimens an incremental moment was applied in the sagittal plane to one innominate with respect to the fixed contralateral innominate. Ranges of motion of the sacroiliac joint were recorded using the Vicon Motion Capture System. Load-deformation curves were plotted and flexibility of the sacroiliac joint was calculated separately for anterior and posterior rotations of the innominate, with and without simulated muscle force. Flexibility of the sacroiliac joint was significantly bigger during anterior rotation of the innominate, as compared to posterior rotation (Anova P<0.05). After application of simulated force of transversus abdominis, flexibility of the joint did not change both during anterior and posterior rotations of the innominate. A lack of a stiffening effect of simulated transversus abdominis force on the sacroiliac joint was demonstrated. Earlier hypotheses suggesting a stiffening influence of this muscle on the pelvis cannot be confirmed. Consistent with previous findings smaller flexibility of the joint recorded during posterior rotation of the innominate may be of clinical importance for physio- and manual therapists. However, major limitations of the study should be acknowledged: in vitro conditions and simulation of only solitary muscle force. Copyright © 2015 Elsevier Ltd. All rights reserved.

Vascular Augmentation in Renal Transplantation: Supercharging and Turbocharging.

PubMed

Jeong, Euicheol C; Hwang, Seung Hwan; Eo, Su Rak

2017-05-01

The most common anatomic variant seen in donor kidneys for renal transplantation is the presence of multiple renal arteries, which can cause an increased risk of complications. Accessory renal arteries should be anastomosed to the proper source arteries to improve renal perfusion via the appropriate vascular reconstruction techniques. In microsurgery, 2 kinds of vascular augmentation methods, known as 'supercharging' and 'turbocharging,' have been introduced to ensure vascular perfusion in the transferred flap. Supercharging uses a distant source of the vessels, while turbocharging uses vascular sources within the same flap territory. These technical concepts can also be applied in renal transplantation, and in this report, we describe 2 patients who underwent procedures using supercharging and turbocharging. In one case, the ipsilateral deep inferior epigastric artery was transposed to the accessory renal artery (supercharging), and in the other case, the accessory renal artery was anastomosed to the corresponding main renal artery with a vascular graft (turbocharging). The transplanted kidneys showed good perfusion and proper function. No cases of renal failure, hypertension, rejection, or urologic complications were observed. These microsurgical techniques can be safely utilized for renal transplantation with donor kidneys that have multiple arteries with a lower complication rate and better outcome.

An anatomical study of the transversus abdominis plane block: location of the lumbar triangle of Petit and adjacent nerves.

PubMed

Jankovic, Zorica B; du Feu, Frances M; McConnell, Patricia

2009-09-01

The transversus abdominis plane (TAP) block is a new technique for providing analgesia to the anterior abdominal wall. Most previous studies have used the lumbar triangle of Petit as a landmark for the block. In this cadaveric study, we determined the exact position and size of the lumbar triangle of Petit and identified the nerves affected by the TAP block. The position of the lumbar triangle of Petit was assessed unilaterally in 26 cadaveric specimens relative to reliably palpable surface landmarks. In addition, a series of dissections were performed to explore the course of the nerves blocked by the TAP. The mean distance from the midaxillary line along the iliac crest to the center of the base of the lumbar triangle of Petit at the level of the subcutaneous tissue and over the skin surface was 6.9 cm (range, 4.5-9.2 cm) and 9.3 cm (range, 4-15.1 cm), respectively. The center of the lumbar triangle of Petit was 1.4 cm above the iliac crest. The depth of the TAP at the lumbar triangle of Petit position was 0.5-4 cm and at the midaxillary line it was 0.5-2 cm. The average size of the lumbar triangle of Petit was 2.3 cm x 3.3 cm x 2.2 cm, with an average area of 3.63 +/- 1.93 cm2. The three cadaveric specimens we explored showed the nerves blocked by TAP passed lateral to the triangle. An incidental finding was that in 66% of specimens the lumbar triangle of Petit contained small branches of the subcostal artery. The lumbar triangles of Petit found in the specimens in this study were more posterior than the literature suggests. The position of the lumbar triangle of Petit varies largely and the size is relatively small. The relevant nerves to be blocked had not entered the TAP in the specimens in this study at the point of the lumbar triangle of Petit. At the midaxillary line, however, all the nerves were in the TAP.

Rectus abdominis muscle injuries in elite handball players: management and rehabilitation

PubMed Central

Balius, Ramon; Pedret, Carles; Pacheco, Laura; Gutierrez, Josep Antoni; Vives, Joan; Escoda, Jaume

2011-01-01

Muscle injuries generally occur in two-joint muscles with a high percentage of type II fibers during the performance of eccentric activity. Some muscle injuries, such as those located in the adductor longus, a monoarticular muscle, as well as rectus abdominis do not fully comply with these requirements. This study examines five cases of elite handball players with ruptured rectus abdominals. Sonographically, lesions in rectus abdominis are shown as a disruption of the fibrillar pattern with a hematic suffusion that invades the entire lesion. In some of the cases, the ultrasound study was complemented with a MRI. A unified rehabilitation protocol was applied and the return to play time of each handball player ranged between 16 and 22 days, with an average of 18.2 days. Follow-up at 15 months showed no evidence of re-injury or residual discomfort and all of them are playing at their highest level. The aim of this study was to illustrate a feature of handball injury that, as in tennis and volleyball, is uncommon and so far has not been specifically reported. The phenomenon of contralateral abdominal hypertrophy in handball appears in the dominant arm as in tennis and volleyball. PMID:24198573

Right Lower Quadrant Pain in a Young Female: Ultrasound Diagnosis of Rectus Abdominis Tear.

PubMed

Minardi, Joseph; Shaver, Erica; Monseau, Aaron; Pratt, Adam; Layman, Shelley M

2015-11-01

Right lower quadrant pain in young females presents a frequent diagnostic challenge for emergency physicians, with a broad differential and several important diagnoses. Using an "ultrasound first" imaging strategy can help decrease the use of computed tomography scans, with associated savings in radiation exposure, cost, and other resource use. We report a case of right lower quadrant pain in a young woman. After her initial history and physical examination, appendicitis was the leading differential. A bedside ultrasound was performed, leading to the uncommon diagnosis of rectus abdominis muscle tear. The sonographic findings of a muscle tear include increase in size, loss of linear, homogeneous architecture, and decreased echogenicity. Making this diagnosis at the bedside using ultrasound obviated the need for further imaging, avoiding unnecessary radiation exposure, and decreasing emergency department length of stay and overall cost, while leading to a tailored treatment plan. Why Should an Emergency Physician Be Aware of This? Rectus abdominis tear is a cause of right lower quadrant pain that may mimic appendicitis and should be considered in patients with this complaint. The ability to make this diagnosis with bedside ultrasound may assist in several important patient-oriented outcomes. Copyright © 2015 Elsevier Inc. All rights reserved.

Change in trunk muscle activities with prone bridge exercise in patients with chronic low back pain.

PubMed

Kong, Yong-Soo; Park, Seol; Kweon, Mi-Gyong; Park, Ji-Won

2016-01-01

[Purpose] The aim of this study was to determine the effect of three different bridge exercises on internal oblique, external oblique, transverse abdominis, and erector spinae activities. [Subjects and Methods] Forty-five subjects with chronic low back pain participated in this study. The training outcome was evaluated with three different testing methods: supine bridge exercise, supine bridge on Swiss ball exercise, and prone bridge exercise. The activities of the transverse abdominis, internal oblique, external oblique, and erector spinae were measured using surface electromyography. [Results] There were significant differences in the internal oblique, external oblique, and erector spinae according to the three kinds of bridging exercises. The internal oblique, external oblique and transverse abdominis activities were highest in the prone bridge exercise, followed by those in the supine bridge on Swiss ball exercise, and supine bridge exercises. The activity of erector spine was highest in the supine bridge on Swiss ball exercise followed by the supine bridge exercise and prone bridge exercise. [Conclusion] These results suggest that prone bridge exercise is more effective than conventional supine bridge exercise and supine bridge on Swiss ball in increasing trunk muscle activity of chronic low back pain patients.

Advantages and disadvantages of pinless external fixation.

PubMed

Thomas, S R; Giele, H; Simpson, A H

2000-12-01

The AO pinless external fixator (PEF) uses trocar tipped clamps to grip the outer tibial cortex rather than pins to transfix it. Its main advantage is to avoid further contamination of the medullary canal in open tibial fractures where a nail may subsequently be used. We tested the anatomical safety of this device and its effect on plastic surgical procedures compared with a standard unilateral external fixator (UEF).The PEF and UEF were placed on two amputated limbs which were then dissected. Structures at risk were traced on ten cadaver limbs. We found that important anatomical structures were endangered by the PEF and that safe zones could not always be defined. The UEF avoided these structures. Plastic surgical approaches were made more difficult by the PEF which imposed limitations on local flap design and endangered the arterial perforators which supply them. We conclude that safety is compromised by the PEF because margins for error are small. It poses additional problems in soft tissue reconstruction and highlights the need for co-operation between plastic surgical and orthopaedic teams in choice of fixation device.

Omental anatomy of non-human primates.

PubMed

Chaffanjon, Philippe C J; Kenyon, Norman M; Ricordi, Camillo; Kenyon, Norma S

2005-11-01

The anatomy and physiology of the omentum provide optimum reconstructive characteristics and the omentum may be used as a free or pedicled autograft, but also as the receptor site for engraftment of glandular islets. Our purpose was the study of the omental anatomy of non-human primate (NHP), in order to determine an experimental model for pancreatic islets transplantation. Seventeen cadavers NHP (age range 4 years to 23 years) were utilised in this anatomical study. Both cynomolgus monkeys (macaca fascicularis) and baboons (papio hamadryas) were analysed. The animals were without known medical or anatomical abnormalities. We studied the morphology of the omentum, with an emphasis on arterial vascularisation. The omental anatomy of the NHP is very similar to that of humans. The main difference lies in the shape of the lesser sac, which has a complete caudal recess. The arterial vascularisation has a double origin. Based on the anastomosis between them and on the vascular density, the NHP omentum can be divided into four vascular areas. Our results demonstrate that one or two long pedicled flaps can be constructed from the omentum.

The Influence of a Pfannenstiel Scar on Venous Anatomy of the Lower Abdominal Wall and Implications for Deep Inferior Epigastric Artery Perforator Flap Breast Reconstruction.

PubMed

Kim, So Young; Lee, Kyeong-Tae; Mun, Goo-Hyun

2017-03-01

A Pfannenstiel incision involves the obstruction of superficial venous pathways and functional diversion of flow through alternative pathways and adjacent vessels. This study investigated the effect of a prior Pfannenstiel incision on venous anatomy of the lower abdominal wall; specifically, the superficial inferior epigastric vein (SIEV), using computed tomographic angiography. A case-control study was performed of 50 patients with Pfannenstiel scars and 50 age-matched, body mass index-matched control patients without Pfannenstiel scars. The authors compared the number of direct/indirect and total communications between the SIEV and deep inferior epigastric artery perforator (DIEP) venae comitantes, midline crossover, and other SIEV-related anatomical changes by using computed tomographic angiography. Flap-related clinical outcomes and donor-site-related complications were also assessed. The median number of direct and total communications between the SIEV and DIEP venae comitantes in the study group was greater than in the control group. The percentage of SIEVs having more than two branching patterns per hemiabdomen was significantly higher in the study group than in the control group. The study group also showed a significantly lower rate of fat necrosis compared with the control group (p = 0.03). The rate of donor-site seroma was significantly higher in the study group. This study suggests that the presence of a Pfannenstiel scar may promote the development of direct and total communications between the SIEV and DIEP venae comitantes and branching within the SIEV in the lower abdominal wall, which may facilitate venous drainage of adipose tissue in DIEP flap breast reconstruction. Risk, II.

[Radical hysterectomy in a patient with Steinert disease: spinal anaesthesia, ketamine and TAP and rectus sheath blocks].

PubMed

Armendáriz-Buil, I; Marenco-Arellano, V

2015-01-01

The case of a patient with Steinert disease who underwent surgery for radical hysterectomy is presented. Because of her advanced disease, she suffered from chronic respiratory failure which required non-invasive ventilation (NIV) at night. Spinal anaesthesia was chosen as an anaesthetic treatment. At the time of aortic lymphadenectomy, the patient reported moderate pain at hypogastrium, which was well controlled with boluses of 10 mg of ketamine. Postoperatively, opioid administration was avoided by applying abdominal wall blocks: transverse abdominis plane (TAP) block and sheath of rectus abdominis muscle block. The evolution of the patient was satisfactory and she was discharged on the fifth day after surgery.

Short-term outcomes of mandibular reconstruction in oncological patients using a CAD/CAM prosthesis including a condyle supporting a fibular free flap.

PubMed

Tarsitano, Achille; Battaglia, Salvatore; Ramieri, Valerio; Cascone, Piero; Ciocca, Leonardo; Scotti, Roberto; Marchetti, Claudio

2017-02-01

Condylar reconstruction and replacement using alloplastic materials currently attracts much surgical interest. The major challenge is to functionally reconstruct the anatomical region; this is crucial in terms of correct mandibular function. The goal of the present study was to evaluate the clinical outcomes of and complications experienced by a series of oncological patients who underwent computer-aided design/computer-aided manufacturing (CAD/CAM) condylar reconstruction following resection-disarticulation of the mandible. We included nine patients who underwent disarticulation resection surgery to treat benign and malignant mandibular tumors involving the condylar region. All resections preserved the articular meniscus and featured placement of a CAD/CAM reconstructive plate supporting a fibular, microvascular free flap. The head of the prosthetic condyle reproduced the anatomical morphology of the native condyle. Patients were clinically evaluated in terms of occlusion stability, mandibular functional recovery, static and dynamic pain, and preservation of the normal mandibular contour. Planning and postoperative computed tomography (CT) scans were superimposed to assess the accuracy of reconstruction. No patient experienced plate exposure and, on direct clinical examination, no patient complained of joint pain. No patient developed plate loosening. No resorption of the glenoid fossa was evident when pre- and postoperative bone thicknesses were compared by CT. Preoperative occlusion was preserved in all dentate patients. One patient exhibited condylar displacement. In terms of reconstructive accuracy, the average postoperative deviation of the condyle from the preoperative position was 3.8 mm (range: 1.3-6.7 mm). The clinical outcomes of our series of oncological patients who underwent reconstruction using CAD/CAM plates including condyles were encouraging. The utility of our protocol needs to be confirmed in larger patient series. Copyright © 2016 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.

The effects of bridge exercise on an unstable base of support on lumbar stability and the thickness of the transversus abdominis.

PubMed

Cho, Misuk; Jeon, Hyewon

2013-06-01

[Purpose] We examined the effects of an abdominal drawing-in bridge exercise using a pressure biofeedback unit on different bases on the thickness of trunk and abdominal muscles, and lumbar stability. [Subjects] Thirty healthy young adults (2 males, 28 females) took part in this study. The subjects were randomly and equally assigned to a stable bridge exercise group and an unstable bridge exercise group. [Methods] The subjects performed bridge exercises using an abdominal drawing-in method on a stable base and on an unstable base, and changes in their abdominal muscle thickness and on the stable and on unstable bases lumbar stability were evaluated. [Results] After the intervention, the stable bridge exercise group showed a statistically significantly increased muscle thickness in the transversus abdominis, and the unstable bridge exercise group showed significantly increased muscle thicknesses of the transversus abdominis and internal obliques in static and dynamic lumbar stability. The unstable bridge exercise group showed significant increase after performing the exercise. [Conclusion] Lumbar stability exercise, with the compensation of the lumbar spine minimized, using an abdominal drawing-in method on an unstable support of base is effective and efforts to prevent the compensation may induce a greater exercise effect.

Surgical treatment of benign tracheo-oesophageal fistulas with tracheal resection and oesophageal primary closure: is the muscle flap really necessary?

PubMed

Camargo, José Jesus; Machuca, Tiago Noguchi; Camargo, Spencer Marcantônio; Lobato, Vivalde F; Medina, Carlos Remolina

2010-03-01

Nowadays, despite the advances of the low-pressure high-volume cuffs, post-intubation tracheo-oesophageal fistula (TEF) still poses a major challenge to thoracic surgeons. The original technique includes interposition of muscle flaps between suture lines to avoid recurrence. It is not clear if this manoeuvre is indispensable and, in fact, we and others have faced problems with it. Our aim is to present our experience with TEF management in a consecutive group with no muscle interposition. From June 1992 to November 2007, we evaluated 14 patients presenting with TEF, with a mean age of 44 years (from 18 to 79 years). Thirteen patients had a prolonged intubation history. The remaining case was a 40-year-old male with congenital TEF. Three patients had been previously submitted to failed repairs in other institutions. Ten patients had associated tracheal stenosis, which was subglottic in three of them. Regarding surgical technique, in all cases, we performed a single-staged procedure, which consisted of tracheal resection and anastomosis with double-layer oesophageal closure. In none of our cases was a muscle flap interposed between suture lines. All operations were performed through a cervical incision; however, in one case, an extension with partial sternotomy was required. There was no operative mortality. Thirteen patients were extubated in the first 24h after the procedure, while one patient required 48 h of mechanical ventilation. Four complications were recorded: one each of pneumonia and left vocal cord paralysis and two small tracheal dehiscences managed with a T-tube and a tracheostomy tube. After discharge, three patients returned to their native cities and were lost to follow-up. The remaining 11 patients have been followed up by a mean of 32 months (from three to 108 months), with 10 presenting excellent and one good anatomic and functional results. The single-staged repair with tracheal resection and anastomosis with oesophageal closure provides good short- and mid-term results for TEF management. The interposition of a muscle flap between suture lines may not be crucial to prevent recurrence. Copyright (c) 2009 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.

Mechanisms of ear trauma and reconstructive techniques in 105 consecutive patients.

PubMed

Kolodzynski, Michail N; Kon, Moshe; Egger, Silvan; Breugem, Corstiaan C

2017-02-01

Acquired auricular deformities may diminish facial esthetics and cause psychological distress. The aim of this article is to provide an overview of the type of injuries and applied reconstructive techniques in a large academic hospital in The Netherlands. A retrospective chart review was conducted for the last 105 patients who underwent auricular reconstruction for an acquired deformity. Data concerning gender, affected side, cause of injury, anatomical region, the previous and further surgeries, type of cartilage, and skin cover used were collected and analyzed. 105 patients were included. Acquired auricular deformities were mainly caused by bite injuries (22 %), traffic accidents (17 %), burns (9.5 %), and post-otoplasty complications (9.5 %). The upper third of the auricle was most often injured (41 %), followed by the entire auricle (19 %). 70 % of cases required reconstruction with costal cartilage. The most common form of cutaneous cover was a postauricular skin flap (40 % of cases). This study gives a complete overview of causes and treatment of acquired auricular deformities. The results are comparable with the results of similar studies found in literature. Bite wounds are the leading cause of acquired auricular injuries. The upper third is most commonly affected. In the largest percentage of reconstructions, costal cartilage and a postauricular flap were used to correct the deformity.

Clinical applications of dynamic infrared thermography in plastic surgery: a systematic review

PubMed Central

John, Hannah Eliza; Niumsawatt, Vachara; Whitaker, Iain S.

2016-01-01

Background Infrared thermography (IRT) has become an increasingly utilized adjunct to more expensive and/or invasive investigations in a range of surgical fields, no more so than in plastic surgery. The combination of functional assessment, flow characteristics and anatomical localization has led to increasing applications of this technology. This article aims to perform a systematic review of the clinical applications of IRT in plastic surgery. Methods A systematic literature search using the keywords ‘IRT’ and ‘dynamic infrared thermography (DIRT)’ has been accomplished. A total of 147 papers were extracted from various medical databases, of which 34 articles were subjected to a full read by two independent reviewers, to ensure the papers satisfied the inclusion and exclusion criteria. Studies focusing on the use of IRT in breast cancer diagnosis were excluded. Results A systematic review of 29 publications demonstrated the clinical applications of IRT in plastic surgery today. They include preoperative planning of perforators for free flaps, post operative monitoring of free flaps, use of IRT as an adjunct in burns depth analysis, in assessment of response to treatment in hemangioma and as a diagnostic test for cutaneous melanoma and carpal tunnel syndrome (CTS). Conclusions Modern infrared imaging technology with improved standardization protocols is now a credible, useful non-invasive tool in clinical practice. PMID:27047781

The occult submucous cleft palate.

PubMed

Kaplan, E N

1975-10-01

We have studied 41 patients with classic submucous cleft and 32 cases with occult submucous cleft. Both groups have the same anatomic abnormality that leads to velar dysfunction-the insertion of the palate muscles onto the hard palate rather than onto the midline soft palate raphe. However, the occult submucous cleft palate does not have the classic triad of bifid uvula, hard palate bony notch, and furrow in the midline of the soft palate. Characteristic facial features, cephalmetric x-rays, and cine voice studies can help make a presumptive diagnosis of occult submucous cleft palate. Surgical management includes a diagnostic palate exploration to identify muscle configuration followed by levator muscle sling reconstruction, palate pushback, and pharyngeal flap. Excellent speech results are obtained except with patients having palate paresis.

Anomalous Putamen Volume in Children with Complex Motor Stereotypies

PubMed Central

Mahone, E. Mark; Crocetti, Deana; Tochen, Laura; Kline, Tina; Mostofsky, Stewart H.; Singer, Harvey S.

2016-01-01

Introduction Complex motor stereotypies in children are repetitive, rhythmic movements that have a predictable pattern and location, seem purposeful, but serve no obvious function, tend to be prolonged, and stop with distraction, e.g., arm/hand flapping, waving. They occur in both “primary” (otherwise typically developing) and secondary conditions. These movements are best defined as habitual behaviors and therefore pathophysiologically hypothesized to reside in premotor to posterior putamen circuits. This study sought to clarify the underlying neurobiological abnormality in children with primary complex motor stereotypies using structural neuroimaging, emphasizing brain regions hypothesized to underlie these atypical behaviors. Methods High-resolution anatomical MRI images, acquired at 3.0T, were analyzed in children ages 8–12 years (20 with primary complex motor stereotypies, 20 typically developing). Frontal lobe sub-regions and striatal structures were delineated for analysis. Results Significant reductions (p=0.045) in the stereotypies group were identified in total putamen volume, but not caudate, nucleus accumbens or frontal sub-regions. There were no group differences in total cerebral volume. Conclusion Findings of a smaller putamen provide preliminary evidence suggesting the potential involvement of the habitual pathway as the underlying anatomical site in primary complex motor stereotypies. PMID:27751663

"Reading man flap" design for reconstruction of circular infraorbital and malar skin defects.

PubMed

Seyhan, Tamer; Caglar, Baris

2008-11-01

Surgical complications such as lid retraction and ectropion from graft or flap scar contracture make reconstruction of skin defects in the malar and infraorbital regions challenging. A new flap design, the reading man flap, was used to overcome these problems. The Limberg and bilobed flap were compared with the reading man flap. The reading man flap consists mainly of a superiorly based quadrangular flap and an inferiorly based triangular flap. Malar and infraorbital circular skin defects measuring 14 x 14 to 40 x 40 mm were reconstructed with a reading man flap in 13 patients. The defects occurred after basal cell carcinoma in all patients. The Limberg flap, bilobed flap, and reading man flap were planned for same-sized defects on the abdominoplasty resection material. The results were compared in terms of total scar area, scar length, and total healthy skin area discarded. When comparing the 3 flap designs, the reading man flap was the most suitable flap in terms of total scar area and length. The reading man flap can be used to reconstruct malar and infraorbital circular defects with good cosmetic results and without creating any tractional forces to the eyelids.

Four-flap Breast Reconstruction: Bilateral Stacked DIEP and PAP Flaps

PubMed Central

Mayo, James L.; Allen, Robert J.

2015-01-01

Background: In cases of bilateral breast reconstruction when the deep inferior epigastric perforator (DIEP) free flap alone does not provide sufficient volume for body-specific reconstruction, stacking each DIEP flap with a second free flap will deliver added volume and maintain a purely autologous reconstruction. Stacking the profunda artery perforator (PAP) flap with the DIEP flap offers favorable aesthetics and ideal operative efficiency. We present the indications, technique, and outcomes of our experience with 4-flap breast reconstruction using stacked DIEP/PAP flaps. Methods: The authors performed 4-flap DIEP/PAP breast reconstruction in 20 patients who required bilateral reconstruction without adequate single donor flap volume. The timing of reconstruction, average mastectomy/flap weights, and operative time are reported. Complications reviewed include fat necrosis, dehiscence, hematoma, seroma, mastectomy flap necrosis, and flap loss. Results: Twenty patients underwent 4-flap DIEP/PAP breast reconstruction. Surgical time averaged 7 hours and 20 minutes. The primary recipient vessels were the antegrade and retrograde internal mammary vessels. No flap losses occurred. Complications included 1 hematoma, 1 incidence of arterial and venous thrombosis successfully treated with anastomotic revision, 1 incidence of thigh donor site dehiscence, and 3 episodes of minor mastectomy skin flap necrosis. Conclusions: Four-flap breast reconstruction is a favorable autologous reconstructive option for patients requiring bilateral reconstruction without adequate single donor flap volume. Stacking DIEP/PAP flaps as described is both safe and efficient. Furthermore, this combination provides superior aesthetics mirroring the natural geometry of the breast. Bilateral stacked DIEP/PAP flaps represent our first choice for breast reconstruction in this patient population. PMID:26090273

Transperitoneal rectus sheath block and transversus abdominis plane block for laparoscopic inguinal hernia repair: A novel approach.

PubMed

Nagata, Jun; Watanabe, Jun; Nagata, Masato; Sawatsubashi, Yusuke; Akiyama, Masaki; Tajima, Takehide; Arase, Koichi; Minagawa, Noritaka; Torigoe, Takayuki; Nakayama, Yoshifumi; Horishita, Reiko; Kida, Kentaro; Hamada, Kotaro; Hirata, Keiji

2017-08-01

A laparoscopic approach for inguinal hernia repair is now considered the gold standard. Laparoscopic surgery is associated with a significant reduction in postoperative pain. Epidural analgesia cannot be used in patients with perioperative anticoagulant therapy because of complications such as epidural hematoma. As such, regional anesthetic techniques, such as ultrasound-guided rectus sheath block and transversus abdominis plane block, have become increasingly popular. However, even these anesthetic techniques have potential complications, such as rectus sheath hematoma, if vessels are damaged. We report the use of a transperitoneal laparoscopic approach for rectus sheath block and transversus abdominis plane block as a novel anesthetic procedure. An 81-year-old woman with direct inguinal hernia underwent laparoscopic transabdominal preperitoneal inguinal repair. Epidural anesthesia was not performed because anticoagulant therapy was administered. A Peti-needle™ was delivered through the port, and levobupivacaine was injected though the peritoneum. Surgery was performed successfully, and the anesthetic technique did not affect completion of the operative procedure. The patient was discharged without any complications. This technique was feasible, and the procedure was performed safely. Our novel analgesia technique has potential use as a standard postoperative regimen in various laparoscopic surgeries. Additional prospective studies to compare it with other techniques are required. © 2017 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and John Wiley & Sons Australia, Ltd.

Complete resection of a rectus abdominis muscle invaded by desmoid tumors and subsequent management with an abdominal binder: a case report.

PubMed

Ogawa, Tatsuhiko

2018-02-07

Desmoid-type fibromatosis is characterized by desmoid tumors, which are benign soft tissue tumors that can be locally aggressive but typically do not metastasize. Desmoid tumors can manifest anywhere in the body, and those in the abdominal cavity account for approximately 30 to 50% of all such tumors. Complete resection with free margins has been the standard treatment, but non-surgical therapies have been implemented recently. However, if tumors are strongly invasive and/or persistently recur, radical surgical resection with free margins remains the primary treatment. Unfortunately, radical resection may cause large abdominal defects and hinder reconstruction. Several reports and recommendations have addressed this issue; however, to the best of our knowledge, few reports have described complete resection and the subsequent reconstruction of the rectus abdominis muscle. A 35-year-old Asian woman presented at our hospital with a chief complaint of abdominal pain. She had abdominal desmoid tumors that required complete resection of her rectus abdominis muscle. Due to necrosis in her own reconstructed tissue, we failed to cover her anterior abdominal wall; thus, we used an abdominal binder as a substitute material to avoid exacerbating the incisional hernia and help her generate intra-abdominal pressure. This case report may be informative and helpful for the treatment of patients with desmoid tumors, as managing desmoid-type fibromatosis is difficult.

Feasibility study of contralateral risk-reducing mastectomy with breast reconstruction for breast cancer patients with BRCA mutations in Japan.

PubMed

Yoshimura, Akiyo; Okumura, Seiko; Sawaki, Masataka; Hattori, Masaya; Ishiguro, Junko; Adachi, Yayoi; Kotani, Haruru; Gondo, Naomi; Kataoka, Ayumi; Iwase, Madoka; Onishi, Sakura; Sugino, Kayoko; Terada, Mitsuo; Horisawa, Nanae; Mori, Makiko; Takaiso, Nobue; Hyodo, Ikuo; Iwata, Hiroji

2018-03-08

Contralateral risk-reducing mastectomy (CRRM) for breast cancer patients with BRCA mutations has been reported to not only reduce breast cancer incidence but also to improve survival. The National Comprehensive Cancer Network guidelines recommend providing CRRM to women with BRCA mutations who desire CRRM after risk-reduction counseling. However, in Japan, CRRM cannot be performed generally because it is not covered by health insurance. Thus, we conducted a feasibility study to confirm the safety of CRRM. CRRM with bilateral breast reconstructions were performed for breast cancer patients with BRCA mutations. The primary endpoint was early adverse events within 3 months, and secondary endpoints were late adverse events. Between August 2014 and November 2016, ten patients were enrolled. The median age was 37.5 years, and five of the patients had the BRCA1 mutation while five had the BRCA2 mutation. Six patients received neoadjuvant chemotherapy. Eight patients selected silicone breast implants, and two patients selected transverse rectus abdominis myocutaneous flap reconstruction. Pathological findings showed no evidence of occult breast cancers in any of the patients. At a median of 25.5 months follow-up time, CRRM-related early adverse events were hematoma (subsequently removed by re-operation; grade 2, n = 1), wound infection (grade 2, n = 1), skin ulceration (grade 1, n = 2) and wound pain (grade 1, n = 1). Overall, there were no grade 3 or more severe adverse events. Our results confirm that CRRM with reconstruction could be performed safely.

Muscle activity and spine load during anterior chain whole body linkage exercises: the body saw, hanging leg raise and walkout from a push-up.

PubMed

McGill, Stuart; Andersen, Jordan; Cannon, Jordan

2015-01-01

This study examined anterior chain whole body linkage exercises, namely the body saw, hanging leg raise and walkout from a push-up. Investigation of these exercises focused on which particular muscles were challenged and the magnitude of the resulting spine load. Fourteen males performed the exercises while muscle activity, external force and 3D body segment motion were recorded. A sophisticated and anatomically detailed 3D model used muscle activity and body segment kinematics to estimate muscle force, and thus sensitivity to each individual's choice of motor control for each task. Gradations of muscle activity and spine load characteristics were observed across tasks. On average, the hanging straight leg raise created approximately 3000 N of spine compression while the body saw created less than 2500 N. The hanging straight leg raise created the highest challenge to the abdominal wall (>130% MVC in rectus abdominis, 88% MVC in external oblique). The body saw resulted in almost 140% MVC activation of the serratus anterior. All other exercises produced substantial abdominal challenge, although the body saw did so in the most spine conserving way. These findings, along with consideration of an individual's injury history, training goals and current fitness level, should assist in exercise choice and programme design.

The possibility for use of venous flaps in plastic surgery

DOE Office of Scientific and Technical Information (OSTI.GOV)

Baytinger, V. F., E-mail: baitinger@mail.tomsknet.ru; Kurochkina, O. S., E-mail: kurochkinaos@yandex.ru; Selianinov, K. V.

2015-11-17

The use of venous flaps is controversial. The mechanism of perfusion of venous flaps is still not fully understood. The research was conducted on 56 white rats. In our experimental work we studied two different models of venous flaps: pedicled venous flap (PVF) and pedicled arterialized venous flap (PAVF). Our results showed that postoperative congestion was present in all flaps. However 66.7% of all pedicled venous flaps and 100% of all pedicled arterialized venous flaps eventually survived. Histological examination revealed that postoperatively the blood flow in the skin of the pedicled arterialized venous flap became «re-reversed» again; there were nomore » differences between mechanism of survival of venous flaps and other flaps. On the 7-14th day in the skin of all flaps were processes of neoangiogenesis and proliferation. Hence the best scenario for the clinical use of venous flaps unfolds when both revascularization and skin coverage are required.« less

Analgesic efficacy of transversus abdominis plane block in neonates and early infants for colostomy and reversal of colostomy.

PubMed

Chen, Chee Kean; Teo, Shu Ching; Phui, Vui Eng; Saman, Mat Ariffin

2015-01-01

The application of ultrasound-guided transversus abdominis plane (TAP) block in paediatric population is gaining popularity among anaesthetists. We present a case series of ultrasound-guided TAP block in ten neonate and infants undergoing colostomy and reversal of stoma. Classical TAP as described by Hebbard was carried out and a maximum dosage of 1ml/kg of 0.25% levobupivacaine was injected. Pain score was assessed using Neonatal Infant Pain Scale for 24 hours. In all patients, the block was successful with minimal hemodynamic changes intraoperatively and no additional systemic analgesia was needed intraoperative and immediate postoperatively. Ultrasound-guided TAP block has an important role in providing safe and effective analgesia for colostomy creation and reversal of stoma surgeries in paediatric population.

Experimental Study of Wake / Flap Interaction Noise and the Reduction of Flap Side Edge Noise

NASA Technical Reports Server (NTRS)

Hutcheson, Florence V.; Stead, Daniel J.; Plassman, Gerald E.

2016-01-01

The effects of the interaction of a wake with a half-span flap on radiated noise are examined. The incident wake is generated by bars of various widths and lengths or by a simplified landing gear model. Single microphone and phased array measurements are used to isolate the effects of the wake interaction on the noise radiating from the flap side edge and flap cove regions. The effects on noise of the wake generator's geometry and relative placement with respect to the flap are assessed. Placement of the wake generators upstream of the flap side edge is shown to lead to the reduction of flap side edge noise by introducing a velocity deficit and likely altering the instabilities in the flap side edge vortex system. Significant reduction in flap side edge noise is achieved with a bar positioned directly upstream of the flap side edge. The noise reduction benefit is seen to improve with increased bar width, length and proximity to the flap edge. Positioning of the landing gear model upstream of the flap side edge also leads to decreased flap side edge noise. In addition, flap cove noise levels are significantly lower than when the landing gear is positioned upstream of the flap mid-span. The impact of the local flow velocity on the noise radiating directly from the landing gear is discussed. The effects of the landing gear side-braces on flap side edge, flap cove and landing gear noise are shown.

Evaluation of the cranial rectus abdominus muscle pedicle flap as a blood supply for the caudal superficial epigastric skin flap in dogs.

PubMed

Degner, D A; Walshaw, R; Arnoczky, S P; Smith, R J; Patterson, J S; Degner, L A; Hamaide, A; Rosenstein, D

1996-01-01

This study evaluates the cranial rectus abdominus muscle pedicle flap as the sole blood supply for the caudal superficial epigastric skin flap. This flap was composed of a cranially based rectus abdominus muscle pedicle flap that was attached to the caudal superficial epigastric island skin flap (including mammary glands 2 to 5) via the pudendoepigastric trunk. Selective angiography of the cranial epigastric artery in eight cadaver dogs proved that the arterial vasculature in the cranial rectus abdominus was contiguous with that in the caudal superficial epigastric skin flap. In the live dog study, three of six of the flaps failed because of venous insufficiency. Necrosis of mammary gland 2 occurred in two of six flaps. One of six flaps survived with the exception of the cranial most aspect of mammary gland 2. Angiography of the cranial epigastric artery proved that arterial blood supply to these flaps was intact. Histological evaluation of the failed flaps showed full-thickness necrosis of the skin and subcutaneous tissues, the presence of severe congestion, and venous thrombosis. Retrograde venous blood flow through the flap was inconsistent, and hence resulted in failure of this myocutaneous flap. Use of this flap for clinical wound reconstruction cannot be recommended.

Vascularized osseous flaps and assessing their bipartate perfusion pattern via intraoperative fluorescence angiography.

PubMed

Valerio, Ian; Green, J Marshall; Sacks, Justin M; Thomas, Shane; Sabino, Jennifer; Acarturk, T Oguz

2015-01-01

Large segmental bone and composite tissue defects often require vascularized osseous flaps for definitive reconstruction. However, failed osseous flaps due to inadequate perfusion can lead to significant morbidity. Utilization of indocyanine green (ICG) fluorescence angiography has been previously shown to reliably assess soft tissue perfusion. Our group will outline the application of this useful intraoperative tool in evaluating the perfusion of vascularized osseous flaps. A retrospective review was performed to identify those osseous and/or osteocutaneous bone flaps, where ICG angiography was employed. Data analyzed included flap types, success and failure rates, and perfusion-related complications. All osseous flaps were evaluated by ICG angiography to confirm periosteal and endosteal perfusion. Overall 16 osseous free flaps utilizing intraoperative ICG angiography to assess vascularized osseous constructs were performed over a 3-year period. The flaps consisted of the following: nine osteocutaneous fibulas, two osseous-only fibulas, two scapular/parascapular with scapula bone, two quadricep-based muscle flaps, containing a vascularized femoral bone component, and one osteocutaneous fibula revision. All flap reconstructions were successful with the only perfusion-related complication being a case of delayed partial skin flap loss. Intraoperative fluorescence angiography is a useful adjunctive tool that can aid in flap design through angiosome mapping and can also assess flap perfusion, vascular pedicle flow, tissue perfusion before flap harvest, and flap perfusion after flap inset. Our group has successfully extended the application of this intraoperative tool to assess vascularized osseous flaps in an effort to reduce adverse outcomes related to preventable perfusion-related complications. Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Ultrasound Assessment of the Transverse Abdominis During Functional Movement.

PubMed

Mangum, L Colby; Henderson, Kaitlin; Murray, Kyle P; Saliba, Susan A

2018-05-01

The traditional activation ratio divides contracted muscle thickness by resting muscle thickness while an abdominal draw-in maneuver is performed during hook lying. Ultrasound imaging during function, such as standing or gait, or peak knee flexion in a single-leg squat allows for further visualization of muscle activity. The goal of this study was to examine activation ratio calculations for transverse abdominis function in supine versus loaded conditions to determine the most informative normalization strategy for muscle activity based on thickness values. Transverse abdominis thickness was measured via ultrasound in 35 healthy participants under 4 different conditions. Comparisons were made between the traditional activation ratio tabletop, standing activation ratio (standing abdominal draw-in maneuver thickness/quiet standing thickness), and functional activation ratio (single-leg squat thickness/quiet standing thickness). Additionally, a cued activation ratio (single-leg squat with cued abdominal draw-in maneuver thickness/single-leg squat thickness) during the single-leg squat was obtained. Activation ratios of greater than 1.0 indicated that participants could activate the muscle during activity, and values were compared by analysis of variance. The participants included 23 women and 12 men with a mean age ± SD of 21.3 ± 2.7 years, mass of 66.1 ± 14.4 kg, and height of 168.5 ± 10.1 cm. Activation ratios exceeded 1.0 in 94.3% for the traditional activation ratio, 85.7% for the standing activation ratio, 82.9% for the cued activation ratio, and 82.9% for the functional activation ratio. With groups defined as tabletop activated or not, the standing, cued, and functional activation ratios were all significantly different (all P < .05). Normalizing muscle thickness to the corresponding functional position quiet value provides a useful functional activation ratio and may help clinicians better understand the transverse abdominis role during complex functional tasks. Assessment techniques using various formulas for activation ratios reveal that the muscle functions differently during weight bearing compared to traditional measures. © 2017 by the American Institute of Ultrasound in Medicine.

Effectiveness of dry needling of rectus abdominis trigger points for the treatment of primary dysmenorrhoea: a randomised parallel-group trial.

PubMed

Gaubeca-Gilarranz, Alberto; Fernández-de-Las-Peñas, César; Medina-Torres, José Raúl; Seoane-Ruiz, José M; Company-Palonés, Aurelio; Cleland, Joshua A; Arias-Buría, Jose L

2018-05-02

To compare the effectiveness of trigger point dry needling (TrP-DN) versus placebo needling, relative to an untreated control group, on pain and quality of life in primary dysmenorrhoea. In this randomised, single blind, parallel-group trial, 56 females with primary dysmenorrhoea were randomly allocated to TrP-DN (n=19), placebo needling (n=18) or no treatment (n=19). Patients in both groups were asked to undertake a stretching exercise of the rectus abdominis daily. The needling group received a single session of TrP-DN to trigger points (TrPs) in the rectus abdominis, and the placebo group received placebo needling. The primary outcome was pain intensity (visual analogue scale). Secondary outcomes were quality of life, use of non-steroidal anti-inflammatory drugs, the number of days with pain, and self-perceived improvement, measured using a Global Rate of Change. Outcomes were assessed at baseline, and 1 and 2 months after the treatment. Females receiving TrP-DN exhibited greater decreases (P<0.001) in pain than those receiving placebo (1 month: Δ-19.8 mm, 25.9 to -13.7; 2 months: Δ-26.0 mm, -33.1 to -18.9) or assigned to the untreated control group (1 month: Δ-26.0mm, -32.5 to -19.5; 2 months: Δ-20.1 mm, -26.4 to -13.8). Females in the TrP-DN group also exhibited a greater decrease in the amount of medications (P<0.001). No differences in the number of days with pain or quality of life were found (all P>0.1). This trial suggests that a single session of TrP-DN of the rectus abdominis combined with stretching was more effective than placebo needling and stretching alone at reducing pain and the amount of medication used in primary dysmenorrhoea. ACTRN12616000170426. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Swiss ball abdominal crunch with added elastic resistance is an effective alternative to training machines.

PubMed

Sundstrup, Emil; Jakobsen, Markus D; Andersen, Christoffer H; Jay, Kenneth; Andersen, Lars L

2012-08-01

Swiss ball training is recommended as a low intensity modality to improve joint position, posture, balance, and neural feedback. However, proper training intensity is difficult to obtain during Swiss ball exercises whereas strengthening exercises on machines usually are performed to induce high level of muscle activation. To compare muscle activation as measured by electromyography (EMG) of global core and thigh muscles during abdominal crunches performed on Swiss ball with elastic resistance or on an isotonic training machine when normalized for training intensity. 42 untrained individuals (18 men and 24 women) aged 28-67 years participated in the study. EMG activity was measured in 13 muscles during 3 repetitions with a 10 RM load during both abdominal crunches on training ball with elastic resistance and in the same movement utilizing a training machine (seated crunch, Technogym, Cesena, Italy). The order of performance of the exercises was randomized, and EMG amplitude was normalized to maximum voluntary isometric contraction (MVIC) EMG. When comparing between muscles, normalized EMG was highest in the rectus abdominis (P<0.01) and the external obliques (P<0.01). However, crunches on Swiss ball with elastic resistance showed higher activity of the rectus abdominis than crunches performed on the machine (104±3.8 vs 84±3.8% nEMG respectively, P<0.0001). By contrast, crunches performed on Swiss ball induced lower activity of the rectus femoris than crunches in training machine (27±3.7 vs 65±3.8% nEMG respectively, P<0.0001) Further, gender, age and musculoskeletal pain did not significantly influence the findings. Crunches on a Swiss ball with added elastic resistance induces high rectus abdominis activity accompanied by low hip flexor activity which could be beneficial for individuals with low back pain. In opposition, the lower rectus abdominis activity and higher rectus femoris activity observed in machine warrant caution for individuals with lumbar pain. Importantly, both men and women, younger and elderly, and individuals with and without pain benefitted equally from the exercises.

The transnasal approach to the skull base. From sinus surgery to skull base surgery

PubMed Central

Wagenmann, Martin; Schipper, Jörg

2012-01-01

The indications for endonasal endoscopic approaches to diseases of the skull base and its adjacent structures have expanded considerably during the last decades. This is not only due to improved technical possibilities such as intraoperative navigation, the development of specialized instruments, and the compilation of anatomical studies from the endoscopic perspective but also related to the accumulating experience with endoscopic procedures of the skull base by multidisciplinary centers. Endoscopic endonasal operations permit new approaches to deeply seated lesions and are characterized by a reduced manipulation of neurovascular structures and brain parenchyma while at the same time providing improved visualization. They reduce the trauma caused by the approach, avoid skin incisions and minimize the surgical morbidity. Transnasal endoscopic procedures for the closure of small and large skull base defects have proven to be reliable and more successful than operations with craniotomies. The development of new local and regional vascularized flaps like the Hadad-flap have contributed to this. These reconstructive techniques are furthermore effectively utilized in tumor surgery in this region. This review delineates the classification of expanded endonasal approaches in detail. They provide access to lesions of the anterior, middle and partly also to the posterior cranial fossa. Successful management of these complex procedures requires a close interdisciplinary collaboration as well as continuous education and training of all team members. PMID:22558058

Clinical applications of perforator-based propeller flaps in upper limb soft tissue reconstruction.

PubMed

Ono, Shimpei; Sebastin, Sandeep J; Yazaki, Naoya; Hyakusoku, Hiko; Chung, Kevin C

2011-05-01

A propeller flap is an island flap that moves from one orientation to another by rotating around its vascular axis. The vascular axis is stationary, and flap movement is achieved by revolving on this axis. Early propeller flaps relied on a thick, subcutaneous pedicle to maintain vascularity, and this limited the flap rotation to 90°. With increasing awareness of the location and the vascular territory perfused by cutaneous perforators, it is now possible to design propeller flaps based on a single perforator, so-called "perforator-based propeller flaps." These flaps permit flap rotation up to 180°. We present the results of upper limb soft tissue reconstruction using perforator-based propeller flaps. We constructed a treatment strategy based on the location of the soft tissue defect and the perforator anatomy for expedient wound coverage in 1 stage. All perforator-based propeller flaps derived from 3 institutions that were used for upper limb soft tissue reconstruction were retrospectively analyzed. The parameters studied included the size and location of the defect, the perforator that was used, the size and shape of the flap, the direction (ie, clockwise or counter-clockwise) of flap rotation, the degree of twisting of the perforator, the management of the donor site (ie, linear closure or skin grafting), and flap survival (recorded as the percentage of the flap area that survived). Twelve perforator-based propeller flaps were used to reconstruct upper limb soft tissue defects in 12 patients. Six different perforators were used as vascular pedicles. The donor defects of 11 flaps could be closed primarily. One flap was partially lost in a patient with electrical burns. Perforator-based propeller flaps provide a reliable option for covering small- to medium-size upper limb soft tissue defects. Copyright © 2011 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.

PIV Measurements on a Blowing Flap

NASA Technical Reports Server (NTRS)

Hutcheson, Florence V.; Stead, Daniel J.

2004-01-01

PIV measurements of the flow in the region of a flap side edge are presented for several blowing flap configurations. The test model is a NACA 63(sub 2)-215 Hicks Mod-B main-element airfoil with a half-span Fowler flap. Air is blown from small slots located along the flap side edge on either the top, bottom or side surfaces. The test set up is described and flow measurements for a baseline and three blowing flap configurations are presented. The effects that the flap tip jets have on the structure of the flap side edge flow are discussed for each of the flap configurations tested. The results indicate that blowing air from a slot located along the top surface of the flap greatly weakened the top vortex system and pushed it further off the top surface. Blowing from the bottom flap surface kept the strong side vortex further outboard while blowing from the side surface only strengthened the vortex system or accelerated the merging of the side vortex to the flap top surface. It is concluded that blowing from the top or bottom surfaces of the flap may lead to a reduction of flap side edge noise.

Long-Term Follow-Up of Flap Prefabrication in Facial Reconstruction.

PubMed

Wang, Weixin; Zhao, Muxin; Tang, Yong; Chen, Wen; Yang, Zhe; Ma, Ning; Xu, Lisi; Feng, Jun; Li, Yangqun

2017-07-01

Flap prefabrication is to turn a random flap into an axial flap by transferring a vascular pedicle. In the past 13 years, we have prefabricated 20 flaps in 20 patients by the superficial temporal artery and its concomitant veins. Typically, a 50- to 800-mL tissue expander was implanted in the donor site. After flap maturation, the prefabricated flap was raised and transferred locally to cover the large defect on the face. All the cases were followed up regularly. The patients' age were between 3 and 27 years, the size of the flaps were between 3.5 × 5.5 cm and 13 × 15 cm, the superficial temporal artery length was between 10 and 15 cm. All flaps were transferred successfully: 10 of the flaps had venous congestion, partial epidermis exfoliation and flap necrosis occurred in 4 flaps. All cases were followed up for at least 1 year, the longest follow-up period was 9 years. Long-term follow-up results showed the prefabricated flap survived in good condition and had a satisfactory outcome. Because flap prefabrication is practical, and long-term follow-ups have proved its preferable characters and stability, it is a fine method for large area facial reconstructions.

Long-Term Patency of Twisted Vascular Pedicles in Perforator-Based Propeller Flaps.

PubMed

Jakubietz, Rafael G; Nickel, Aljoscha; Neshkova, Iva; Schmidt, Karsten; Gilbert, Fabian; Meffert, Rainer H; Jakubietz, Michael G

2017-10-01

Propeller flaps require torsion of the vascular pedicle of up to 180 degrees. Contrary to free flaps, where the relevance of an intact vascular pedicle has been documented, little is known regarding twisted pedicles of propeller flaps. As secondary surgeries requiring undermining of the flap are common in the extremities, knowledge regarding the necessity to protect the pedicle is relevant. The aim of this study was a long-term evaluation of the patency of vascular pedicle of propeller flaps. In a retrospective clinical study, 22 patients who underwent soft-tissue reconstruction with a propeller flap were evaluated after 43 months. A Doppler probe was used to locate and evaluate the patency of the vascular pedicle of the flap. The flaps were used in the lower extremity in 19 cases, on the trunk in 3 cases. All flaps had healed. In all patients, an intact vascular pedicle could be found. Flap size, source vessel, or infection could therefore not be linked to an increased risk of pedicle loss. The vascular pedicle of propeller flaps remains patent in the long term. This allows reelevation and undermining of the flap. We therefore recommend protecting the pedicle in all secondary cases to prevent later flap loss.

New model of flap-gliding flight.

PubMed

Sachs, Gottfried

2015-07-21

A new modelling approach is presented for describing flap-gliding flight in birds and the associated mechanical energy cost of travelling. The new approach is based on the difference in the drag characteristics between flapping and non-flapping due to the drag increase caused by flapping. Thus, the possibility of a gliding flight phase, as it exists in flap-gliding flight, yields a performance advantage resulting from the decrease in the drag when compared with continuous flapping flight. Introducing an appropriate non-dimensionalization for the mathematical relations describing flap-gliding flight, results and findings of generally valid nature are derived. It is shown that there is an energy saving of flap-gliding flight in the entire speed range compared to continuous flapping flight. The energy saving reaches the highest level in the lower speed region. The travelling speed of flap-gliding flight is composed of the weighted average of the differing speeds in the flapping and gliding phases. Furthermore, the maximum range performance achievable with flap-gliding flight and the associated optimal travelling speed are determined. Copyright © 2015 Elsevier Ltd. All rights reserved.

Intercostal artery perforator propeller flap for reconstruction of trunk defects following sarcoma resection.

PubMed

Zang, Mengqing; Yu, Shengji; Xu, Libin; Zhao, Zhenguo; Zhu, Shan; Ding, Qiang; Liu, Yuanbo

2015-06-01

Trunk defects following soft tissue sarcoma resection are usually managed by myocutaneous flaps or free flaps. However, harvesting muscle will cause functional morbidities and some trunk regions lack reliable recipient vessels. The intercostal arteries give off multiple perforators, which distribute widely over the trunk and can supply various pedicle flaps. Our purpose is to use various intercostal artery perforator propeller flaps for trunk oncologic reconstruction. Between November 2013 and July 2014, nine intercostal artery perforator propeller flaps were performed in seven patients to reconstruct the defects following sarcoma resection in different regions of the trunk, including the back, lumbar, chest, and abdomen. Two perforators from intercostal arteries were identified for each flap using Doppler ultrasound probe adjacent to the defect. The perforator with visible pulsation was chosen as the pedicle vessel. An elliptical flap was raised and rotated in a propeller fashion to repair the defects. There were one dorsal intercostal artery perforator flap, four dorsolateral intercostal artery perforator flaps, three lateral intercostal artery perforator flaps, and one anterior intercostal artery perforator flap. The mean skin paddle dimension was 9.38 cm in width (range 6-14 cm) and 21.22 cm in length (range 13-28 cm). All intercostal artery perforator flaps survived completely, except for marginal necrosis in one flap harvested close to the previous flap donor site. The intercostal artery perforator propeller flap provides various and valuable options in our reconstructive armamentarium for trunk oncologic reconstruction. To our knowledge, this is the first case series of using intercostal artery perforator propeller flaps for trunk oncologic reconstruction and clinical application of dorsolateral intercostal artery perforator flaps. Copyright © 2015 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

An innovative method of planning and displaying flap volume in DIEP flap breast reconstructions.

PubMed

Hummelink, S; Verhulst, Arico C; Maal, Thomas J J; Hoogeveen, Yvonne L; Schultze Kool, Leo J; Ulrich, Dietmar J O

2017-07-01

Determining the ideal volume of the harvested flap to achieve symmetry in deep inferior epigastric artery perforator (DIEP) flap breast reconstructions is complex. With preoperative imaging techniques such as 3D stereophotogrammetry and computed tomography angiography (CTA) available nowadays, we can combine information to preoperatively plan the optimal flap volume to be harvested. In this proof-of-concept, we investigated whether projection of a virtual flap planning onto the patient's abdomen using a projection method could result in harvesting the correct flap volume. In six patients (n = 9 breasts), 3D stereophotogrammetry and CTA data were combined from which a virtual flap planning was created comprising perforator locations, blood vessel trajectory and flap size. All projected perforators were verified with Doppler ultrasound. Intraoperative flap measurements were collected to validate the determined flap delineation volume. The measured breast volume using 3D stereophotogrammetry was 578 ± 127 cc; on CTA images, 527 ± 106 cc flap volumes were planned. The nine harvested flaps weighed 533 ± 109 g resulting in a planned versus harvested flap mean difference of 5 ± 27 g (flap density 1.0 g/ml). In 41 out of 42 projected perforator locations, a Doppler signal was audible. This proof-of-concept shows in small numbers that flap volumes can be included into a virtual DIEP flap planning, and transferring the virtual planning to the patient through a projection method results in harvesting approximately the same volume during surgery. In our opinion, this innovative approach is the first step in consequently achieving symmetric breast volumes in DIEP flap breast reconstructions. Copyright © 2017 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

Influence of Flap Thickness on Nipple Projection After Nipple Reconstruction Using a Modified Star Flap.

PubMed

Ishii, Naohiro; Ando, Jiro; Harao, Michiko; Takemae, Masaru; Kishi, Kazuo

2018-05-07

In nipple reconstruction, the width, length, and thickness of modified star flaps are concerns for long-term reconstructed nipple projection. However, the flap's projection has not been analyzed, based on its thickness. The aim of the present study was to investigate how flap thickness in a modified star flap influences the resulting reconstructed nipple and achieves an appropriate flap width in design. Sixty-three patients who underwent nipple reconstruction using a modified star flap following implant-based breast reconstruction between August 2014 and July 2016 were included in this case-controlled study. The length of laterally diverging flaps was 1.5 times their width. The thickness of each flap was measured using ultrasonography, and the average thickness was defined as the flap thickness. We investigated the correlation between the resulting reconstructed nipple and flap thickness, and the difference of the change in the reconstructed nipple projection after using a thin or thick flap. The average flap thickness was 3.8 ± 1.7 (range 2.5-6.0) mm. There was a significant, linear correlation between the flap thickness and resulting reconstructed nipple projection (β = 0.853, p < 0.01). Furthermore, the difference between the thin and thick flaps in the resulting reconstructed nipple projection was significant (p < 0.01). Measuring the flap thickness preoperatively may allow surgeons to achieve an appropriate flap width; otherwise, alternative methods for higher projection might be used. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Medium- and Large-Sized Autologous Breast Reconstruction using a Fleur-de-lys Profunda Femoris Artery Perforator Flap Design: A Report Comparing Results with the Horizontal Profunda Femoris Artery Perforator Flap.

PubMed

Hunsinger, Vincent; Lhuaire, Martin; Haddad, Kevin; Wirz, Francesco-Saverio; Abedalthaqafi, Samah; Obadia, Déborah; Derder, Mohamed; Marchac, Alexandre; Benjoar, Marc David; Hivelin, Mikael; Lantieri, Laurent

2018-06-02

 The volume of the profunda femoris artery perforator (PAP) flap limits its indications to small- and medium-sized breast reconstructions after modified radical mastectomy for cancer. We report a modified PAP flap design, including not only a vertical extension that increases its volume but also the skin surface, which suits larger breasts requiring immediate or delayed breast reconstructions and compare the results with our horizontal skin paddle PAP flap experience.  In our center between November 2014 and November 2016, 51 consecutive patients underwent a PAP flap breast reconstruction following breast cancer. A retrospective analysis on the collected data was performed to compare 34 patients with a bra cup smaller than C who underwent 41 horizontal PAP flap procedures, with those ( n  = 17) of a bra cup greater than or equal to C who underwent 21 fleur-de-lys PAP flap procedures. Demographic, anthropometric, flap and surgical characteristics, postoperative complication rates, and hospital stay were compared between the two groups.  The average flap weight was 480 g (range: 340-735 g) for the fleur-de-lys PAP flap group compared with 222 g (range: 187-325 g) for the horizontal PAP flap procedure ( p  < 0.001). The mean flap dimensions were 25 × 18 cm for the fleur-de-lys PAP flap group compared with 25 × 7 cm in the horizontal PAP flap group. No flap failure was observed in the fleur-de-lys PAP flap group compared with two flap failures secondary to venous thrombosis in the horizontal PAP flap group ( NS ). Three patients (14%) experienced delayed healing at the donor site compared with four patients (10%) in the horizontal PAP flap group ( NS ).  The fleur-de-lys skin paddle design not only allows an increase of the horizontal PAP flap volume, but also increases the skin surface, with an acceptable donor site morbidity. For medium- or large-sized breasts, the fleur-de-lys PAP flap seems to be ideal when a DIEP flap-based reconstruction is contraindicated. Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Free-style dual plane recycling tensor fascia lata musculocutaneous perforator flap for reconstruction of recurrent trochanteric defects.

PubMed

Han, Ba Leun; Choi, Hwan Jun

2014-03-01

Sequential flap coverage might be required for recurrent defects, but reusing a flap as a donor site has seldom been reported. The concept of a "free-style flap" has been developed, and it allows reconstructive surgeons to raise flaps with various designs reliably, even at sites of previous flap surgery. This article presents the concept of free-style recycling of a tensor fascia lata flap into a perforator-based flap separated in 2 planes in a patient with a recurrent bilateral trochanteric defect. If a reliable perforator is preserved and identified within the tissues by computed tomography angiography or a Doppler device, a new perforator flap can be designed and raised at the previous flap site.

Foucher first dorsal metacarpal artery flap versus littler heterodigital neurovascular flap in resurfacing thumb pulp loss defects.

PubMed

Delikonstantinou, Iraklis P; Gravvanis, Andreas I; Dimitriou, Vasilios; Zogogiannis, Ioannis; Douma, Amalia; Tsoutsos, Dimosthenis A

2011-08-01

Our study aims to illustrate the advantages and disadvantages of Foucher's first dorsal metacarpal artery flap and Littler's heterodigital neurovascular flap in thumb pulp reconstruction, by assessing wound healing of donor and recipient sites, sensibility, and functional outcome of the reconstructed thumb. Fourteen male patients were reconstructed either with Foucher (n = 8) or Littler flap (n = 6). Dissection of Foucher's flap was faster than that of Littler's flap. All Littler flaps survived completely, but we experienced 1 partial Foucher flap necrosis. Thumb motility and stability was optimal in all patients. Wound healing of donor sites was achieved in both groups. Two patients reconstructed with Littler flap developed scar contractures and presented a reduced range of motion of donor finger and first webspace, respectively. Although Littler flap resulted in better sensibility and tactile gnosis of the reconstructed thumb-pulp, Foucher flap ensured negligible donor site morbidity, complete cortical reorientation, and better overall hand function.

Wind-Tunnel Investigation of an NACA 23021 Airfoil with a 0.32-Airfoil-Chord Double Slotted Flap

NASA Technical Reports Server (NTRS)

Fischel, Jack; Riebe, John M

1944-01-01

An investigation was made in the LMAL 7- by 10-foot wind tunnel of a NACA 23021 airfoil with a double slotted flap having a chord 32 percent of the airfoil chord (0.32c) to determine the aerodynamic section characteristics with the flaps deflected at various positions. The effects of moving the fore flap and rear flap as a unit and of deflecting or removing the lower lip of the slot were also determined. Three positions were selected for the fore flap and at each position the maximum lift of the airfoil was obtained with the rear flap at the maximum deflection used at that fore-flap position. The section lift of the airfoil increased as the fore flap was extended and maximum lift was obtained with the fore flap deflected 30 deg in the most extended position. This arrangement provided a maximum section lift coefficient of 3.31, which was higher than the value obtained with either a 0.2566c or a 0.40c single-slotted-flap arrangement and 0.25 less than the value obtained with a 0.4c double-slotted-flap arrangement on the same airfoil. The values of the profile-drag coefficient obtained with the 0.32c double slotted flap were larger than those for the 0.2566c or 0.40c single slotted flaps for section lift coefficients between 1.0 and approximately 2.7. At all values of the section lift coefficient above 1.0, the 0.40c double slotted flap had a lower profile drag than the 0.32c double slotted flap. At various values of the maximum section lift coefficient produced by various flap defections, the 0.32c double slotted flap gave negative section pitching-moment coefficients that were higher than those of other slotted flaps on the same airfoil. The 0.32c double slotted flap gave approximately the same maximum section lift coefficient as, but higher profile-drag coefficients over the entire lift range than, a similar arrangement of a 0.30c double slotted flap on an NACA 23012 airfoil.

The Economy in Autologous Tissue Transfer: Part 1. The Kiss Flap Technique.

PubMed

Zhang, Yi Xin; Hayakawa, Thomas J; Levin, L Scott; Hallock, Geoffrey G; Lazzeri, Davide

2016-03-01

All reconstructive microsurgeons realize the need to improve aesthetic and functional donor-site outcomes. A "kiss" flap design concept was developed to increase the surface area of skin flap coverage while minimizing donor-site morbidity. The main goal of the kiss flap technique is to harvest multiple skin paddles that are smaller than those raised with traditional techniques, to minimize donor-site morbidity. These smaller flap components are then sutured to each other, or said to kiss each other side-by-side, to create a large, wide flap. The skin paddles in the kiss technique can be linked to one another by a variety of native intrinsic vascular connections, by additional microanastomosis, or both. This technique can be widely applied to both free and pedicle flaps, and essentially allows for the reconstruction of a large defect while providing the easy primary closure of a smaller donor-site defect. According to their origin of blood supply, kiss flaps are classified into three styles and five types. All of the different types of kiss flaps are unique in both flap design and harvest technique. Most kiss flaps are based on common flaps already familiar to the reconstructive surgeon. The basis of the kiss flap design concept is to convert multiple narrow flaps into a single unified flap of the desired greater width. This maximizes the size of the resulting flap and minimizes donor-site morbidity, as a direct linear closure is usually possible. Therapeutic, V.

The Temporalis Muscle Flap for Palate Reconstruction: Case Series and Review of the Literature

PubMed Central

Brennan, Tara; Tham, Tristan M.; Costantino, Peter

2017-01-01

Introduction  The temporalis myofascial (TM) is an important reconstructive flap in palate reconstruction. Past studies have shown the temporalis myofascial flap to be safe as well as effective. Free flap reconstruction of palate defects is also a popular method used by contemporary surgeons. We aim to reaffirm the temporalis myofascial flap as a viable alternative to free flaps for palate reconstruction. Objective  We report our results using the temporalis flap for palate reconstruction in one of the largest case series reported. Our literature review is the first to describe complication rates of palate reconstruction using the TM flap. Methods  Retrospective chart review and review of the literature. Results  Fifteen patients underwent palate reconstruction with the TM flap. There were no cases of facial nerve injury. Five (33%) of these patients underwent secondary cranioplasty to address temporal hollowing after the TM flap. Three out of fifteen (20%) had flap related complications. Fourteen (93%) of the palate defects were successfully reconstructed, with the remaining case pending a secondary procedure to close the defect. Ultimately, all of the flaps (100%) survived. Conclusion  The TM flap is a viable method of palate defect closure with a high defect closure rate and flap survival rate. TM flaps are versatile in repairing palate defects of all sizes, in all regions of the palate. Cosmetic deformity created from TM flap harvest may be addressed using cranioplasty implant placement, either primarily or during a second stage procedure. PMID:28680495

Improved wound healing of postischemic cutaneous flaps with the use of bone marrow-derived stem cells.

PubMed

Hu, Melissa; Ludlow, David; Alexander, J Steven; McLarty, Jerry; Lian, Timothy

2014-03-01

To determine if the intravascular delivery of mesenchymal stem cells improves wound healing and blood perfusion to postischemic cutaneous flap tissues. Randomized controlled study. A murine model of a cutaneous flap was created based on the inferior epigastric vessels. Mice (n = 14) underwent 3.5 hours of ischemia followed by reperfusion. Bone marrow stromal cells (BMSCs) 1 × 10(6) were injected intravenously. Wound healing was then assessed measuring percent flap necrosis, flap perfusion, and tensile strength of the flap after a period of 14 days. Localization of BMSCs was determined with radiolabeled and fluorescent labeled BMSCs. Postischemic cutaneous flap tissues treated with BMSCs demonstrated significantly less necrosis than control flaps (P <0.01). Beginning on postoperative day 5, BMSC-treated flaps demonstrated greater blood perfusion than untreated flaps (P <0.01). Tensile strength of BMSC-treated cutaneous flaps was significantly higher (P <0.01), with a mean strength of 283.4 ± 28.4 N/m than control flaps with a mean of 122.4 ± 23.5 N/m. Radiolabeled BMSCs localized to postischemic flaps compared to untreated tissues (P = 0.001). Fluorescent microscopy revealed incorporation of BMSCs into endothelial and epithelial tissues of postischemic flaps. This study demonstrates that the intravascular delivery of BMSCs increases wound healing and promotes flap survival following ischemia-reperfusion injury of cutaneous tissue flaps. © 2013 The American Laryngological, Rhinological and Otological Society, Inc.

[A variant of island flaps for the covering of pressure sores: the hatchet flap. Apropos of 31 cases].

PubMed

Quillot, M; Lodde, J P; Pegorier, O; Reynaud, J P; Cormerais, A

1994-08-01

The authors propose a modification of the classical design of island flaps for cover of pressure sores, applied to gluteus maximus and tensor fascia lata muscles: the hatchet flap. 31 flaps have been used including 13 gluteus maximus superior flaps for sacral pressure sores, 9 gluteal inferior flaps for ischial pressure sores and 9 tensor fascia lata flaps for trochanteric pressure sores. A small partial necrosis and two cases of sepsis were observed in this series, but did not require surgical revision. The authors emphasize the value of this modification of the classical flap design, which preserves an even better musculocutaneous capital in these patients, who are often already multi-operated. The very rapid recovery of patients supports the authors' application of hatchet flaps to the surgery of pressure sores, and suggests the extension to other musculocutaneous flaps in the future.

Comparison of ultrasound-guided posterior transversus abdominis plane block and lateral transversus abdominis plane block for postoperative pain management in patients undergoing cesarean section: a randomized double-blind clinical trial study.

PubMed

Faiz, Seyed Hamid Reza; Alebouyeh, Mahmoud Reza; Derakhshan, Pooya; Imani, Farnad; Rahimzadeh, Poupak; Ghaderi Ashtiani, Maryam

2018-01-01

Due to the importance of pain control after abdominal surgery, several methods such as transversus abdominis plane (TAP) block are used to reduce the pain after surgery. TAP blocks can be performed using various ultrasound-guided approaches. Two important approaches to do this are ultrasound-guided lateral and posterior approaches. This study aimed to compare the two approaches of ultrasound-guided lateral and posterior TAP blocks to control pain after cesarean section. In this double-blind clinical trial study, 76 patients scheduled for elective cesarean section were selected and randomly divided into two groups of 38 and underwent spinal anesthesia. For pain management after the surgery, one group underwent lateral TAP block and the other group underwent posterior TAP block using 20cc of ropivacaine 0.2% on both sides. Pain intensity was evaluated based on Numerical Analog Scale (NAS) at rest and when coughing, 2, 4, 6, 12, 24 and 36 hours after surgery. The pain at rest in the posterior group at all hours post surgery was lower than the lateral group, especially at 6, 12 and 24 hours after the surgery and the difference was statistically significant ( p =0.03, p <0.004, p =0.001). The results of this study show that ultrasound-guided posterior TAP block compared with the lateral TAP block was more effective in pain control after cesarean section.

Rehabilitation and Return to Sport Following Surgical Repair of the Rectus Abdominis and Adductor Longus in a Professional Basketball Player: A Case Report.

PubMed

Short, Steven M; Anloague, Philip A; Strack, Donald S

2016-08-01

Study Design Case report. Background Acute traumatic avulsion of the rectus abdominis and adductor longus is rare. Chronic groin injuries, often falling under the athletic pubalgia spectrum, have been reported to be more common. There is limited evidence detailing the comprehensive rehabilitation and return to sport of an athlete following surgical or conservative treatment of avulsion injuries of the pubis or other sports-related groin pathologies. Case Description A 29-year-old National Basketball Association player sustained a contact injury during a professional basketball game. This case report describes a unique clinical situation specific to professional sport, in which a surgical repair of an avulsed rectus abdominis and adductor longus was combined with a multimodal impairment- and outcomes-based rehabilitation program. Outcomes The patient returned to in-season competition at 5 weeks postoperation. Objective measures were tracked throughout rehabilitation and compared to baseline assessments. Measures such as the Copenhagen Hip and Groin Outcome Score and numeric pain-rating scale revealed progress beyond the minimal important difference. Discussion This case report details the clinical reasoning and evidence-informed interventions involved in the return to elite sport. Detailed programming and objective assessment may assist in achieving desired outcomes ahead of previously established timelines. Level of Evidence Therapy, level 4. J Orthop Sports Phys Ther 2016;46(8):697-706. Epub 3 Jul 2016. doi:10.2519/jospt.2016.6352.

A hippotherapy simulator is effective to shift weight bearing toward the affected side during gait in patients with stroke.

PubMed

Sung, Yun-Hee; Kim, Chang-Ju; Yu, Byong-Kyu; Kim, Kyeong-Mi

2013-01-01

We investigated whether a hippotherapy simulator has influence on symmetric body weight bearing during gait in patients with stroke. Stroke patients were divided into a control group (n = 10) that received conventional rehabilitation for 60 min/day, 5 times/week for 4 weeks and an experimental group (n = 10) that used a hippotherapy simulator for 15 min/day, 5 times/week for 4 weeks after conventional rehabilitation for 45 min/day. Temporospatial gait assessed using OptoGait and trunk muscles (abdominis and erector spinae on affected side) activity evaluated using surface electromyography during sit-to-stand and gait. Prior to starting the experiment, pre-testing was performed. At the end of the 4-week intervention, we performed post-testing. Activation of the erector spinae in the experimental group was significantly increased compared to that in the control group (p < 0.01), whereas activation of the rectus abdominis decreased during sit-to-stand. Of the gait parameters, load response, single support, total double support, and pre-swing showed significant changes in the experimental group with a hippotherapy simulator compared to control group (p < 0.05). Moreover, activation of the erector spinae and rectus abdominis in gait correlate with changes of gait parameters including load response, single support, total double support, and pre-swing in experimental group. These findings suggest that use of a hippotherapy simulator to patients with stroke can improve asymmetric weight bearing by influencing trunk muscles.

[Aesthetic effect of wound repair with flaps].

PubMed

Tan, Qian; Zhou, Hong-Reng; Wang, Shu-Qin; Zheng, Dong-Feng; Xu, Peng; Wu, Jie; Ge, Hua-Qiang; Lin, Yue; Yan, Xin

2012-08-01

To investigate the aesthetic effect of wound repair with flaps. One thousand nine hundred and ninety-six patients with 2082 wounds hospitalized from January 2004 to December 2011. These wounds included 503 deep burn wounds, 268 pressure sores, 392 soft tissue defects caused by trauma, 479 soft tissue defects due to resection of skin cancer and mole removal, 314 soft tissue defects caused by scar excision, and 126 other wounds. Wound area ranged from 1.5 cm x 1.0 cm to 30.0 cm x 22.0 cm. Sliding flaps, expanded flaps, pedicle flaps, and free flaps were used to repair the wounds in accordance with the principle and timing of wound repair with flaps. Five flaps showed venous congestion within 48 hours post-operation, 2 flaps of them improved after local massage. One flap survived after local heparin wet packing and venous bloodletting. One flap survived after emergency surgical embolectomy and bridging with saphenous vein graft. One flap showed partial necrosis and healed after skin grafting. The other flaps survived well. One thousand three hundred and twenty-one patients were followed up for 3 months to 2 years, and flaps of them were satisfactory in shape, color, and elasticity, similar to that of normal skin. Some patients underwent scar revision later with good results. Application of suitable flaps in wound repair will result in quick wound healing, good function recovery, and satisfactory aesthetic effect.

[Predictability of the corneal flap creation with the femtosecond laser in LASIK].

PubMed

Mai, Zhi-bin; Liu, Su-bing; Nie, Xiao-li; Sun, Hong-xia; Xin, Bao-li; Tang, Xiu-xia

2012-05-01

To observe the predictability of corneal flap creation with the FEMTO LDV femtosecond laser and analyze preliminarily the factors correlating to the thickness and diameter of the flap . It was a study of serial cases. 260 eyes of 130 consecutive patients were treated with the FEMTO LDV. The eyes were assigned to two groups according to intended flap thickness, 110 µm (208 eyes) and 90 µm (52 eyes). Intended flap diameter varied from 8.5 to 9.5 mm. Difference analysis of flap diameter and intended diameter as well as flap thickness and intended thickness were made. The data was analyzed with SPSS to sum up a multiple stepwise regression formula that could express their quantitative relationship. The 90 µm flap group had a average flap thickness of (95.12 ± 7.65) µm, while for the 110 µm group the average flap thickness was (104.81 ± 3.09) µm. The difference between right and left eyes was not statistically significant (t(110 µm) = -1.223, t(90 µm) = -1.343, P > 0.05). Corneal flap thickness was inversely correlated with flap diameter (r(110 µm) = -0.143, r(90 µm) = -0.315, P < 0.05), but was not related to preoperative patient age, corneal thickness, keratometric value K or intraocular pressure (r(110 µm) = -0.160, 0.054, -0.011, -0.363; r(90 µm) = 0.024, 0.074, -0.212, -0.434, all P > 0.05). Corneal flap diameter was positively correlated with preoperative corneal keratometric value K and thickness (P < 0.001, P < 0.05). Multiple stepwise regression analysis showed flap diameter was an influencing factor for flap thickness. Preoperative corneal keratometric value K and thickness were influencing factors for flap diameter. The LASIK flap creation with the FEMTO LDV laser has relatively good predictability. Flap diameter is an influencing factor for flap thickness.

Gender identity disorder: general overview and surgical treatment for vaginoplasty in male-to-female transsexuals.

PubMed

Selvaggi, Gennaro; Ceulemans, Peter; De Cuypere, Griet; VanLanduyt, Koen; Blondeel, Phillip; Hamdi, Moustapha; Bowman, Cameron; Monstrey, Stan

2005-11-01

After studying this article, the participant should be able to discuss: 1. The terminology related to male-to-female gender dysphoria. 2. The different theories regarding cause, epidemiology, and treatment of gender dysphoria. 3. The surgical goals of sex reassignment surgery in male-to-female transsexualism. 4. The surgical techniques available for sex reassignment surgery in male-to-female transsexualism. Gender identity disorder (previously "transsexualism") is the term used for individuals who show a strong and persistent cross-gender identification and a persistent discomfort with their anatomical sex, as manifested by a preoccupation with getting rid of one's sex characteristics, or the belief of being born in the wrong sex. Since 1978, the Harry Benjamin International Gender Dysphoria Association (in honor of Dr. Harry Benjamin, one of the first physicians who made many clinicians aware of the potential benefits of sex reassignment surgery) has played a major role in the research and treatment of gender identity disorder, publishing the Standards of Care for Gender Dysphoric Persons. The authors performed an overview of the terminology related to male-to-female gender identity disorder; the different theories regarding cause, epidemiology, and treatment; the goals expected; and the surgical technique available for sex reassignment surgery in male-to-female transsexualism. Surgical techniques available for sex reassignment surgery in male-to-female transsexualism, with advantages and disadvantages offered by each technique, are reviewed. Other feminizing nongenital operative interventions are also examined. This review describes recent etiopathogenetic theories and actual guidelines on the treatment of the gender identity disorder in male-to-female transsexuals; the penile-scrotal skin flap technique is considered the state of the art for vaginoplasty in male-to-female transsexuals, whereas other techniques (rectosigmoid flap, local flaps, and isolated skin grafts) should be considered only in secondary cases. As techniques in vaginoplasty become more refined, more emphasis is being placed on aesthetic outcomes by both surgeons and patients.

Tracheal reconstruction with a composite graft: fascial flap-wrapped allogenic aorta with external cartilage-ring support

PubMed Central

Wurtz, Alain; Hysi, Ilir; Kipnis, Eric; Zawadzki, Christophe; Hubert, Thomas; Jashari, Ramadan; Copin, Marie-Christine; Jude, Brigitte

2013-01-01

OBJECTIVES Animal and clinical studies have demonstrated the feasibility of tracheal replacement by silicone-stented allogenic aortas. In clinical trials, however, this graft did not show mature cartilage regeneration into the grafts as was observed in animal models. To solve this issue, we investigated tracheal replacement with a composite graft based on a fascial flap-wrapped allogenic aorta with external cartilage-ring support in a rabbit model. METHODS Seven male 'Géant des Flandres' and 'New Zealand' rabbits served as donors of aortas and cartilage rings, respectively. Nineteen female 'New Zealand' rabbits were used as recipients. First, in nine animals, neoangiogenesis of the composite graft following a wrap using a pedicled lateral thoracic fascial flap and implantation under the skin of the chest wall was investigated. Animal sacrifice was scheduled at regular intervals up to 38 days. Second, 10 animals underwent tracheal replacement with the composite graft after a 7-to-9 day revascularization period, and were followed-up to death. Macroscopic and microscopic examinations were used to study the morphology, stiffness and viability of the construct. RESULTS There was one operative death after tracheal replacement. The first group of animals was found to have a satisfactory tubular morphology and stiffness of their construct associated with preserved histological structure of cartilages and moderate to severe aortic ischaemic lesions. In the group of rabbits having undergone tracheal replacement, the anatomical results were characterized by a discrepancy between the severity of ischaemic lesions involving both allogenic aorta and cartilage rings and the satisfactory biomechanical characteristics of the graft in 7 of 10 animals, probably due to cartilage calcification deposits associated with inflammatory scar tissue ensuring the stiffness of the construct. CONCLUSIONS Our investigations demonstrate the feasibility of the replacement of circumferential tracheal defects using our composite graft. Future experiments using therapeutic bronchoscopy tools are required to draw conclusions regarding the effectiveness of this tracheal substitute in the long-term. PMID:23049080

Intraoperative fluorescence angiography: a review of applications and outcomes in war-related trauma.

PubMed

Green, J Marshall; Sabino, Jennifer; Fleming, Mark; Valerio, Ian

2015-03-01

In the recent Iraq and Afghanistan conflicts, survival rates from complex battlefield injuries have continued to improve. The resulting war-related wounds are challenging, with confounding issues making assessment of tissue perfusion subjective and variable. This review discusses the utility of intraoperative fluorescence angiography, and its usefulness as an objective tool to evaluate the perfusion of tissues in the face of complex war-related injuries. A retrospective review of all war-related traumatic and reconstructive cases employing intraoperative indocyanine green laser angiography (ICGLA) was performed. Data analyzed included indication for use, procedure success/failure rates, modifications performed, and perfusion-related complications. Anatomical regions assessed were extremity, head and neck, truncal, and intra-abdominal viscera. The endpoint of specific interest involved the decision for additional debridement of poorly perfused tissue, as based on the ICGLA findings. Over a 3-year period, this study examined 123 extremity soft tissue flaps, 41 extremity injuries including amputation and/or amputation revision cases, 13 craniofacial flaps, and 9 truncal/abdomen/gastrointestinal cases in which ICGLA was utilized to assess tissue perfusion and viability. A total of 35 (18.8%) of cases employing ICGLA required intraoperative modifications to address perfusion-related issues. Intraoperative fluorescent angiography is an objective, useful tool to assess various war-related traumatic injuries. This study expands on prior cited indications for ICGLA to include (1) guiding debridement in heavily contaminated wounds, (2) providing improved assessment of avulsion soft tissue injuries, (3) allowing for rapid detection of vascular and/or microvascular compromise in soft tissue and osseous flap reconstructions, (4) reducing and preventing perfusion-related complications in trauma, amputation closures, and reconstruction procedures, (5) contributing to better outcomes in certain complex orthopedic and composite tissue injuries, and (6) enabling improved postoperative wound and reconstruction assessment in those cases of perfusion-related issues that arise within a delayed setting. Reprint & Copyright © 2015 Association of Military Surgeons of the U.S.

Wind-Tunnel Investigation of a Rectangular NACA 2212 Airfoil with Semispan Ailerons and with Nonperforated, Balanced Double Split Flaps for Use as Aerodynamic Brakes

NASA Technical Reports Server (NTRS)

Ivey, Margaret F

1945-01-01

Flat-plate flaps with no wing cutouts and flaps having Clark Y sections with corresponding cutouts made in wing were tested for various flap deflections, chord-wise locations, and gaps between flaps and airfoil contour. The drag was slightly lower for wing with airfoil section flaps. Satisfactory aileron effectiveness was obtained with flap gap of 20% wing chord and flap-nose location of 80 percent wing chord behind leading edge. Airflow was smooth and buffeting negligible.

[Pedicle flap of nasal septum-basis nasi and temporal muscucofascial flap to repair nasoseptal perforation].

PubMed

Yin, Xinghong; Hu, Wei; Zhang, Xinhai; Sun, Min

2014-10-01

To explore curative effect with pedicle flap of nasal septum-basis nasi and temporal muscucofascial flap to repair nasal septal perforation. Dissecting mucoperichondrium and mucoperioseptum around the perforation and taking dowm and out xia-ward to the floor of nasal cavity to make a inferior extremity pedicle flap. Then,the flap was tumbled and sutured onto raw surface of contralateral side through perforation. Reapplicating autoallergic temporal musculofascial flap to repair another side perforation. Repairing perforation Sin twelve cases were sucessfully healed in endoscope. The pedicle flap of nasal septum-basis nasi and temporal muscucofascial flap is easy to acquire and no rejection. The flap has good blood supplying, high survival rate and provides adequate transplantating materail to repair comparatively large perforation.

[The repair of bulky tissue defect of forearm with skin flaps].

PubMed

Huang, Xiaoyuan; Long, Jianhong; Xie, Tinghong; Zhang, Minghua; Zhang, Pihong; Yang, Xinghua; Zhong, Keqin

2002-12-01

To evaluate the repairing methods of bulky tissue defect of forearm with flaps. Twenty-one burned patients with wounds in the forearm were enrolled in this study. The injury causes were high-voltage electricity, hot press or crush injury. After local debridement, the forearm defects were repaired with pedicled complex flaps, latissimus dorsi musculocutaneous island flaps or large thoraco-abdominal flaps immediately. All the flaps survived very well with satisfactory results except for 1 patient in whom local ischemic necrosis and sub-flap infection at the distal end of the flap occurred. Early debridement followed by skin flaps with pedicles or musculocutaneous flaps transfer could be simple, safe and reliable treatment strategies in the management of bulky tissue defects of the forearm due to burn, electric injury, or other devastating injuries.

The perforator pedicled propeller (PPP) flap method: report of two cases.

PubMed

Hyakusoku, Hiko; Ogawa, Rei; Oki, Koichiro; Ishii, Nobuaki

2007-10-01

Perforator flaps are thin free-tissue transfers consisting of skin and subcutaneous tissue which have the advantage of decreasing donor site morbidity. We have reconstructed postburn scar contractures using "propeller flaps" of the remaining healthy skin around the recipient sites. In this paper, we report on two cases and describe the concept of using "perforator flaps" and "propeller flaps" together as what are called "perforator pedicled propeller (PPP) flaps." Patient 1 was an 18-year-old man with a sacral pressure ulcer. The soft tissue defect was reconstructed with a rotated superior gluteal artery PPP flap. Patient 2 was a 53-year-old woman who presented with an open fracture of the right elbow. The skin defect over the fracture was covered with a rotated deep brachial artery PPP flap raised on the lateral upper arm. The PPP flaps are useful for burn reconstruction and repairing various types of wound. Moreover, microsurgery is unnecessary. The PPP flap may be classified into two types: the central axis type and the acentric axis type. The central axis PPP flap is significant when used as a 90-degree-rotation island flap, and the acentric axis PPP flap is significant when used as a 180-degree-rotation island flap. Both types are easy to harvest and useful for repairing various kinds of wound.

The "Tokyo" consensus on propeller flaps.

PubMed

Pignatti, Marco; Ogawa, Rei; Hallock, Geoffrey G; Mateev, Musa; Georgescu, Alexandru V; Balakrishnan, Govindasamy; Ono, Shimpei; Cubison, Tania C S; D'Arpa, Salvatore; Koshima, Isao; Hyakusoku, Hikko

2011-02-01

Over the past few years, the use of propeller flaps, which base their blood supply on subcutaneous tissue or isolated perforators, has become increasingly popular. Because no consensus has yet been reached on terminology and nomenclature of the propeller flap, different and confusing uses of the term can be found in the literature. In this article, the authors report the consensus on the definition and classification of propeller flaps reached by the authors that gathered at the First Tokyo Meeting on Perforator and Propeller Flaps in June of 2009. Some peculiar aspects of the surgical technique are discussed. A propeller flap can be defined as an "island flap that reaches the recipient site through an axial rotation." The classification is based on the nourishing pedicle (subcutaneous pedicled propeller flap, perforator pedicled propeller flap, supercharged propeller flap), the degrees of skin island rotation (90 to 180 degrees) and, when possible, the artery of origin of the perforator. The propeller flap is a useful reconstructive tool that can achieve good cosmetic and functional results. A flap should be called a propeller flap only if it fulfils the definition above. The type of nourishing pedicle, the source vessel (when known), and the degree of skin island rotation should be specified for each flap.

Reconstruction of the Foot and Ankle Using Pedicled or Free Flaps: Perioperative Flap Survival Analysis

PubMed Central

Li, Xiucun; Cui, Jianli; Maharjan, Suraj; Lu, Laijin; Gong, Xu

2016-01-01

Objective The purpose of this study is to determine the correlation between non-technical risk factors and the perioperative flap survival rate and to evaluate the choice of skin flap for the reconstruction of foot and ankle. Methods This was a clinical retrospective study. Nine variables were identified. The Kaplan-Meier method coupled with a log-rank test and a Cox regression model was used to predict the risk factors that influence the perioperative flap survival rate. The relationship between postoperative wound infection and risk factors was also analyzed using a logistic regression model. Results The overall flap survival rate was 85.42%. The necrosis rates of free flaps and pedicled flaps were 5.26% and 20.69%, respectively. According to the Cox regression model, flap type (hazard ratio [HR] = 2.592; 95% confidence interval [CI] (1.606, 4.184); P < 0.001) and postoperative wound infection (HR = 0.266; 95% CI (0.134, 0.529); P < 0.001) were found to be statistically significant risk factors associated with flap necrosis. Based on the logistic regression model, preoperative wound bed inflammation (odds ratio [OR] = 11.371,95% CI (3.117, 41.478), P < 0.001) was a statistically significant risk factor for postoperative wound infection. Conclusion Flap type and postoperative wound infection were both independent risk factors influencing the flap survival rate in the foot and ankle. However, postoperative wound infection was a risk factor for the pedicled flap but not for the free flap. Microvascular anastomosis is a major cause of free flap necrosis. To reconstruct complex or wide soft tissue defects of the foot or ankle, free flaps are safer and more reliable than pedicled flaps and should thus be the primary choice. PMID:27930679

Supraclavicular artery perforator flap in management of post-burn neck reconstruction: clinical experience

PubMed Central

Ismail, H.; Elshobaky, A.

2016-01-01

Summary Anterior cervical contractures of the neck represent a great challenge for plastic and reconstructive surgeons. Necks can be reconstructed with a wide range of surgical techniques, including chimeric flaps, supercharged flap, pre-expanded flaps, “superthin” flaps and perforator flaps. The supraclavicular flap is easy to harvest without the need for free tissue transfer. It provides a relatively large flap for neck resurfacing with tissue very similar to that of the neck. Between January 2013 and March 2015, 20 patients suffering from postburn neck contracture underwent reconstruction with 20 unilateral supraclavicular artery perforator flaps. Nineteen patients had post-burn neck contractures (9 cases type Іc, 10 cases type Пc) while only one had post-burn granulation tissue in the neck. We harvested fifteen flaps from the right side and five from the left. Size of the reconstructed defect ranged from 23x10 to14x6, and flap size varied from 25/11 to 16/7cm. Period of follow up ranged from 27-2months (average 12.3). Nineteen flaps survived well (95% survival rate): only one was lost due to iatrogenic extensive dissection over the pedicle. Five cases showed distal superficial epidermolysis, and 2 cases showed 2 cm complete distal necrosis. All patients were managed conservatively. Our results coincide with other literature results confirming the efficacy and rich vascularity of this flap. In all cases with distal partial necrosis, flaps were 23 cm or more. We recommend that supraclavicular flaps of more than 22 cm in length are not harvested immediately and that flaps are expanded before harvesting. Expanding the supraclavicular flap increases its surface area and decreases donor site morbidity. PMID:28149252

Cracking the perfusion code?: Laser-assisted Indocyanine Green angiography and combined laser Doppler spectrophotometry for intraoperative evaluation of tissue perfusion in autologous breast reconstruction with DIEP or ms-TRAM flaps.

PubMed

Ludolph, Ingo; Arkudas, Andreas; Schmitz, Marweh; Boos, Anja M; Taeger, Christian D; Rother, Ulrich; Horch, Raymund E; Beier, Justus P

2016-10-01

The aim of this prospective study was to assess the correlation of flap perfusion analysis based on laser-assisted Indocyanine Green (ICG) angiography with combined laser Doppler spectrophotometry in autologous breast reconstruction using free DIEP/ms-TRAM flaps. Between February 2014 and July 2015, 35 free DIEP/ms-TRAM flaps were included in this study. Besides the clinical evaluation of flaps, intraoperative perfusion dynamics were assessed by means of laser-assisted ICG angiography and post-capillary oxygen saturation and relative haemoglobin content (rHb) using combined laser Doppler spectrophotometry. Correlation of the aforementioned parameters was analysed, as well as the impact on flap design and postoperative complications. Flap survival rate was 100%. There were no partial flap losses. In three cases, flap design was based on the angiography, contrary to clinical evaluation and spectrophotometry. The final decision on the inclusion of flap areas was based on the angiographic perfusion pattern. Angiography and spectrophotometry showed a correlation in most of the cases regarding tissue perfusion, post-capillary oxygen saturation and relative haemoglobin content. Laser-assisted ICG angiography is a useful tool for intraoperative evaluation of flap perfusion in autologous breast reconstruction with DIEP/ms-TRAM flaps, especially in decision making in cases where flap perfusion is not clearly assessable by clinical signs and exact determination of well-perfused flap margins is difficult to obtain. It provides an objective real-time analysis of flap perfusion, with high sensitivity for the detection of poorly perfused flap areas. Concerning the topographical mapping of well-perfused flap areas, laser-assisted angiography is superior to combined laser Doppler spectrophotometry. Copyright © 2016 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

Full-scale-wind-tunnel Tests of a 35 Degree Sweptback Wing Airplane with High-velocity Blowing over the Training-edge Flaps

NASA Technical Reports Server (NTRS)

Kelley, Mark W; Tolhurst, William H JR

1955-01-01

A wind-tunnel investigation was made to determine the effects of ejecting high-velocity air near the leading edge of plain trailing-edge flaps on a 35 degree sweptback wing. The tests were made with flap deflections from 45 degrees to 85 degrees and with pressure ratios across the flap nozzles from sub-critical up to 2.9. A limited study of the effects of nozzle location and configuration on the efficiency of the flap was made. Measurements of the lift, drag, and pitching moment were made for Reynolds numbers from 5.8 to 10.1x10(6). Measurements were also made of the weight rate of flow, pressure, and temperature of the air supplied to the flap nozzles.The results show that blowing on the deflected flap produced large flap lift increments. The amount of air required to prevent flow separation on the flap was significantly less than that estimated from published two-dimensional data. When the amount of air ejected over the flap was just sufficient to prevent flow separation, the lift increment obtained agreed well with linear inviscid fluid theory up to flap deflections of 60 degrees. The flap lift increment at 85 degrees flap deflection was about 80 percent of that predicted theoretically.With larger amounts of air blown over the flap, these lift increments could be significantly increased. It was found that the performance of the flap was relatively insensitive to the location of the flap nozzle, to spacers in the nozzle, and to flow disturbances such as those caused by leading-edge slats or discontinuities on the wing or flap surfaces. Analysis of the results indicated that installation of this system on an F-86 airplane is feasible.

Refining the cross-finger flap: Considerations of flap insetting, aesthetics and donor site morbidity.

PubMed

Chong, Chew-Wei; Lin, Cheng-Hung; Lin, Yu-Te; Hsu, Chung-Chen; Chen, Shih-Heng

2018-04-01

We described a laterally based cross-finger flap for reconstruction of soft tissue defects in the fingers. This modification enables coverage of volar or dorsal soft tissue defects at the distal, middle or proximal phalanx. From March 2015 to January 2017, a total of 12 patients (13 fingers) underwent soft tissue reconstruction of the fingers with a laterally based cross-finger flap. The flap dimensions ranged from 13 ×7 mm to 43 ×13 mm. Eleven of the 13 flaps survived completely. The two flap failures were attributed to injuries in the donor fingers, rendering the blood supply of the flaps unreliable. All donor sites were closed primarily without the need for skin grafting, negating the problem of donor site morbidity that is associated with skin graft harvesting. The laterally based cross-finger flap is a versatile flap with less donor site morbidity and better aesthetics than a conventional cross-finger flap. We described the design of the flap, as well as the advantages and disadvantages, in doing a laterally based cross-finger flap. Copyright © 2017 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

Propeller Perforator Flaps in Distal Lower Leg: Evolution and Clinical Applications

PubMed Central

2012-01-01

Simple or complex defects in the lower leg, and especially in its distal third, continue to be a challenging task for reconstructive surgeons. A variety of flaps were used in the attempt to achieve excellence in form and function. After a long evolution of the reconstructive methods, including random pattern flaps, axial pattern flaps, musculocutaneous flaps and fasciocutaneous flaps, the reappraisal of the works of Manchot and Salmon by Taylor and Palmer opened the era of perforator flaps. This era began in 1989, when Koshima and Soeda, and separately Kroll and Rosenfield described the first applications of such flaps. Perforator flaps, whether free or pedicled, gained a high popularity due to their main advantages: decreasing donor-site morbidity and improving aesthetic outcome. The use as local perforator flaps in lower leg was possible due to a better understanding of the cutaneous circulation, leg vascular anatomy, angiosome and perforasome concepts, as well as innovations in flaps design. This review will describe the evolution, anatomy, flap design, and technique of the main distally pedicled propeller perforator flaps used in the reconstruction of defects in the distal third of the lower leg and foot. PMID:22783507

Free versus perforator-pedicled propeller flaps in lower extremity reconstruction: What is the safest coverage? A meta-analysis.

PubMed

Bekara, Farid; Herlin, Christian; Somda, Serge; de Runz, Antoine; Grolleau, Jean Louis; Chaput, Benoit

2018-01-01

Currently, increasingly reconstructive surgeon consider the failure rates of perforator propeller flaps especially in the distal third of the lower leg are too important and prefer to return to the use of free flap at first line option with failure rates frequently lower than 5%. So, we performed a systematic review with meta-analysis comparing free flaps (perforator-based or not) and pedicled-propeller flaps to respond to the question "what is the safest coverage for distal third of the lower limb?" This review was conducted according to PRISMA criteria. From 1991 to 2015, MEDLINE®, Pubmed central, Embase and Cochrane Library were searched. The pooled estimations were performed by meta-analysis. The homogeneity Q statistic and the I 2 index were computed. We included 36 articles for free flaps (1,226 flaps) and 19 articles for pedicled-propeller flaps (302 flaps). The overall failure rate was 3.9% [95%CI:2.6-5.3] for free flaps and 2.77% [95%CI:0.0-5.6] for pedicled-propeller flaps (P = 0.36). The complication rates were 19.0% for free flaps and 21.4% for pedicled-propeller flaps (P = 0.37). In more detail, we noted for free flaps versus pedicled-propeller flaps: partial necrosis (2.70 vs. 6.88%, P = 0.001%), wound dehiscence (2.38 vs. 0.26%, P = 0.018), infection (4.45 vs. 1.22%, P = 0.009). The coverage failure rate was 5.24% [95%CI:3.68-6.81] versus 2.99% [95%CI:0.38-5.60] without significant difference (P = 0.016). In the lower limb the complications are not rare and many teams consider the free flaps to be safer. In this meta-analysis we provide evidence that failure and overall complications rate of perforator propeller flaps are comparable with free flaps. Although, partial necrosis is significantly higher for pedicled-propeller flaps than free flaps, in reality the success of coverage appears similar. © 2016 Wiley Periodicals, Inc. Microsurgery, 38:109-119, 2018. © 2016 Wiley Periodicals, Inc.

Investigation of Full-Scale Split Trailing-Edge Wing Flaps with Various Chords and Hinge Locations

NASA Technical Reports Server (NTRS)

Wallace, Rudolf

1936-01-01

This report gives the results of an investigation conducted in the NACA full-scale wind tunnel on a small parasol monoplane equipped with three different split trailing-edge wing flaps. The object of the investigation was to determine and correlate data on the characteristics of the airplane and flaps as affected by variation in flap chord, flap deflection, and flap location along the wing chord. The results give the lift, the drag, and the pitching moment characteristics of the airplane, and the flap forces and moments, the pressure distribution over the flaps and wing at one section, and the downwash characteristics of the flap and wing combinations.

Reconstruction of Complex Facial Defects Using Cervical Expanded Flap Prefabricated by Temporoparietal Fascia Flap.

PubMed

Zhang, Ling; Yang, Qinghua; Jiang, Haiyue; Liu, Ge; Huang, Wanlu; Dong, Weiwei

2015-09-01

Reconstruction of complex facial defects using cervical expanded flap prefabricated by temporoparietal fascia flap. Complex facial defects are required to restore not only function but also aesthetic appearance, so it is vital challenge for plastic surgeons. Skin grafts and traditional flap transfer cannot meet the reconstructive requirements of color and texture with recipient. The purpose of this sturdy is to create an expanded prefabricated temporoparietal fascia flap to repair complex facial defects. Two patients suffered severe burns on the face underwent complex facial resurfacing with prefabricated cervical flap. The vasculature of prefabricated flap, including the superficial temporal vessel and surrounding fascia, was used as the vascular carrier. The temporoparietal fascia flap was sutured underneath the cervical subcutaneous tissue, and expansion was begun in postoperative 1 week. After 4 to 6 months of expansion, the expander was removed, facial scars were excised, and cervical prefabricated flap was elevated and transferred to repair the complex facial defects. Two complex facial defects were repaired successfully by prefabricated temporoparietal fascia flap, and prefabricated flaps survived completely. On account of donor site's skin was thinner and expanded too fast, 1 expanded skin flap was rupture during expansion, but necrosis was not occurred after the 2nd operation. Venous congestion was observed in 1 patient, but after dressing, flap necrosis was not happened. Donor site was closed primarily. Postoperative follow-up 6 months, the color, texture of prefabricated flap was well-matched with facial skin. This method of expanded prefabricated flap may provide a reliable solution to the complex facial resurfacing.

Reconstruction of Large Postburn Facial-Scalp Scars by Expanded Pedicled Deltopectoral Flap and Random Scalp Flap: Technique Improvements to Enlarge the Reconstructive Territory.

PubMed

Ma, Xianjie; Li, Yang; Li, Weiyang; Liu, Chaohua; Peng, Pai; Song, Baoqiang; Xia, Wensen; Yi, Chenggang; Lu, Kaihua; Su, Yingjun

2017-09-01

The scars of face and scalp caused by burning often show as 1 large facial-scalp scar. The deltopectoral flap was recognized as one of the first choices for the facial scar reconstruction. However, this flap cannot cross the level of zygomatic arch traditionally when it was transferred with pedicle. When the flap reconstructed the facial-scalp scars with expanded random scalp flap, another flap was often needed to reconstruct the remaining temple and forehead scars. The authors reviewed 24 patients of large facial-scalp scars reconstructed by expanded pedicled deltopectoral flap and scalp flap with several technique improvements. The seaming scar between the deltopectoral flap and scalp flap in the temple region formed the new hairline. The technique improvements included ligation of the perforating branches of the transverse cervical artery and thoracoacromial artery when dissecting the pocket, the partial bolster compressive dressing to the distal part of the flap and dividing the pedicle partly as a delaying procedure before dividing the pedicle completely. Good skin compliance, normal contours, and emotional expression were noted. There were complications including expander exposure in 3 patients, stretch marks in 5 patients, flap tip necrosis in 2 patients, and mild postoperative hypertrophic scars in 3 patients. In conclusion, the expanded pedicled deltopectoral flap can enlarge the reconstructive territory in face successfully with the technique improvements. The combination of the expanded pedicled deltopectoral flap and scalp flap is a reliable and excellent reconstructive option for large postburn facial-scalp scars.

Free style perforator based propeller flaps: Simple solutions for upper extremity reconstruction!

PubMed

Panse, Nikhil; Sahasrabudhe, Parag

2014-01-01

The introduction of perforator flaps by Koshima et al. was met with much animosity in the plastic surgery fraternity. The safety concerns of these flaps following the intentional twist of the perforators have prevented widespread adoption of this technique. Use of perforator based propeller flaps in the lower extremity is gradually on the rise, but their use in upper extremity reconstruction is infrequently reported, especially in the Indian subcontinent. We present a retrospective series of 63 free style perforator flaps used for soft tissue reconstruction of the upper extremity from November 2008 to June 2013. Flaps were performed by a single surgeon for various locations and indications over the upper extremity. Patient demographics, surgical indication, defect features, complications and clinical outcome are evaluated and presented as an uncontrolled case series. 63 free style perforator based propeller flaps were used for soft tissue reconstruction of 62 patients for the upper extremity from November 2008 to June 2013. Of the 63 flaps, 31 flaps were performed for trauma, 30 for post burn sequel, and two for post snake bite defects. We encountered flap necrosis in 8 flaps, of which there was complete necrosis in 4 flaps, and partial necrosis in four flaps. Of these 8 flaps, 7 needed a secondary procedure, and one healed secondarily. Although we had a failure rate of 12-13%, most of our failures were in the early part of the series indicative of a learning curve associated with the flap. Free style perforator based propeller flaps are a reliable option for coverage of small to moderate sized defects. Therapeutic IV.

Parasacral Perforator Flaps for Reconstruction of Sacral Pressure Sores.

PubMed

Lin, Chin-Ta; Chen, Shih-Yi; Chen, Shyi-Gen; Tzeng, Yuan-Sheng; Chang, Shun-Cheng

2015-07-01

Despite advances in reconstruction techniques, pressure sores continue to present a challenge to the plastic surgeon. The parasacral perforator flap is a reliable flap that preserves the entire contralateral side as a future donor site. On the ipsilateral side, the gluteal muscle itself is preserved and all flaps based on the inferior gluteal artery are still possible. We present our experience of using parasacral perforator flaps in reconstructing sacral defects. Between August 2004 and January 2013, 19 patients with sacral defects were included in this study. All the patients had undergone surgical reconstruction of sacral defects with a parasacral perforator flap. The patients' sex, age, cause of sacral defect, flap size, flap type, numbers of perforators used, rotation angle, postoperative complications, and hospital stay were recorded. There were 19 parasacral perforator flaps in this series. All flaps survived uneventfully except for 1 parasacral perforator flap, which failed because of methicillin-resistant Staphylococcus aureus infection. The overall flap survival rate was 95% (18/19). The mean follow-up period was 17.3 months (range, 2-24 months). The average length of hospital stay was 20.7 days (range, 9-48 days). No flap surgery-related mortality was found. Also, there was no recurrence of sacral pressure sores or infected pilonidal cysts during the follow-up period. Perforator-based flaps have become popular in modern reconstructive surgery because of low donor-site morbidity and good preservation of muscle. Parasacral perforator flaps are durable and reliable in reconstructing sacral defects. We recommend the parasacral perforator flap as a good choice for reconstructing sacral defects.

Improving Pressure Ulcer Reconstruction: Our Protocol and the COP (Cone of Pressure) Flap

PubMed Central

Edstrom, Lee; Szymanski, Karen; Schmidt, Scott; Bevivino, Jack; Zienowicz, Richard; Stark, Jennifer; Taylor, Helena O.; Podda, Silvio; Liu, Paul

2017-01-01

Background: Surgical treatment of pressure ulcers is challenging for high recurrence rates. Deepithelialized flaps have been used previously with the aim to eliminate shearing forces and the cone of pressure (COP) effect. The goal of this study is to adopt a standardized protocol and evaluate if 2 different flap techniques affect outcomes. Methods: The novel COP flap is illustrated. Twenty patients were prospectively treated with flap coverage over a 36-month period. According to the flap type, patients were assigned to 2 groups: group 1 with 11 patients treated with the COP flap and group 2 with 9 patients treated with conventional flap without anchoring technique. We adopted a standardized protocol of debridement, tissue cultures, and negative-pressure wound therapy. Rotation fasciocutaneous flaps were used for both groups and mean follow-up was 19 months. The COP flap is a large deepithelialized rotation flap inset with transcutaneous nonabsorbable bolster sutures. The 2 groups were comparable for demographics and ulcer location and size (P < 0.05). Five patients showed positive cultures and were treated with antibiotics and negative-pressure therapy before surgery. Results: Recurrence rates were 12% in the COP flap group and 60% in the conventional flap coverage group (P < 0.001). Results were compared at 16-month follow-up. Conclusions: The COP flap significantly reduces recurrences and eliminates shearing forces, suture ripping, and tension on superficial soft-tissue layers. The technique can be applied to both ischial and sacral pressure sores. The flap provides padding over bony prominence without jeopardizing flap vascularity. PMID:28458961

Propeller thoracodorsal artery perforator flap for breast reconstruction.

PubMed

Angrigiani, Claudio; Rancati, Alberto; Escudero, Ezequiel; Artero, Guillermo; Gercovich, Gustavo; Deza, Ernesto Gil

2014-08-01

The thoracodorsal artery perforator (TDAP) flap has been described for breast reconstruction. This flap requires intramuscular dissection of the pedicle. A modification of the conventional TDAP surgical technique for breast reconstruction is described, utilizing instead a propeller TDAP flap. The authors present their clinical experience with the propeller TDAP flap in breast reconstruction alone or in combination with expanders or permanent implants. From January 2009 to February 2013, sixteen patients had breast reconstruction utilizing a propeller TDAP flap. Retrospective analysis of patient characteristics, clinical indications, procedure and outcomes were performed. The follow-up period ranged from 4 to 48 months. Sixteen patients had breast reconstruction using a TDAP flap with or without simultaneous insertion of an expander or implant. All flaps survived, while two cases required minimal resection due to distal flap necrosis, healing by second intention. There were not donor-site seromas, while minimal wound dehiscence was detected in two cases. The propeller TDAP flap appears to be safe and effective for breast reconstruction, resulting in minimal donor site morbidity. The use of this propeller flap emerges as a true alternative to the traditional TDAP flap.

Facial artery musculomucosal flap for reconstruction of skull base defects: a cadaveric study.

PubMed

Xie, Liyue; Lavigne, François; Rahal, Akram; Moubayed, Sami Pierre; Ayad, Tareck

2013-08-01

Failure in skull base defects reconstruction following tumor resection can have serious consequences such as ascending meningitis and pneumocephaly. The nasoseptal flap showed a very low incidence of cerebrospinal fluid leak but is not always available. The superiorly pedicled facial artery musculomucosal (FAMM) flap has been successfully used for reconstruction of head and neck defects. Our objective is to show that the FAMM flap can be used as a new alternative in skull base reconstruction. Cadaveric study. Feasibility. Thirteen specimens underwent bilateral FAMM flap dissection. Two new modifications of the traditional FAMM flap have been developed. Feasibility in FAMM flap transfer to the skull base was investigated through endoscopic skull base dissection and maxillectomy in four specimens. Measurements were recorded for each harvested flap. The mean surface area of the modified FAMM flap efficient for reconstruction was 15.90 cm(2) . The flaps easily covered the simulated defects of the frontal sinus and the fovea ethmoidalis areas. Modifications of the traditional FAMM flap were necessary for a tension-free coverage of the planum sphenoidale and sella turcica. The FAMM flap holds high potential as a new alternative vascular flap in skull base reconstruction. However, it has not been used in patients yet and should be considered only when other options are not available. New modifications developed in this article can elongate the traditional FAMM flap, potentially contributing to a tighter seal of the skull base defect than FAMM flap alone. © 2013 The American Laryngological, Rhinological and Otological Society, Inc.

Reconstruction of Anterolateral Thigh Defects Using Perforator-Based Propeller Flaps.

PubMed

Iida, Takuya; Yoshimatsu, Hidehiko; Koshima, Isao

2017-10-01

Usually, anterolateral thigh (ALT) defects with width more than 8 cm cannot be closed directly. Although several methods of using local flaps exist, flap mobility of these methods is limited. We introduced a perforator-based propeller flap for such reconstruction. Their maximal mobility, which minimizes their size, is their greatest advantage. In addition, we present our technical refinements including double-axes propeller flap, the use of indocyanine green real-time angiography, and supercharged propeller flap for safer flap transfer. Seven patients underwent perforator-based propeller flap reconstruction of ALT defects. Flaps were designed cranial or caudal to the defect according to the perforator locations. To maximize mobility, flaps were designed so that the perforator was located at the periphery and closer to the defect. After rotating the flap to the defect, indocyanine green angiography was performed to determine the need for supercharge. In all cases, all flaps survived completely. Defect size ranged from 12 × 11 cm to 18 × 16 cm, and flap size ranged from 7 × 5 cm to 15 × 7 cm. The number of perforators in the flap was 1 in 3 cases and 2 in 4 cases. Supercharging was performed in 3 cases. Donor-site complications, including gait disturbance, were not observed. This method achieves ALT defect closure with minimal donor-site morbidity and can provide prompt and aesthetically acceptable results. Indocyanine green real-time angiography and supercharging technique are also useful for safer and reliable flap transfer.

Comparison of Dorsal Intercostal Artery Perforator Propeller Flaps and Bilateral Rotation Flaps in Reconstruction of Myelomeningocele Defects.

PubMed

Tenekeci, Goktekin; Basterzi, Yavuz; Unal, Sakir; Sari, Alper; Demir, Yavuz; Bagdatoglu, Celal; Tasdelen, Bahar

2018-04-09

Bilateral rotation flaps are considered the workhorse flaps in reconstruction of myelomeningocele defects. Since the introduction of perforator flaps in the field of reconstructive surgery, perforator flaps have been used increasingly in the reconstruction of various soft tissue defects all over the body because of their appreciated advantages. The aim of this study was to compare the complications and surgical outcomes between bilateral rotation flaps and dorsal intercostal artery perforator (DICAP) flaps in the soft tissue reconstruction of myelomeningocele defects. Between January 2005-February 2017, we studied 47 patients who underwent reconstruction of myelomeningocele defects. Patient demographics, operative data, and postoperative data were reviewed retrospectively and are included in the study. We found no statistically significant differences in patient demographics and surgical complications between these two groups; this may be due to small sample size. With regard to complications-partial flap necrosis, cerebrospinal fluid (CSF) leakage, necessity for reoperation, and wound infection-DICAP propeller flaps were clinically superior to rotation flaps. Partial flap necrosis was associated with CSF leakage and wound infection, and CSF leakage was associated with wound dehiscence. Although surgical outcomes obtained with DICAP propeller flaps were clinically superior to those obtained with rotation flaps, there was no statistically significant difference between the two patient groups. A well-designed comparative study with adequate sample size is needed. Nonetheless, we suggest using DICAP propeller flaps for reconstruction of large myelomeningocele defects.

Indocyanine green laser angiography improves deep inferior epigastric perforator flap outcomes following abdominal suction lipectomy.

PubMed

Casey, William J; Connolly, Katharine A; Nanda, Alisha; Rebecca, Alanna M; Perdikis, Galen; Smith, Anthony A

2015-03-01

The reliability of deep inferior epigastric artery perforator (DIEP) flap reconstruction following abdominal liposuction is controversial. The authors' early cases were technically successful; however, they experienced high partial flap loss and fat necrosis rates. The authors sought to compare DIEP flap outcomes in the setting of prior liposuction after the use of intraoperative indocyanine green angiography compared to when flaps were assessed on clinical grounds alone. A retrospective review of a consecutive series of DIEP flaps following liposuction at a single institution was performed, comparing those evaluated on clinical grounds alone and those in which indocyanine green angiography was used intraoperatively. Outcomes measured included anastomotic complications, total flap loss, partial flap loss, fat necrosis, and postoperative abdominal wounds. Thirteen DIEP flaps following prior liposuction were performed on 11 patients from July of 2003 through January of 2014. All patients had preoperative imaging with duplex ultrasound or computed tomographic angiography to analyze perforator suitability before surgical exploration. Seven flaps were evaluated intraoperatively on clinical grounds alone. Six flaps were assessed and modified based on indocyanine green angiography. All flaps were successful; however, partial flap loss and fat necrosis rates dropped from 71.4 percent to 0 percent when indocyanine green angiography was used intraoperatively (p = 0.02). Indocyanine green angiography is an excellent vascular imaging modality for intraoperative use to assess flap perfusion, and improves outcomes in DIEP flaps when harvested after prior abdominal suction lipectomy.

The changing role of pectoralis major flap in head and neck reconstruction.

PubMed

Liu, Hin-Lun; Chan, Jimmy Yu-Wai; Wei, William Ignace

2010-11-01

Although pectoralis major flap (PM flap) has been used as the workhorse flap in head and neck reconstruction, its use in head and neck defects seems to fall out of favour in the era of free tissue transfer. The aim of this review is to find out the role of PM flap in modern head and neck surgery. Medical records of patients who underwent PM flap reconstruction for head and neck defect in our division were reviewed. The age, gender, flap type, indication and complication rate were described. Between January 1998 and December 2008, 202 PM flaps were used for head and neck reconstruction in 192 patients. In the early study period (1998-June 2003), out of the 119 PM flap reconstructions, 106 (89%) were performed for immediate reconstruction after resection of head and neck tumour, while 10 (8%) were performed as salvage procedures for complication after tumour resection e.g. failure of free flap, pharyngocutaneous fistula. In the late study period (July 2003-2008), out of the 83 PM flap reconstructions, 58 (70%) were performed for immediate reconstruction, while 24 (29%) were performed as salvage procedures. For immediate reconstruction after tumour extirpation, 51 flaps (48%) were performed for reconstruction of the tongue in the early study period, while only 14 (24%) were performed in the late study period. The number of PM flap used for immediate reconstruction for other head and neck defects remained relatively static throughout the two study periods. Over the study period, there were 10 (5%) cases of partial flap necrosis and 2 (1%) total flap loss, making the overall flap necrosis rate 6%. In the era of free tissue transfer, the role of PM flap in head and neck surgery has shifted from immediate reconstruction to salvage operation. However, PM flap still has an unique role in the repair of certain head and neck defects.

Tensor fascia lata flap versus tensor fascia lata perforator-based island flap for the coverage of extensive trochanteric pressure sores.

PubMed

Kim, Youn Hwan; Kim, Sang Wha; Kim, Jeong Tae; Kim, Chang Yeon

2013-06-01

Tensor fascia lata (TFL) musculocutaneous flaps often require a donor site graft when harvesting a large flap. However, a major drawback is that it also sacrifices the muscle. To overcome this disadvantage, we designed a TFL perforator-based island flap that was harvested from a site near the defect and involved transposition within 90 degrees without full isolation of the pedicles. We performed procedures on 17 musculocutaneous flaps and 23 perforator-based island flaps, and compared the outcomes of these surgeries. The overall complication rate was 27.5% (11 regions). There were 7 complications related to the musculocutaneous flaps and 4 complications related to the perforator flaps. Although there were no statistical differences between those groups, lower complication rates were associated with procedures involving perforator flaps. The TFL perforator procedure is a simple and fast operation that avoids sacrificing muscle. This decreases complication rates compared to true perforator flap techniques that require dissection around the perforator or pedicle.

Propeller Flap for Complex Distal Leg Reconstruction: A Versatile Alternative when Reverse Sural Artery Flap is Not Feasible.

PubMed

Ademola, Samuel A; Michael, Afieharo I; Oladeji, Femi J; Mbaya, Kefas M; Oyewole, O

2015-01-01

Reverse sural artery fasciocutaneous flap has become a workhorse for the reconstruction of distal leg soft tissue defects. When its use is not feasible, perforator-based propeller flap offers a better, easier, faster, and cheaper alternative to free flap. We present our experience with two men both aged 34 years who sustained Gustilo 3B injuries from gunshot. The donor area for reversed sural artery flap was involved in the injuries. They had early debridement, external fixation, and wound coverage with perforator-based propeller flaps. The donor sites were covered with skin graft. All flaps survived. There were minor wound edge ulcers due to the pressure of positioning that did not affect flap survival and the ulcers healed with conservative management. Perforator-based propeller flap is a versatile armamentarium for reconstruction of soft tissue defects of the distal leg in resource-constrained settings, especially when the donor area for a reverse flow sural flap artery is involved in the injury.

The Arterialized Facial Artery Musculo-Mucosal Island Flap for Post-Oncological Tongue Reconstruction.

PubMed

Moro, Alessandro; Saponaro, Gianmarco; Doneddu, Piero; Cervelli, Daniele; Pelo, Sandro; Gasparini, Giulio; Garagiola, Umberto; D'Amato, Giuseppe; Todaro, Mattia

2018-05-15

In 1992, Pribaz described the facial artery musculomucosal flap (FAMM), an axial musculomucosal flap based on the facial artery. The FAMM flap, a modification of the nasolabial and buccal mucosal flaps, is widely used in the reconstruction of defects in the oral cavity. Many modifications of this flap have been described in the literature. Here we aimed to explore the use of an arterialized tunnelized FAMM island flap (a-FAMMIF) for the reconstruction tongue defects after tumor resection. From January 2015 to December 2016, five cases of tongue cancer were selected for the use of arterialized FAMMIF flap to reconstruct defects after tumor resection. Reconstruction was successful in all cases, except one case of total flap necrosis; partial necrosis of the flap occurred in two patients, which were solved with medications. The authors consider the a-FAMMIF an unreliable flap in the reconstruction of tongue defects.The authors recommend avoiding tunneling and island modification when the vein is not included in the pedicle.

Piloted simulation study of two tilt-wing flap control concepts, phase 2

NASA Technical Reports Server (NTRS)

Birckelbaw, Lourdes G.; Corliss, Lloyd D.; Hindson, William S.; Churchill, Gary B.

1994-01-01

A two phase piloted simulation study has been conducted in the Ames Vertical Motion Simulator to investigate alternative wing and flap controls for tilt-wing aircraft. This report documents the flying qualities results and findings of the second phase of the piloted simulation study and describes the simulated tilt-wing aircraft, the flap control concepts, the experiment design and the evaluation tasks. The initial phase of the study compared the flying qualities of both a conventional programmed flap and an innovative geared flap. The second phase of the study introduced an alternate method of pilot control for the geared flap and further studied the flying qualities of the programmed flap and two geared flap configurations. In general, the pilot ratings showed little variation between the programmed flap and the geared flap control concepts. Some differences between the two control concepts were noticed and are discussed in this report. The geared flap configurations had very similar results. Although the geared flap concept has the potential to reduce or eliminate the pitch control power requirements from a tail rotor or a tail thruster at low speeds and in hover, the results did not show reduced tail thruster pitch control power usage with the geared flap configurations compared to the programmed flap configuration. The addition of pitch attitude stabilization in the second phase of simulation study greatly enhanced the aircraft flying qualities compared to the first phase.

Pedicled Temporalis Muscle Flap for Craniofacial Reconstruction: A 35-Year Clinical Experience with 366 Flaps.

PubMed

Spanio di Spilimbergo, Stefano; Nordera, Paolo; Mardini, Samir; Castiglione, Giusy; Chim, Harvey; Pinna, Vittore; Brunello, Massimo; Cusino, Claudio; Roberto, Squaquara; Baciliero, Ugo

2017-02-01

In the past 130 years, the temporalis muscle flap has been used for a variety of different indications. In this age of microsurgery and perforator flaps, the temporalis muscle flap still has many useful applications for craniofacial reconstruction. Three hundred sixty-six temporalis muscle flaps were performed in a single center between 1978 and 2012. The authors divided the cases into two series-before and after 1994-because, after 1994, they started to perform free flap reconstructions, and indications for reconstruction with a temporalis muscle flap were changed RESULTS:: In the series after 1994, flaps were most commonly used for reconstruction of defects in the maxilla, mandible, and oropharynx, in addition to facial reanimation and filling of orbital defects. Complications included total flap necrosis (1.6 percent) and partial flap necrosis (10.7 percent). The rate of material extrusion at the donor site decreased after porous polyethylene was uniformly used for reconstruction from 17.1 to 7.9 percent. The pedicled temporalis muscle flap continues to have many applications in craniofacial reconstruction. With increasing use of free flaps, the authors' indications for the pedicled temporalis muscle flap are now restricted to (1) orbital filling for congenital or acquired anophthalmia; (2) filling of unilateral maxillectomy defects; and (3) facial reanimation in selected cases of facial nerve palsy. Therapeutic, IV.

The versatile use of revisited de-epithelialization concept in superficial circumflex iliac and anterolateral thigh perforator free flap for head and neck reconstructions.

PubMed

Choi, Jong Woo; Kim, Young Chul; Oh, Tae Suk; Koh, Kyung S; Jeong, Woo Shik

2017-06-01

Although the perforator free flap is now a standard choice for head and neck reconstruction, problems such as microvascular complications, insufficient volume support for the defect, and fistula formation occur. We revisited a de-epithelialized concept for superficial circumflex iliac artery and anterolateral thigh perforator free flap to overcome these problems. We applied the de-epithelized perforator free flaps in 35 cases among 761 microsurgical head and neck reconstructions and investigated flap characteristics (length gain of pedicle, flap size, and volumetric analysis) and outcomes (flap failure, partial flap necrosis, hematoma, infection, and fistula). Satisfactory results were achieved regarding flap survival, volumetric compensation, and fistula formation. Flaps were transferred successfully in all patients, although 1 patient underwent revisional operation due to venous congestion. Transferred flap volume was significantly higher than the resected tumor volume (p < 0.01), which suggests volume augmentation in the destroyed neck envelope and a protective role against adjuvant radiation. Minor dehiscence and bleeding were seen in two cases, and no other complications were identified. The de-epithelialization concept for perforator free flap is helpful to overcome obstacles related to traditional free flaps in terms of flap survival and volumetric augmentation in head and neck reconstructions. Copyright © 2017 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.

[COMPARISON OF REPAIR EFFECT BETWEEN CHIMERIC ANTEROLATERAL THIGH FLAP AND SERIES-WOUND FLAPS FOR DEFECT AFTER RESECTION OF ORAL AND MAXILLOFACIAL CANCER].

PubMed

Yang, Heping; Zhang, Hongwu; Chen, Haidi; Yang, Shuxiong; Wang, Jun; Hu, Dawang

2016-04-01

To compare the effectiveness of complex defects repair between using chimeric anterolateral thigh flap and series-wound flaps after resection of oral and maxillofacial cancer. After resection of oral and maxillofacial cancer, defect was repaired with chimeric anterolateral thigh flap in 39 patients between January 2011 and July 2014 (chimeric anterolateral thigh flap group); and defect was repaired with series-wound flaps in 35 patients between January 2009 and December 2010 (series-wound flaps group). There was no significant difference in gender, age, duration of disease, tumor type, tumor staging, defect location, and defect area between 2 groups (P > 0.05). The operation time, flap harvesting and microvascular anastomosis time, stomach tube extraction time, and oral feeding time were recorded and compared between 2 groups, and postoperative complications were observed; the effectiveness was evaluated according to clinical efficacy evaluation table of bone and soft tissue defects reconstruction surgery in oral and maxillofacial region. Vascular crisis occurred in 2 cases of chimeric anterolateral thigh flap group, and 4 cases of series-wound flaps group. Partial necrosis appeared at distal end of a series-wound flaps, and oral fistula and infection developed in 3 series-wound flaps. The other flaps and the grafted skin at donor site survived; wounds at recipient site healed by first intention. The operation time, stomach tube extraction time, and oral feeding time of chimeric anterolateral thigh flap group were significantly shorter than those of series-wound flaps group (P < 0.05), while the flap harvesting and microvascular anastomosis time was significantly longer than that of series-wound flaps group (P < 0.05). The patients were followed up 1-5 years (mean, 2.5 years). At 3 months after operation, the appearance, patients' satisfaction, working conditions, oral closure function, chew, language performance, and swallowing scores of the chimeric anterolateral thigh-flap group were significantly better than those of the series-wound flaps group (P < 0.05), while there was no significant difference in diet, mouth opening degree, oral cavity holding water test, and occlusion scores between the 2 groups (P > 0.05). Using chimeric anterolateral thigh flap for defect repair after resection of oral and maxillofacial cancer can significantly shorten the operation time, accelerate postoperative rehabilitation, and help the functional recovery of oral closure, chewing, language performance, swallowing function when compared with the series-wound flaps.

The midline central artery forehead flap: a valid alternative to supratrochlear-based forehead flaps.

PubMed

Faris, Callum; van der Eerden, Paul; Vuyk, Hade

2015-01-01

This study clarifies the pedicle geometry and vascular supply of a midline forehead flap for nasal reconstruction. It reports on the vascular reliability of this flap and its ability to reduce hair transposition to the nose, a major complicating factor of previous forehead flap designs. To compare the vascular reliability of 3 different pedicle designs of the forehead flap in nasal reconstruction (classic paramedian, glabellar paramedian, and central artery flap design) and evaluate hair transposition rates and aesthetic results. Retrospective analysis of patient data and outcomes retrieved from computer files generated at the time of surgery, supplemented by data from the patient medical records and photographic documentation, from a tertiary referral nasal reconstructive practice, within a secondary-care hospital setting. The study population included all consecutive patients over a 19-year period who underwent primary forehead flap repair of nasal defects, with more than 3 months of postoperative follow-up and photographic documentation. Three sequential forehead flap patterns were used (classic paramedian flap, glabella flap, and central artery flap) for nasal reconstruction over the study duration. Data collected included patient characteristics, method of repair, complications, functional outcome, and patient satisfaction score. For cosmetic outcome, photographic documentation was scored by a medical juror. No forehead flap had vascular compromise in the first stage. Partial flap necrosis was reported in subsequent stages in 4 patients (1%), with no statistical difference in the rate of vascular compromise between the 3 flap designs. Hair transposition to the nose was lower in the central artery forehead flap (7%) compared with the classic paramedian (23%) and glabellar paramedian (13%) flaps (P < .05). Photographic evaluation in 227 patients showed that brow position (98%) and color match (83%) were good in the majority of the patients. In this series, the central artery forehead flap was as reliable (in terms of vascularity) as the glabellar and classic paramedian forehead flap. Its use resulted in a statistically significant reduction in transfer of hair to the nose in our series. 3.

Anomalous Putamen Volume in Children With Complex Motor Stereotypies.

PubMed

Mahone, E Mark; Crocetti, Deana; Tochen, Laura; Kline, Tina; Mostofsky, Stewart H; Singer, Harvey S

2016-12-01

Complex motor stereotypies in children are repetitive rhythmic movements that have a predictable pattern and location, seem purposeful, but serve no obvious function, tend to be prolonged, and stop with distraction, e.g., arm or hand flapping, waving. They occur in both "primary" (otherwise typically developing) and secondary conditions. These movements are best defined as habitual behaviors and therefore pathophysiologically hypothesized to reside in premotor to posterior putamen circuits. This study sought to clarify the underlying neurobiologic abnormality in children with primary complex motor stereotypies using structural neuroimaging, emphasizing brain regions hypothesized to underlie these atypical behaviors. High-resolution anatomic magnetic resonance images, acquired at 3.0 T, were analyzed in children aged eight to twelve years (20 with primary complex motor stereotypies and 20 typically developing). Frontal lobe subregions and striatal structures were delineated for analysis. Significant reductions (P = 0.045) in the stereotypies group were identified in total putamen volume but not in caudate, nucleus accumbens, or frontal subregions. There were no group differences in total cerebral volume. Findings of a smaller putamen provide preliminary evidence suggesting the potential involvement of the habitual pathway as the underlying anatomic site in primary complex motor stereotypies. Copyright © 2016 Elsevier Inc. All rights reserved.

The sensate free superior gluteal artery perforator (S-GAP) flap: a valuable alternative in autologous breast reconstruction.

PubMed

Blondeel, P N

1999-04-01

The superior and inferior myocutaneous gluteal free flaps have been considered as valuable alternatives to the latissimus dorsi or TRAM flap since 1975. The superior gluteal artery perforator (S-GAP) flap is the ultimate refinement of this myocutaneous flap as no gluteus maximus muscle is harvested. The flap is vascularised by one single perforator originating from the superior gluteal artery. This study summarises the prospectively gathered data on 20 free S-GAP flaps used for breast reconstruction in 16 patients. Immediate reconstruction was performed in six breasts and delayed in 14 breasts. Mean follow-up was 11.1 months. Two risk factors, Raynaud's disease and radiotherapy, were the cause of flap revision in two different patients. Total flap loss occurred in one case. Partial flap loss was not observed and a small area of fat necrosis was diagnosed by mammography in one other patient. All flaps were anastomosed to the internal mammary vessels at the 3rd costochondral junction. The anatomy of the sensate nerves of the S-GAP flap is described. Two nervous repairs provided early sensory recovery. The free S-GAP flap has become my personal second choice for autologous breast reconstruction after the DIEP (deep inferior epigastric perforator) flap. The S-GAP flap is indicated in patients with an asthenic body habitus or with excessive abdominal scarring. The advantages are the abundance of adipose tissue in this area even in thin patients, a long vascular pedicle, a hidden scar, improved projection of the reconstructed breast compared to the DIEP and TRAM flaps and the preservation of the entire gluteus maximus muscle. The donor morbidity is extremely low.

Perforator Propeller Flap for Oncologic Reconstruction of Soft Tissue Defects in Trunk and Extremities.

PubMed

Yu, Shengji; Zang, Mengqing; Xu, Libin; Zhao, Zhenguo; Zhang, Xinxin; Zhu, Shan; Chen, Bo; Ding, Qiang; Liu, Yuanbo

2016-10-01

Defects after soft tissue sarcoma resection are usually managed by myocutaneous flaps or free flaps. However, harvesting muscle will cause functional morbidities, and some regions lack reliable recipient vessel. Our purpose is to use various perforator propeller flaps for oncologic reconstruction. Between 2008 and 2014, 33 perforator propeller flaps were performed in 24 patients to reconstruct the defects after tumor resection in trunk and extremities. Fifteen patients underwent tumor resection previously. Thirteen patients underwent adjuvant radiotherapy or chemotherapy. Flaps based on perforators adjacent to the lesions were raised and rotated in propeller fashion to repair the defects. Twenty-seven flaps were based on perforators of known source vessels, and 6 were harvested in freestyle fashion. The defects were repaired with 2 flaps in 4 patients and 3 flaps in 2 patients. The mean skin paddle dimension was 8.36 cm in width and 20.42 cm in length. The mean degree of flap rotation was 158.79°. Complications include partial necrosis of 6 flaps in 5 cases and venous congestion of 1 flap. In these 6 patients, 3 underwent adjuvant radiotherapy. The donor sites were primarily closed in 21 patients and skin grafted in 3 patients. No functional loss related to flap harvesting was recognized. The perforator propeller flaps can be used to manage the medium defects in extremities and large defects in torso after soft tissue sarcoma resection. They avoid the sacrifice of the underlying muscle and eliminate the concerns of the unavailability of recipient vessels. The perforator propeller flaps provide flexible options for versatile oncologic reconstruction in trunk and extremities. However, the impact of radiotherapy on the viability of the flaps for local reconstruction needs further investigation.

Medial sural artery perforator flap: a challenging free flap.

PubMed

Toyserkani, Navid Mohamadpour; Sørensen, Jens Ahm

Oral and extremity defect reconstruction can often require a flap that is thin, and traditionally, the radial forearm free flap has been used, however, this has significant donor site morbidity. Over the last decade, the medial sural artery perforator (MSAP) flap has emerged as a possible alternative with lower donor site morbidity. We present our experiences and review the literature regarding this promising but challenging flap. The study was a retrospective case series in a university hospital setting. All patients who had a MSAP flap performed at our institution were included until March 2015, and their data was retrieved from electronic patient records. In total, ten patients were reconstructed with a MSAP flap for floor of mouth (eight) and lower extremity (two) defect reconstruction. The median flap dimensions were as follows: 10 cm (range 7-14 cm), width 5 cm (range 3.5-8 cm), thickness 5 mm (range 4-8 mm), and pedicle length 10 cm (range 8-12 cm). In one case, the procedure was abandoned because of very small perforators and another flap was used. In two cases, late onset of venous congestion occurred which could not be salvaged. There were no donor site complaints. The MSAP flap is an ideal flap when a thin free flap is needed with lower donor site morbidity than alternative solutions. There seems to be a higher rate of late onset of venous thrombosis compared with more established flaps. Therefore, this flap should be monitored more closely for venous problems and we recommend performing two venous anastomoses when using this flap. Level of Evidence: Level IV, therapeutic study.

Rate-determining Step of Flap Endonuclease 1 (FEN1) Reflects a Kinetic Bias against Long Flaps and Trinucleotide Repeat Sequences.

PubMed

Tarantino, Mary E; Bilotti, Katharina; Huang, Ji; Delaney, Sarah

2015-08-21

Flap endonuclease 1 (FEN1) is a structure-specific nuclease responsible for removing 5'-flaps formed during Okazaki fragment maturation and long patch base excision repair. In this work, we use rapid quench flow techniques to examine the rates of 5'-flap removal on DNA substrates of varying length and sequence. Of particular interest are flaps containing trinucleotide repeats (TNR), which have been proposed to affect FEN1 activity and cause genetic instability. We report that FEN1 processes substrates containing flaps of 30 nucleotides or fewer at comparable single-turnover rates. However, for flaps longer than 30 nucleotides, FEN1 kinetically discriminates substrates based on flap length and flap sequence. In particular, FEN1 removes flaps containing TNR sequences at a rate slower than mixed sequence flaps of the same length. Furthermore, multiple-turnover kinetic analysis reveals that the rate-determining step of FEN1 switches as a function of flap length from product release to chemistry (or a step prior to chemistry). These results provide a kinetic perspective on the role of FEN1 in DNA replication and repair and contribute to our understanding of FEN1 in mediating genetic instability of TNR sequences. © 2015 by The American Society for Biochemistry and Molecular Biology, Inc.

Pedicled Extranasal Flaps in Skull Base Reconstruction

PubMed Central

Kim, Grace G.; Hang, Anna X.; Mitchell, Candace; Zanation, Adam M.

2013-01-01

Cerebrospinal fluid (CSF) leaks most commonly arise during or after skull base surgery, although they occasionally present spontaneously. Recent advances in the repair of CSF leaks have enabled endoscopic endonasal surgery to become the preferred option for management of skull base pathology. Small defects (<1cm) can be repaired by multilayered free grafts. For large defects (>3cm), pedicled vascular flaps are the repair method of choice, resulting in much lower rates of postoperative CSF leaks. The pedicled nasoseptal flap (NSF) constitutes the primary reconstructive option for the vast majority of skull base defects. It has a large area of potential coverage and high rates of success. However, preoperative planning is required to avoid sacrificing the NSF during resection. In cases where the NSF is unavailable, often due to tumor involvement of the septum or previous resection removing or compromising the flap, other flaps may be considered. These flaps include intranasal options—inferior turbinate (IT) or middle turbinate (MT) flaps—as well as regional pedicled flaps: pericranial flap (PCF), temporoparietal fascial flap (TPFF), or palatal flap (PF). More recently, novel alternatives such as the pedicled facial buccinator flap (FAB) and the pedicled occipital galeopericranial flap (OGP) have been added to the arsenal of options for skull base reconstruction. Characteristics of and appropriate uses for each flap are described. PMID:23257554

Investigation of leading-edge flap performance on delta and double-delta wings at supersonic speeds

NASA Technical Reports Server (NTRS)

Covell, Peter F.; Wood, Richard M.; Miller, David S.

1987-01-01

An investigation of the aerodynamic performance of leading-edge flaps on three clipped delta and three clipped double-delta wing planforms with aspect ratios of 1.75, 2.11, and 2.50 was conducted in the Langley Unitary Plan Wind Tunnel at Mach numbers of 1.60, 1.90, and 2.16. A primary set of fullspan leading-edge flaps with similar root and tip chords were investigated on each wing, and several alternate flap planforms were investigated on the aspect-ratio-1.75 wings. All leading-edge flap geometries were effective in reducing the drag at lifting conditions over the range of wing aspect ratios and Mach numbers tested. Application of a primary flap resulted in better flap performance with the double-delta planform than with the delta planform. The primary flap geometry generally yielded better performance than the alternate flap geometries tested. Trim drag due to flap-induced pitching moments was found to reduce the leading-edge flap performance more for the delta planform than for the double-delta planform. Flow-visualization techniques showed that leading-edge flap deflection reduces crossflow shock-induced separation effects. Finally, it was found that modified linear theory consistently predicts only the effects of leading-edge flap deflection as related to pitching moment and lift trends.

Mandibular reconstruction in irradiated patients utilizing myosseous-cutaneous flaps

DOE Office of Scientific and Technical Information (OSTI.GOV)

Pearlman, N.W.; Albin, R.E.; O'Donnell, R.S.

1983-10-01

Myosseous-cutaneous flaps were used for mandibular reconstruction in 16 irradiated patients. Three of six sternomastoid-clavicle flaps failed (all in conjunction with a neck dissection), as did one of 10 pectoralis major-anterior-fifth rib flaps. One trapezius-scapular flap was used and it succeeded. We found the blood supply of the sternomastoid-clavicle flap too tenuous for use in conjunction with a neck dissection. The trapezius-scapular flap had too short an arc of rotation to be used for defects other than those in the horizontal ramus. In addition, this flap required a change of position and created an undesirable functional deformity. The pectoralis major-fifthmore » rib flap, in contrast, could be used for a variety of defects, in conjunction with a neck dissection, and did not require a change of position during operation. We found it to be the most versatile and dependable of the flaps employed in this series.« less

A lining vomer flap for palate pushback in unilateral cleft palate repair.

PubMed

Clavin, H D; Owsley, J Q

1978-01-01

A combinaation vomer mucoperiosteal flap and nasal floor mucoperiosteal flap is described which is used to achieve nasal coverage in unilateral cleft palate patients requiring pushbacks. A posteriorly based readily accessible vomer flap is raised on the cleft side and used as nasal lining for the palatal mucoperiosteal flap on the non-cleft side. On the cleft side, a symmetrically sized nasal floor flap is easily elevated under direct vision and used to cover the nasal aspect of the corresponding mucoperiosteal palatal flap.

The role of postoperative hematoma on free flap compromise.

PubMed

Ahmad, Faisal I; Gerecci, Deniz; Gonzalez, Javier D; Peck, Jessica J; Wax, Mark K

2015-08-01

Hematomas may develop in the postoperative setting after free tissue transfer. When hematomas occur, they can exert pressure on surrounding tissues. Their effect on the vascular pedicle of a free flap is unknown. We describe our incidence of hematoma in free flaps and outcomes when the flap is compromised. Retrospective chart review of 1,883 free flaps performed between July 1998 and June 2014 at a tertiary referral center. Patients with free flap compromise due to hematoma were identified. Etiology, demographic data, and outcomes were evaluated. Eighty-eight (4.7%) patients developed hematomas. Twenty (22.7%) of those had flap compromise. Twelve compromises (60%) showed evidence of pedicle thrombosis. The salvage rate was 75% versus 54% in 79 flaps with compromise from other causes (P = .12). Mean time to detection of the hematoma was 35.3 hours in salvaged flaps compared to 91.6 hours in unsalvageable flaps (P = .057). Time to operating room (OR) from detection was 2.8 hours in salvageable flaps compared to 12.4 hours in nonsalvageable flaps (P = .053). The salvage rate for flaps that returned to the OR in <5 hours was 93.3% compared to 20% (P = .0049) for those that did not. Vascular thrombosis reduced salvage rate to 58.3% from 100% (P = .002) when there was no thrombosis. In our series hematomas developed rarely. When they did, 23% went on to develop flap compromise. Prompt recognition and re-exploration allowed for a high salvage rate. Vessel thrombosis predicted inability to salvage the flap. 4 © 2015 The American Laryngological, Rhinological and Otological Society, Inc.

The trapezius perforator flap: an underused but versatile option in the reconstruction of local and distant soft-tissue defects.

PubMed

Sadigh, Parviz L; Chang, Li-Ren; Hsieh, Ching-Hua; Feng, Wen-Jui; Jeng, Seng-Feng

2014-09-01

The trapezius myocutaneous flap is an established reconstructive option in head and neck cases The authors present their experience with 10 trapezius perforator flaps, all raised using a freestyle technique of perforator dissection, to successfully reconstruct both local and distant soft-tissue defects. Ten patients underwent soft-tissue reconstruction using trapezius perforator flaps. After mapping the perforator with a handheld Doppler device at the intersection of a horizontal line drawn 6 to 8 cm inferior to the scapular spine and a vertical line drawn 8 to 9 cm lateral to the midline of the back, perforator flaps were raised in a freestyle fashion, with complete preservation of the trapezius muscle. The flap can be pedicled into local defects or transferred as a free flap. Six flaps were elevated as pedicled flaps and four were transferred as free flaps. Flap size ranged from 6 × 4 cm to 25 × 15 cm. The pedicle length ranged from 4 to 14 cm. The pedicle originated from the dorsal scapular artery. In one case, the authors converted from a pedicled flap to a free flap secondary to insufficient pedicle length. All donor sites were closed directly. The follow-up period ranged from 4 months to 4 years. All of the flaps survived completely with no major complications, and no patients developed any shoulder dysfunction. The trapezius perforator flap is a reliable and versatile reconstructive option that can be used to repair both local and distant soft-tissue defects. The donor-site morbidity is minimal. Therapeutic, IV.

Comparison of gluteal perforator flaps and gluteal fasciocutaneous rotation flaps for reconstruction of sacral pressure sores.

PubMed

Chen, Yen-Chou; Huang, Eng-Yen; Lin, Pao-Yuan

2014-03-01

The gluteus maximus myocutaneous flap was considered the workhorse that reconstructed sacral pressure sores, but was gradually replaced by fasciocutaneous flap because of several disadvantages. With the advent of the perforator flap technique, gluteal perforator (GP) flap has gained popularity nowadays. The aim of this study was to compare the complications and outcomes between GP flaps and gluteal fasciocutaneous rotation (FR) flaps in the treatment of sacral pressure sores. Between April 2007 and June 2012, 63 patients underwent sacral pressure sore reconstructions, with a GP flap used in 31 cases and an FR flap used in 32 cases. Data collected on the patients included patient age, gender, co-morbidity for being bedridden and follow-up time. Surgical details collected included the defect size, operative time and estimated blood loss. Complications recorded included re-operation, dehiscence, flap necrosis, wound infection, sinus formation, donor-site morbidity and recurrence. The complications and clinical outcomes were compared between these two groups. We found that there was no significant difference in patient demographics, surgical complications and recurrence between these two groups. In gluteal FR flap group, all recurrent cases (five) were treated by reuse of previous flaps. Both methods are comparable, good and safe in treating sacral pressure sores. Gluteal FR flap can be performed without microsurgical dissection, and re-rotation is feasible in recurrent cases. The authors suggest using gluteal FR flaps in patients with a high risk of sore recurrence. Copyright © 2013 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

Pectoralis Major Musculocutaneous Flap With a Midline Sternal Skin Paddle for Head and Neck Reconstruction: A New Design.

PubMed

Oh, Jeongseok; Ahn, Hee Chang; Youn, Seungki; Tae, Kyung

2018-05-14

The pectoralis major musculocutaneous (PMMC) flap is a classic flap for head and neck reconstruction, relatively unpopular with the advancement of microsurgery and free flaps. The classic parasternal paddle design provided a thick flap with a small rotation arch leaving objectionable scarring. Our new symmetric midsternal design overcomes these problems. Chart review was done from the years 2000 to 2017. Flap skin paddle was placed symmetrically on both sides of the midsternal line. The pectoralis major (PM) muscle and aponeurosis were attached in the lateral half of the skin paddle. Most of PM muscle was elevated with the thoracoacromial vessel and dissected to the main trunk, where the PM muscle was cut and used for bulk. The flap was transferred to the neck and lower mandibular area. The flap was inset either supraclavicularly, covering the anterior neck, or subclavicularly, for intraoral/maxillary defects. Eight patients underwent head and neck reconstruction using the new design of PMMC flap between the years 2000 and 2017. The etiologies of the defect were radiation necrosis in 3 patients, repair of cutaneous fistulas in 3, recurrent hypopharyngeal cancer in 1, and recurrent tongue cancer in 1 patient. There were no flap losses or major complications. With the advancement of free-flap techniques, the classic flaps have become less popular. Our new design supplements the PMMC flap by providing a thin pliable flap with a long pedicle and rotation arc, allowing a combination of different types of flaps to cover composite head and neck defects, especially in cases that lack a reliable recipient vessel due to radiation.

Free Flap Reconstruction Monitoring Techniques and Frequency in the Era of Restricted Resident Work Hours.

PubMed

Patel, Urjeet A; Hernandez, David; Shnayder, Yelizaveta; Wax, Mark K; Hanasono, Matthew M; Hornig, Joshua; Ghanem, Tamer A; Old, Matthew; Jackson, Ryan S; Ledgerwood, Levi G; Pipkorn, Patrik; Lin, Lawrence; Ong, Adrian; Greene, Joshua B; Bekeny, James; Yiu, Yin; Noureldine, Salem; Li, David X; Fontanarosa, Joel; Greenbaum, Evan; Richmon, Jeremy D

2017-08-01

Free flap reconstruction of the head and neck is routinely performed with success rates around 94% to 99% at most institutions. Despite experience and meticulous technique, there is a small but recognized risk of partial or total flap loss in the postoperative setting. Historically, most microvascular surgeons involve resident house staff in flap monitoring protocols, and programs relied heavily on in-house resident physicians to assure timely intervention for compromised flaps. In 2003, the Accreditation Council for Graduate Medical Education mandated the reduction in the hours a resident could work within a given week. At many institutions this new era of restricted resident duty hours reshaped the protocols used for flap monitoring to adapt to a system with reduced resident labor. To characterize various techniques and frequencies of free flap monitoring by nurses and resident physicians; and to determine if adapted resident monitoring frequency is associated with flap compromise and outcome. This multi-institutional retrospective review included patients undergoing free flap reconstruction to the head and/or neck between January 2005 and January 2015. Consecutive patients were included from different academic institutions or tertiary referral centers to reflect evolving practices. Technique, frequency, and personnel for flap monitoring; flap complications; and flap success. Overall, 1085 patients (343 women [32%] and 742 men [78%]) from 9 institutions were included. Most patients were placed in the intensive care unit postoperatively (n = 790 [73%]), while the remaining were placed in intermediate care (n = 201 [19%]) or in the surgical ward (n = 94 [7%]). Nurses monitored flaps every hour (q1h) for all patients. Frequency of resident monitoring varied, with 635 patients monitored every 4 hours (q4h), 146 monitored every 8 hours (q8h), and 304 monitored every 12 hours (q12h). Monitoring techniques included physical examination (n = 949 [87%]), handheld external Doppler sonography (n = 739 [68%]), implanted Doppler sonography (n = 333 [31%]), and needle stick (n = 349 [32%]); 105 patients (10%) demonstrated flap compromise, prompting return to the operating room in 96 patients. Of these 96 patients, 46 had complete flap salvage, 22 had partial loss, and 37 had complete loss. The frequency of resident flap checks did not affect the total flap loss rate (q4h, 25 patients [4%]; q8h, 8 patients [6%]; and q12h, 8 patients [3%]). Flap salvage rates for compromised flaps were not statistically different. Academic centers rely primarily on q1h flap checks by intensive care unit nurses using physical examination and Doppler sonography. Reduced resident monitoring frequency did not alter flap salvage nor flap outcome. These findings suggest that institutions may successfully monitor free flaps with decreased resident burden.

Influence of two different flap designs on the sequelae of mandibular third molar surgery.

PubMed

Erdogan, Ozgür; Tatlı, Ufuk; Ustün, Yakup; Damlar, Ibrahim

2011-09-01

The aim of this study was to compare the influence of triangular and envelope flaps on trismus, pain, and facial swelling after mandibular third molar surgery. Twenty healthy patients with bilateral, symmetrically impacted mandibular third molars were included in this double-blinded, prospective, cross-over, randomized study. The patients were operated with envelope flap on one side and triangular flap on the other side. Trismus was determined by measuring maximum interincisal opening, and facial swelling was evaluated using a tape measuring method. Pain was determined using visual analog scale (VAS) and recording the number of pain pills taken. The facial swelling measurements and VAS scores were lower in the envelope flap group compared to the triangular flap group. There was no significant difference between the two flap designs in operation time, maximum interincisal opening, and the number of analgesics taken. Envelope flap yields to less facial swelling and reduced VAS scores in comparison to triangular flap. There is no clinical difference in trismus between the two flap designs. Despite the higher VAS scores with triangular flap, no additional doses of analgesics were required in triangular flap.

Effect of topically applied minoxidil on the survival of rat dorsal skin flap.

PubMed

Gümüş, Nazım; Odemiş, Yusuf; Yılmaz, Sarper; Tuncer, Ersin

2012-12-01

Flap necrosis still is a challenging problem in reconstructive surgery that results in irreversible tissue loss. This study evaluated the effect of topically applied minoxidil on angiogenesis and survival of a caudally based dorsal rat skin flap. For this study, 24 male Wistar rats were randomly divided into three groups of eight each. A caudally based dorsal skin flap with the dimensions of 9 × 3 cm was raised. After elevation of the flaps, they were sutured back into their initial positions. In group 1 (control group), 1 ml of isotonic saline was applied topically to the flaps of all the animals for 14 days. In group 2, minoxidil solution was spread uniformly over the flap surface for 7 days after the flap elevation. In group 3, minoxidil solution was applied topically to the flap surface during a 14-day period. On day 7 after the flap elevation, the rats were killed. The average area of flap survival was determined for each rat. Subdermal vascular architecture and angiogenesis were evaluated under a light microscope after two full-thickness skin biopsy specimens had been obtained from the midline of the flaps. The lowest flap survival rate was observed in group 1, and no difference was observed between groups 1 and 2. Compared with groups 1 and 2, group 3 had a significantly increased percentage of flap survival (P < 0.05). Intense and moderate angiogenesis also was observed respectively at the proximal and distal areas of the flaps in group 3. The results of this experiment seem to show that the early effect of minoxidil is vasodilation and that prolonged use before flap elevation leads to angiogenesis, increasing flap viability. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

An experimental study of pressures on 60 deg Delta wings with leading edge vortex flaps

NASA Technical Reports Server (NTRS)

Marchman, J. F., III; Terry, J. E.; Donatelli, D. A.

1983-01-01

An experimental study was conducted in the Virginia Tech Stability Wind Tunnel to determine surface pressures over a 60 deg sweep delta wing with three vortex flap designs. Extensive pressure data was collected to provide a base data set for comparison with computational design codes and to allow a better understanding of the flow over vortex flaps. The results indicated that vortex flaps can be designed which will contain the leading edge vortex with no spillage onto the wing upper surface. However, the tests also showed that flaps designed without accounting for flap thickness will not be optimum and the result can be oversized flaps, early flap vortex reattachment and a second separation and vortex at the wing/flap hinge line.

Ectopic banking of amputated great toe for delayed thumb reconstruction: case report.

PubMed

Valerio, Ian L; Hui-Chou, Helen G; Zelken, Jonathan; Basile, Patrick L; Ipsen, Derek; Higgins, James P

2014-07-01

Ectopic banking of amputated parts is a recognized technique for delayed replantation of an amputated part when the amputation stump will not permit immediate replantation. This is conventionally performed with the intent of transferring the injured part back to its anatomic position when the amputation stump is more appropriate for replantation. Current warfare conditions have led to a commonly encountered military trauma injury pattern of multiple extremity amputations with protected trunk and core structures. This pattern poses many challenges, including the limit or absence of donor sites for immediate or delayed flap reconstructive procedures. We describe a case in which we ectopically banked the great toe of an amputated lower extremity for delayed thumb reconstruction. Copyright © 2014 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.

Risk factors for pedicled flap necrosis in hand soft tissue reconstruction: a multivariate logistic regression analysis.

PubMed

Gong, Xu; Cui, Jianli; Jiang, Ziping; Lu, Laijin; Li, Xiucun

2018-03-01

Few clinical retrospective studies have reported the risk factors of pedicled flap necrosis in hand soft tissue reconstruction. The aim of this study was to identify non-technical risk factors associated with pedicled flap perioperative necrosis in hand soft tissue reconstruction via a multivariate logistic regression analysis. For patients with hand soft tissue reconstruction, we carefully reviewed hospital records and identified 163 patients who met the inclusion criteria. The characteristics of these patients, flap transfer procedures and postoperative complications were recorded. Eleven predictors were identified. The correlations between pedicled flap necrosis and risk factors were analysed using a logistic regression model. Of 163 skin flaps, 125 flaps survived completely without any complications. The pedicled flap necrosis rate in hands was 11.04%, which included partial flap necrosis (7.36%) and total flap necrosis (3.68%). Soft tissue defects in fingers were noted in 68.10% of all cases. The logistic regression analysis indicated that the soft tissue defect site (P = 0.046, odds ratio (OR) = 0.079, confidence interval (CI) (0.006, 0.959)), flap size (P = 0.020, OR = 1.024, CI (1.004, 1.045)) and postoperative wound infection (P < 0.001, OR = 17.407, CI (3.821, 79.303)) were statistically significant risk factors for pedicled flap necrosis of the hand. Soft tissue defect site, flap size and postoperative wound infection were risk factors associated with pedicled flap necrosis in hand soft tissue defect reconstruction. © 2017 Royal Australasian College of Surgeons.

Navier-Stokes Computations of a Wing-Flap Model With Blowing Normal to the Flap Surface

NASA Technical Reports Server (NTRS)

Boyd, D. Douglas, Jr.

2005-01-01

A computational study of a generic wing with a half span flap shows the mean flow effects of several blown flap configurations. The effort compares and contrasts the thin-layer, Reynolds averaged, Navier-Stokes solutions of a baseline wing-flap configuration with configurations that have blowing normal to the flap surface through small slits near the flap side edge. Vorticity contours reveal a dual vortex structure at the flap side edge for all cases. The dual vortex merges into a single vortex at approximately the mid-flap chord location. Upper surface blowing reduces the strength of the merged vortex and moves the vortex away from the upper edge. Lower surface blowing thickens the lower shear layer and weakens the merged vortex, but not as much as upper surface blowing. Side surface blowing forces the lower surface vortex farther outboard of the flap edge by effectively increasing the aerodynamic span of the flap. It is seen that there is no global aerodynamic penalty or benefit from the particular blowing configurations examined.

The radix nasi island flap: a versatile musculocutaneous flap for defects of the eyelids, nose, and malar region.

PubMed

Seyhan, Tamer

2009-03-01

A versatile musculocutan flap from the radix nasi region, the radix nasi island flap, is described. The flap has an axial blood supply derived from the dorsal nasal branch of the ophthalmic artery which is anastomosed to the terminal branch of the facial artery. The flap includes the skin, subcutaneous tissue, and procerus muscle. Ten patients, aged 50 to 86 years, have been reconstructed with this flap for defects in the nose (in 4 cases), midface (in 4 cases) and lower eyelids (in 2 cases). The mean flap size was 17 x 23 mm (range: 15 x 20 to 20 x 27 mm). All flaps fully survived. Additional complications and morbidity were not observed. The donor sites were closed a primarily closure in all cases. Follow-up ranged from 3 to 12 months (mean: 8.2 months). The radix nasi flap is a safe flap, has minimal donor site morbidity, and is especially suited for nasal and midface reconstruction in terms of attaining a suitable color and thickness.

Reconstruction of lower face defect or deformity with submental artery perforator flaps.

PubMed

Shi, Cheng-li; Wang, Xian-cheng

2012-07-01

Reconstruction of lower face defects or deformity often presents as a challenge for plastic surgeons. Many methods, including skin graft, tissue expander, or free flap are introduced. Submental artery perforator flaps have been used in the reconstruction of defects or deformities of the lower face. Between August 2006 and December 2008, 22 patients with lower face defects or deformity underwent reconstruction with pedicled submental artery perforator flaps. Their age ranged between 14 and 36 years. The perforator arteries were detected and labeled with a hand-held Doppler flowmeter. The size of flaps ranged from 4 × 6 to 6 × 7 cm, and the designed flaps included the perforator artery. All the flaps survived well, except 1 flap which resulted in partial necrosis in distal region and healed after conservative therapy. No other complication occurred with satisfactory aesthetic appearance of the donor site. The submental artery perforator flap is a thin and reliable flap with robust blood supply. This flap can reduce donor-site morbidity significantly and is a good choice for reconstructive surgery of lower face.

Reliability of real-time ultrasound for the assessment of transversus abdominis function.

PubMed

Kidd, Adrian W; Magee, Scott; Richardson, Carolyn A

2002-07-01

Transversus abdominis (TrA) has now been established as a key muscle for the stabilization of the lumbar spine and sacroiliac joints. Significantly, dysfunction of this muscle has also been implicated in low back pain. Real-time ultrasound (US) is a non-invasive procedure that has the potential to evaluate objectively the function of TrA. To investigate M-mode US as a reliable method of assessing TrA function. M-mode US was used to measure the width of TrA as subjects drew in their lower abdominal wall at a controlled speed to a target depth. Eleven subjects were imaged. the measures of TrA width were reliable and ranged between 3.14mm relaxed and 6.35mm contracted. The standard error of measurement ranged between 0.18mm and 0.57mm. M-mode US provides a reliable non-invasive measure of a controlled contraction of TrA.

Aerodynamic characteristics of a wing with Fowler flaps including flap loads, downwash, and calculated effect on take-off

NASA Technical Reports Server (NTRS)

Platt, Robert C

1936-01-01

This report presents the results of wind tunnel tests of a wing in combination with each of three sizes of Fowler flap. The purpose of the investigation was to determine the aerodynamic characteristics as affected by flap chord and position, the air loads on the flaps, and the effect of flaps on the downwash.

Face resurfacing using a cervicothoracic skin flap prefabricated by lateral thigh fascial flap and tissue expander.

PubMed

Li, Qingfeng; Zan, Tao; Gu, Bin; Liu, Kai; Shen, Guoxiong; Xie, Yun; Weng, Rui

2009-01-01

Resurfacing of facial massive soft tissue defect is a formidable challenge because of the unique character of the region and the limitation of well-matched donor site. In this report, we introduce a technique for using the prefabricated cervicothoracic skin flap for facial resurfacing, in an attempt to meet the principle of flap selection in face reconstructive surgery for matching the color and texture, large dimension, and thinner thickness (MLT) of the recipient. Eleven patients with massive facial scars underwent resurfacing procedures with prefabricated cervicothoracic flaps. The vasculature of the lateral thigh fascial flap, including the descending branch of the lateral femoral circumflex vessels and the surrounding muscle fascia, was used as the vascular carrier, and the pedicles of the fascial flap were anastomosed to either the superior thyroid or facial vessels in flap prefabrication. A tissue expander was placed beneath the fascial flap to enlarge the size and reduce the thickness of the flap. The average size of the harvested fascia flap was 6.5 x 11.7 cm. After a mean interval of 21.5 weeks, the expanders were filled to a mean volume of 1,685 ml. The sizes of the prefabricated skin flaps ranged from 12 x 15 cm to 15 x 32 cm. The prefabricated skin flaps were then transferred to the recipient site as pedicled flaps for facial resurfacing. All facial soft tissue defects were successfully covered by the flaps. The donor sites were primarily closed and healed without complications. Although varied degrees of venous congestion were developed after flap transfers, the marginal necrosis only occurred in two cases. The results in follow-up showed most resurfaced faces restored natural contour and regained emotional expression. MLT is the principle for flap selection in resurfacing of the massive facial soft tissue defect. Our experience in this series of patients demonstrated that the prefabricated cervicothoracic skin flap could be a reliable alternative tool for resurfacing of massive facial soft tissue defects. (c) 2009 Wiley-Liss, Inc. Microsurgery, 2009.

Application of multidetector-row computed tomography in propeller flap planning.

PubMed

Ono, Shimpei; Chung, Kevin C; Hayashi, Hiromitsu; Ogawa, Rei; Takami, Yoshihiro; Hyakusoku, Hiko

2011-02-01

The propeller flap is defined as (1) being island-shaped, (2) having an axis that includes the perforators, and (3) having the ability to be rotated around an axis. The advantage of the propeller flap is that it is a pedicle flap that can be applied to cover defects located at the distal ends of the extremities. The specific aims of the authors' study were (1) to evaluate the usefulness of multidetector-row computed tomography in the planning of propeller flaps and (2) to present a clinical case series of propeller flap reconstructions that were planned preoperatively using multidetector-row computed tomography. The authors retrospectively analyzed all cases between April of 2007 and April of 2010 at Nippon Medical School Hospital in Tokyo, where multidetector-row computed tomography was used preoperatively to plan surgical reconstructions using propeller flaps. Thirteen patients underwent 16 flaps using the propeller flap technique. The perforators were identified accurately by multidetector-row computed tomography preoperatively in all cases. This is the first report describing the application of multidetector-row computed tomography in the planning of propeller flaps. Multidetector-row computed tomography is superior to other imaging methods because it demonstrates more precisely the perforator's position and subcutaneous course using high-resolution three-dimensional images. By using multidetector-row computed tomography to preoperatively identify a flap's perforators, the surgeon can better plan the flap design to efficiently conduct the flap surgery.

Comparison of fasciocutaneous V-Y and rotational flaps for defect coverage of sacral pressure sores: a critical single-centre appraisal.

PubMed

Djedovic, Gabriel; Metzler, Julia; Morandi, Evi M; Wachter, Tanja; Kühn, Shafreena; Pierer, Gerhard; Rieger, Ulrich M

2017-12-01

Pressure sore rates remain high in both nursing homes as well as in hospitals. Numerous surgical options are available for defect coverage in the sacral region. However, objective data is scarce as to whether a specific flap design is superior to another. Here, we aim to compare two fasciocutaneous flap designs for sacral defect coverage: the gluteal rotation flap and the gluteal V-Y flap. All primary sacral pressure sores of grades III-IV that were being covered with gluteal fasciocutaneous rotational or V-Y flaps between January 2008 and December 2014 at our institution were analysed. A total of 41 patients received a total of 52 flaps. Of these, 18 patients received 20 gluteal rotational flaps, and 23 patients received 32 V-Y flaps. Both groups were comparable with regards to demographics, comorbidities and complications. Significantly more V-Y flaps were needed to cover smaller defects. Mean length of hospital stay was significantly prolonged when surgical revision had to be carried out. Both flap designs have proven safe and reliable for defect coverage after sacral pressure sores. Gluteal rotational flaps appear to be more useful for larger defects. Both flap designs facilitate their reuse in case of pressure sore recurrence. Complication rates appear to be comparable in both designs and to the current literature. © 2017 Medicalhelplines.com Inc and John Wiley & Sons Ltd.

Continuous-infusion local anesthetic pain pump use and seroma formation with abdominal procedures: is there a correlation?

PubMed

Smith, Melissa M; Hovsepian, Raffi V; Markarian, Mark K; Degelia, Amber L; Paul, Malcolm D; Evans, Gregory R D; Wirth, Garrett A

2008-11-01

Seroma formation is the most commonly occurring complication in plastic surgery abdominal procedures. Continuous local anesthetic pain pump delivery systems are often used to decrease postoperative pain. An unreported concern with use of these devices in abdominal procedures is the effect of continuous fluid infiltration of the surgical site and a possible increase in the incidence of seroma formation. The authors performed a retrospective chart review to evaluate all patients (n = 159) who underwent abdominal procedures (abdominoplasty, panniculectomy, and transverse rectus abdominis myocutaneous flap harvest) over a 3-year period. Patient charts were evaluated for sex, age, body mass index, procedure performed, surgeon, operation length, pain pump use, postoperative seroma formation, and any complications. In cases with pain pump use, catheter placement location, anesthetic medication and strength, continuous-infusion rate, and duration of pain pump use were also reviewed. If a postoperative seroma formation was identified, treatment and outcomes were also recorded. The overall seroma formation rate was 11.3 percent (18 of 159 patients). Other complications occurred at a rate of 2.5 percent (four of 159). The incidence of seroma was 11.0 percent (11 of 100) in patients with pain pump use versus 11.9 percent (7 of 59) in those who did not use a pain pump. There was no statistically significant difference (p = 0.9) in the incidence of seroma formation between those who did and did not use a pain pump device. There was no correlation between increased rate of seroma formation and use of a continuous-infusion local anesthetic pain pump system in our patient population.

Glove box shield

DOEpatents

Brackenbush, L.W.; Hoenes, G.R.

A shield for a glove box housing radioactive material is comprised of spaced apart clamping members which maintain three overlapping flaps in place therebetween. There is a central flap and two side flaps, the side flaps overlapping at the interior edges thereof and the central flap extending past the intersection of the side flaps in order to insure that the shield is always closed when the user wthdraws his hand from the glove box. Lead loaded neoprene rubber is the preferred material for the three flaps, the extent of lead loading depending upon the radiation levels within the glove box.

Magnitude of Myocutaneous Flaps and Factors Associated With Loss of Volume in Oral Cancer Reconstructive Surgery.

PubMed

Sakamoto, Yuki; Yanamoto, Souichi; Ota, Yoshihide; Furudoi, Shungo; Komori, Takahide; Umeda, Masahiro

2016-03-01

Myocutaneous flaps are often used to repair oral and maxillofacial defects after surgery for oral cancer; however, their volume decreases during the postoperative period. To facilitate treatment planning, the authors measured the extent of such postoperative flap volume loss and identified associated factors in patients who underwent oral reconstruction with myocutaneous flaps. The authors designed and performed a retrospective observational study of patients who underwent reconstructive procedures involving rectus abdominal myocutaneous (RAM) or pectoralis major myocutaneous (PMMC) flaps at Tokai University Hospital, Kobe University Hospital, or Nagasaki University Hospital from April 2009 through March 2013. Flap type and other clinical variables were examined as potential predictors of flap loss. The primary outcome was flap loss at 6 months postoperatively. Correlations between each potential predictor and the primary outcome were examined using multiple regression analysis. The subjects were 75 patients whose oral defects were reconstructed with RAM flaps (n = 57) or PMMC flaps (n = 18). RAM flaps exhibited a mean volume shrinkage of 22% at 6 months postoperatively, which was less than the 27.5% displayed by the PMMC flaps, but the difference was not important. Renal failure, previous surgery of the oral region, postoperative radiotherapy, and postoperative serum albumin level were found to be meaningful risk factors for postoperative flap volume loss. The results of this study suggest that larger flaps should be used in patients who possess these risk factors or are scheduled to undergo postoperative radiotherapy. Future studies should examine the utility of postoperative nutritional management for preventing flap volume loss. Copyright © 2016 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.

[Management of vascular crisis of free flaps after reconstruction of head and neck defects caused by tumor resection].

PubMed

Ni, Song; Zhu, Yiming; Li, Dezhi; Liu, Jie; An, Changming; Zhang, Bin; Liu, Shaoyan

2015-11-01

To discuss the management of vascular crisis of free flaps after reconstruction of head and neck defects caused by tumor resection. A total of 259 cases of free flap reconstruction performed in the Cancer Hospital of Chinese Academy of Medical Sciences from 2010 to 2013 were retrospectively analyzed, including 89 cases of anterolateral thigh flaps, 48 cases of radial forearm flaps, 46 free fibula flaps, 5 cases of inferior epigastric artery perforator flaps, 5 cases of free latissimus dorsi flaps, one case of lateral arm flap, and one case of medial femoral flap. The surveillance frequency of free flaps was q1h on post-operative day (POD) 1, q2h on POD 2 and 3, and q4h after POD 3. Vascular crises were reviewed for analysis. The incidence rate of vascular crisis was 8.1% (21/259), with 15 males and 6 females. The average age was 54.8 years old (17-68), and the average time of vascular crisis was 100.8 h post-operation (3-432). There were 7 cases of free jejunum flaps and 14 dermal free flaps. Seven of these 21 cases with vascular crisis were rescued by surgery. The success rate of salvage surgery within 72 hours from the primary operation was 54.5% (6/11), significantly higher than that of salvage surgery performed later than 72 hours from primary operation (10.0%, 1/10, P=0.043). There were 14 cases of flap necrosis, two of which died of local infection. Early detection of vascular crisis can effectively improve the success rate of salvage, so as to avoid the serious consequences caused by free flap necrosis.

Development of Bird-like Micro Aerial Vehicle with Flapping and Feathering Wing Motions

NASA Astrophysics Data System (ADS)

Maglasang, Jonathan; Goto, Norihiro; Isogai, Koji

To investigate the feasibility of a highly efficient flapping system capable of avian maneuvers, such as rapid takeoff, hover and gliding, a full scale bird-like (ornithopter) flapping-wing micro aerial vehicle (MAV) shaped and patterned after a typical pigeon (Columba livia) has been designed and constructed. Both numerical and experimental methods have been used in the development of this vehicle. This flapping-wing micro aerial vehicle utilizes both the flapping and feathering motions of an avian wing by employing a novel flapping-feathering mechanism, which has been synthesized and constructed so as to best describe the properly coordinated flapping and feathering wing motions at phase angle difference of 90° in a horizontal steady level flight condition. This design allows high flapping and feathering amplitudes and is configurable for asymmetric wing motions which are desirable in high-speed flapping flight and maneuvering. The preliminary results indicate its viability as a practical and an efficient flapping-wing micro aerial vehicle.

Reconstructive Trends in Post-Ablation Patients with Esophagus and Hypopharynx Defect

PubMed Central

Choi, Jong Hwan; Sim, Seung Hyun

2015-01-01

The main challenge in pharyngoesophageal reconstruction is the restoration of swallow and speech functions. The aim of this paper is to review the reconstructive options and associated complications for patients with head and neck cancer. A literature review was performed for pharynoesophagus reconstruction after ablative surgery of head and neck cancer for studies published between January 1980 to July 2015 and listed in the PubMed database. Search queries were made using a combination of 'esophagus' and 'free flap', 'microsurgical', or 'free tissue transfer'. The search query resulted in 123 studies, of which 33 studies were full text publications that met inclusion criteria. Further review into the reference of these 33 studies resulted in 15 additional studies to be included. The pharyngoesophagus reconstruction should be individualized for each patient and clinical context. Fasciocutaneous free flap and pedicled flap are effective for partial phayngoesophageal defect. Fasciocutaneous free flap and jejunal free flap are effective for circumferential defect. Pedicled flaps remain a safe option in the context of high surgical risk patients, presence of fistula. Among free flaps, anterolateral thigh free flap and jejunal free flap were associated with superior outcomes, when compared with radial forearm free flap. Speech function is reported to be better for the fasciocutaneous free flap than for the jejunal free flap. PMID:28913234

Proximally pedicled medial plantar flap based on superficial venous system alone for venous drainage.

PubMed

Wright, Thomas C; Mossaad, Bassem M; Chummun, Shaheel; Khan, Umraz; Chapman, Thomas W L

2013-07-01

The proximally pedicled medial plantar flap is well described for coverage of wounds around the ankle and heel. This flap is usually based on the deep venae comitantes for venous drainage, with the superficial veins divided during dissection. Usually any disruption of the deep venous system of the flap would result in abandoning this choice of flap. Venous congestion is a recognised complication of medial plantar flaps. The patient described in this case report had a medial ankle defect with exposed bone, for which a proximally pedicled medial plantar flap was used. As we raised the flap, both venae comitantes of the medial planter artery were found to be disrupted. The flap was raised based on the superficial veins draining into the great saphenous, as the only system for venous drainage, with no evidence of venous congestion. The flap was successfully transposed into the defect and healed with no complications. The proximally pedicled medial plantar flap can safely rely on the superficial venous system alone for drainage. In addition, preserving the superficial veins minimise the risk of venous congestion in this flap. We recommend preservation of superficial venous system when possible. Copyright © 2013 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

Reconstruction of cubital fossa skin necrosis with radial collateral artery perforator-based propeller flap (RCAP).

PubMed

Chaput, B; Gandolfi, S; Ho Quoc, C; Chavoin, J-P; Garrido, I; Grolleau, J-L

2014-02-01

In recent years, perforator flaps have become an indispensable tool for the reconstruction process. Most recently, "propeller" perforator flaps allow each perforator vessels to become a flap donor site. Once the perforator of interest is identified by acoustic Doppler, the cutaneous or fascio-cutaneous island is designed and then customized according to the principle of "perforasome". So, the flap can be rotated such a propeller, up to 180°. Ideally the donor site is self-closing, otherwise it can be grafted at the same time. Through a skin necrosis secondary to a contrast medium extravasation of the cubital fossa in a 47-year-old man, we describe the use of propeller perforator flap based on a perforator of the radial collateral artery (RCAP). The perforator was identified preoperatively by acoustic Doppler then the flap was adapted bespoke to cover the loss of substance. Ultimately, the result was very satisfying. Well experienced for lower-extremity reconstruction, perforator-based propeller flap are still few reported for upper limb. It is likely that in the future, propeller flap supersede in many indication not only free flaps and locoregional flaps but also, leaving no room for uncertainties of the vascular network, the classic random flaps. Copyright © 2013 Elsevier Masson SAS. All rights reserved.

Calf Perforator Flaps: A Freestyle Solution for Oral Cavity Reconstruction.

PubMed

Molina, Alexandra R; Citron, Isabelle; Chinaka, Fungayi; Cascarini, Luke; Townley, William A

2017-02-01

Reconstruction of oral cavity defects requires a thin, pliable flap for optimal functional results. Traditional flap choices are imperfect: the anterolateral thigh flap is excessively thick, whereas the radial forearm flap has a poor donor site. The authors therefore favor calf perforator flaps such as the medial sural artery perforator flap to provide thin tissue with an acceptable donor site. This two-part study aims to demonstrate their suitability for intraoral reconstruction. In the radiologic part of the study, the authors compared thigh and calf tissue thickness by examining lower limb computed tomographic scans of 100 legs. For their clinical study, they collected data prospectively on 20 cases of oral cavity reconstruction using calf perforator flaps. The mean thickness of the calf tissue envelope was significantly less than that of the thigh (8.4 mm compared with 17 mm) based on computed tomographic analysis. In the clinical study, a medial sural artery perforator was used in the majority of cases (17 of 20). The mean pedicle length was 10.2 cm and the mean time to raise a flap was 85 minutes. There were no flap losses. One patient was returned to the operating room for management of late hematoma and wound dehiscence. Calf perforator flaps provide ideal tissue for intraoral reconstruction and are significantly thinner than anterolateral thigh flaps. In addition to medial sural artery perforator flaps, the authors raised both sural and soleal artery perforator flaps in this series. Opportunistic use of the calf donor site allows the harvest of thin tissue with minimal donor-site morbidity. Therapeutic, IV.

Freestyle multiple propeller flap reconstruction (jigsaw puzzle approach) for complicated back defects.

PubMed

Park, Sung Woo; Oh, Tae Suk; Eom, Jin Sup; Sun, Yoon Chi; Suh, Hyun Suk; Hong, Joon Pio

2015-05-01

The reconstruction of the posterior trunk remains to be a challenge as defects can be extensive, with deep dead space, and fixation devices exposed. Our goal was to achieve a tension-free closure for complex defects on the posterior trunk. From August 2006 to May 2013, 18 cases were reconstructed with multiple flaps combining perforator(s) and local skin flaps. The reconstructions were performed using freestyle approach. Starting with propeller flap(s) in single or multilobed design and sequentially in conjunction with adjacent random pattern flaps such as fitting puzzle. All defects achieved tensionless primary closure. The final appearance resembled a jigsaw puzzle-like appearance. The average size of defect was 139.6 cm(2) (range, 36-345 cm(2)). A total of 26 perforator flaps were used in addition to 19 random pattern flaps for 18 cases. In all cases, a single perforator was used for each propeller flap. The defect and the donor site all achieved tension-free closure. The reconstruction was 100% successful without flap loss. One case of late infection was noted at 12 months after surgery. Using multiple lobe designed propeller flaps in conjunction with random pattern flaps in a freestyle approach, resembling putting a jigsaw puzzle together, we can achieve a tension-free closure by distributing the tension to multiple flaps, supplying sufficient volume to obliterate dead space, and have reliable vascularity as the flaps do not need to be oversized. This can be a viable approach to reconstruct extensive defects on the posterior trunk. Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

A Simple Strategy in Avulsion Flap Injury: Prediction of Flap Viability Using Wood's Lamp Illumination and Resurfacing with a Full-thickness Skin Graft.

PubMed

Lim, Hyoseob; Han, Dae Hee; Lee, Il Jae; Park, Myong Chul

2014-03-01

Extensive degloving injuries of the extremities usually result in necrosis of the flap, necessitating comprehensive skin grafting. Provided there is a sufficient tool to evaluate flap viability, full-thickness skin can be used from a nonviable avulsed flap. We used a Wood's lamp to determine the viability of avulsed flaps in the operation field after intravenous injection of fluorescein dye. We experienced 13 cases during 16 months. Fifteen minutes after the intravenous injection of fluorescein dye, the avulsed skin flaps were examined and non-fluorescent areas were marked under Wood's lamp illumination. The marked area was defatted for full-thickness skin grafting. The fluorescent areas were sutured directly without tension. The non-fluorescent areas were covered by defatted skin. Several days later, there was soft tissue necrosis within the flap area. We measured necrotic area and revised the flap. Among all the cases, necrotic area was 21.3% of the total avulsed area. However, if we exclude three cases, one of a carelessly managed patient and two cases of the flaps were inappropriately applied, good results were obtained, with a necrotic area of only 8.4%. Eight patients needed split-thickness skin grafts, and heel pad reconstruction was performed with free flap. A full-thickness skin graft from an avulsed flap is a good method for addressing aesthetic concerns without producing donor site morbidity. Fluorescein dye is a useful, simple, and cost-effective tool for evaluating flap viability. Avulsed flap injuries can be managed well with Wood's lamp illumination and a full-thickness skin graft.

The transverse musculocutaneous gracilis flap for breast reconstruction: guidelines for flap and patient selection.

PubMed

Schoeller, Thomas; Huemer, Georg M; Wechselberger, Gottfried

2008-07-01

The transverse musculocutaneous gracilis (TMG) flap has received little attention in the literature as a valuable alternative source of donor tissue in the setting of breast reconstruction. The authors give an in-depth review of their experience with breast reconstruction using the TMG flap. A retrospective review of 111 patients treated with a TMG flap for breast reconstruction in an immediate or a delayed setting between August of 2002 and July of 2007 was undertaken. Of these, 26 patients underwent bilateral reconstruction and 68 underwent unilateral reconstruction, and 17 patients underwent reconstruction unilaterally with a double TMG flap. Patient age ranged between 24 and 65 years (mean, 37 years). Twelve patients had to be taken back to the operating room because of flap-related problems and nine patients underwent successful revision microsurgically, resulting in three complete flap losses in a series of 111 patients with 154 transplanted TMG flaps. Partial flap loss was encountered in two patients, whereas fat tissue necrosis was managed conservatively in six patients. Donor-site morbidity was an advantage of this flap, with a concealed scar and minimal contour irregularities of the thigh, even in unilateral harvest. Complications included delayed wound healing (n = 10), hematoma (n = 5), and transient sensory deficit over the posterior thigh (n = 49). The TMG flap is more than an alternative to the deep inferior epigastric perforator (DIEP) flap in microsurgical breast reconstruction in selected patients. In certain indications, such as bilateral reconstructions, it possibly surpasses the DIEP flap because of a better concealed donor scar and easier harvest.

Effects of BOSU ball(s) during sit-ups with body weight and added resistance on core muscle activation.

PubMed

Saeterbakken, Atle H; Andersen, Vidar; Jansson, June; Kvellestad, Ann C; Fimland, Marius S

2014-12-01

The objective of this study was to assess the electromyographic activity of the rectus abdominis (upper and lower part) and external oblique during sit-ups performed on BOSU ball(s). Twenty-four men participated in a familiarization session, and in the next session, they performed the experimental tests in randomized order. The sit-ups were performed with 10 repetitions with body weight and with 10 repetition maximum (10RM) using elastic bands as external resistance under 4 different conditions: (a) on a stable surface, (b) with the BOSU ball under their feet (dome side down, lower-body instability), (c) BOSU ball under the low back (dome side up, upper-body instability), and (d) with BOSU balls under both feet and the low back (dual instability). The feet were not attached to the surface. We observed that with body weight, external oblique activation was decreased by upper-body instability and dual instability by 22-24% (p = 0.002-0.006), whereas the rectus abdominis was not affected by the surface. Using 10RM loads, the upper and lower rectus abdominis activities were increased by upper body and dual instability by 21-24% compared with that for a stable surface (P ≤ 0.001-0.036). Further, lower-body instability did not affect muscle activities significantly with either load for any condition. Hence, BOSU balls under the low back can increase and decrease abdominal muscle activation depending on the load, whereas placing a BOSU ball under the feet with the dome side down had little impact.

Transversus abdominis plane block in renal allotransplant recipients: A retrospective chart review.

PubMed

Gopwani, S R; Rosenblatt, M A

2016-01-01

The efficacy of the transversus abdominis plane (TAP) block appears to vary considerably, depending on the surgical procedure and block technique. This study aims to add to the existing literature and provide a more clear understanding of the TAP blocks role as a postoperative analgesic technique, specifically in renal allotransplant recipients. A retrospective chart review was conducted by querying the intraoperative electronic medical record system of a 1200-bed tertiary academic hospital over a 5 months period, and reviewing anesthetic techniques, as well as postoperative morphine equivalent consumption. Fifty renal allotransplant recipients were identified, 13 of whom received TAP blocks while 37 received no regional analgesic technique. All blocks were performed under ultrasound guidance, with 20 mL of 0.25% bupivacaine injected in the transversus abdominis fascial plane under direct visualization. The primary outcome was postoperative morphine equivalent consumption. Morphine consumption was compared with the two-tailed Mann-Whitney U -test. Continuous variables of patient baseline characteristics were analyzed with unpaired t -test and categorical variables with Fischer Exact Test. A P < 0.05 was considered statistically significant. A statistically significant decrease in cumulative morphine consumption was found in the group that received the TAP block at 6 h (2.46 mg vs. 7.27 mg, P = 0.0010), 12 h (3.88 mg vs. 10.20 mg, P = 0.0005), 24 h (6.96 mg vs. 14.75 mg, P = 0.0013), and 48 h (11 mg vs. 20.13 mg, P = 0.0092). The TAP block is a beneficial postoperative analgesic, opiate-sparing technique in renal allotransplant recipients.

14 CFR 23.697 - Wing flap controls.

Code of Federal Regulations, 2013 CFR

2013-01-01

... 14 Aeronautics and Space 1 2013-01-01 2013-01-01 false Wing flap controls. 23.697 Section 23.697... STANDARDS: NORMAL, UTILITY, ACROBATIC, AND COMMUTER CATEGORY AIRPLANES Design and Construction Control Systems § 23.697 Wing flap controls. (a) Each wing flap control must be designed so that, when the flap...

14 CFR 23.697 - Wing flap controls.

Code of Federal Regulations, 2011 CFR

2011-01-01

... STANDARDS: NORMAL, UTILITY, ACROBATIC, AND COMMUTER CATEGORY AIRPLANES Design and Construction Control Systems § 23.697 Wing flap controls. (a) Each wing flap control must be designed so that, when the flap... 14 Aeronautics and Space 1 2011-01-01 2011-01-01 false Wing flap controls. 23.697 Section 23.697...

14 CFR 23.697 - Wing flap controls.

Code of Federal Regulations, 2012 CFR

2012-01-01

... STANDARDS: NORMAL, UTILITY, ACROBATIC, AND COMMUTER CATEGORY AIRPLANES Design and Construction Control Systems § 23.697 Wing flap controls. (a) Each wing flap control must be designed so that, when the flap... 14 Aeronautics and Space 1 2012-01-01 2012-01-01 false Wing flap controls. 23.697 Section 23.697...

14 CFR 23.697 - Wing flap controls.

Code of Federal Regulations, 2014 CFR

2014-01-01

... STANDARDS: NORMAL, UTILITY, ACROBATIC, AND COMMUTER CATEGORY AIRPLANES Design and Construction Control Systems § 23.697 Wing flap controls. (a) Each wing flap control must be designed so that, when the flap... 14 Aeronautics and Space 1 2014-01-01 2014-01-01 false Wing flap controls. 23.697 Section 23.697...

14 CFR 23.697 - Wing flap controls.

Code of Federal Regulations, 2010 CFR

2010-01-01

... STANDARDS: NORMAL, UTILITY, ACROBATIC, AND COMMUTER CATEGORY AIRPLANES Design and Construction Control Systems § 23.697 Wing flap controls. (a) Each wing flap control must be designed so that, when the flap... 14 Aeronautics and Space 1 2010-01-01 2010-01-01 false Wing flap controls. 23.697 Section 23.697...

Vascular Patterns and Perfusion of Mucogingival Tissues and their Relation to Periodontal Flap Design

DTIC Science & Technology

1987-05-01

flaps were mosL vulnerable to necrosis . Sutures placed with minimal tension did not adversely affect blood perfusion of surgically replaced flaps. vi * C...perfusion change with narrow flaps most severely affected. In general, narrow thin flaps were most vulnerable to necrosis . Sutures placed with minimal...Day Narrow Pedicle ............. 75 B. Fluorescein Angiography of Envelope Flap Immediately Post Surgery and Necrosis of Marginal Third of Six

Glove box shield

DOEpatents

Brackenbush, Larry W.; Hoenes, Glenn R.

1981-01-01

According to the present invention, a shield for a glove box housing radioactive material is comprised of spaced apart clamping members which maintain three overlapping flaps in place therebetween. There is a central flap and two side flaps, the side flaps overlapping at the interior edges thereof and the central flap extending past the intersection of the side flaps in order to insure that the shield is always closed when the user withdraws his hand from the glove box. Lead loaded neoprene rubber is the preferred material for the three flaps, the extent of lead loading depending upon the radiation levels within the glove box.

Biomimetic Beetle-Inspired Flapping Air Vehicle Actuated by Ionic Polymer-Metal Composite Actuator.

PubMed

Zhao, Yang; Xu, Di; Sheng, Jiazheng; Meng, Qinglong; Wu, Dezhi; Wang, Lingyun; Xiao, Jingjing; Lv, Wenlong; Chen, Qinnan; Sun, Daoheng

2018-01-01

During the last decades, the ionic polymer-metal composite (IPMC) received much attention because of its potential capabilities, such as large displacement and flexible bending actuation. In this paper, a biomimetic flapping air vehicle was proposed by combining the superiority of ionic polymer metal composite with the bionic beetle flapping principle. The blocking force was compared between casted IPMC and IPMC. The flapping state of the wing was investigated and the maximum displacement and flapping angle were measured. The flapping displacement under different voltage and frequency was tested. The flapping displacement of the wing and the support reaction force were measured under different frequency by experiments. The experimental results indicate that the high voltage and low frequency would get large flapping displacement.

Piloted simulation study of two tilt-wing control concepts

NASA Technical Reports Server (NTRS)

Birckelbaw, Lourdes G.; Corliss, Lloyd D.

1994-01-01

A two-phase piloted simulation study was conducted to investigate alternative wing and flap controls for tilt-wing aircraft. The initial phase of the study compared the flying qualities of both a conventional (programmed) flap and an innovative geared flap. The second phase of the study introduced an alternate method of pilot control for the geared flap and further studied the flying qualities of the programmed flap, and two geared flap configurations. In general, the pilot rating showed little variation between the programmed flap and the geared flap control concepts. Some differences between the two concepts were noticed and are discussed in this paper. The addition of pitch attitude stabilization in the second phase of the study greatly enhanced the aircraft flying qualities. This paper describes the simulated tilt-wing aircraft and the flap control concepts and presents the results of both phases of the simulation study.

Optimization design and dynamic analysis on the drive mechanisms of flapping-wing air vehicles based on flapping trajectories

NASA Astrophysics Data System (ADS)

Xie, Lingwang; Zhang, Xingwei; Luo, Pan; Huang, Panpan

2017-10-01

The optimization designs and dynamic analysis on the driving mechanism of flapping-wing air vehicles on base of flapping trajectory patterns is carried out in this study. Three different driving mechanisms which are spatial double crank-rocker, plane five-bar and gear-double slider, are systematically optimized and analysed by using the Mat lab and Adams software. After a series debugging on the parameter, the comparatively ideal flapping trajectories are obtained by the simulation of Adams. Present results indicate that different drive mechanisms output different flapping trajectories and have their unique characteristic. The spatial double crank-rocker mechanism can only output the arc flapping trajectory and it has the advantages of small volume, high flexibility and efficient space utilization. Both planar five-bar mechanism and gear-double slider mechanism can output the oval, figure of eight and double eight flapping trajectories. Nevertheless, the gear-double slider mechanism has the advantage of convenient parameter setting and better performance in output double eight flapping trajectory. This study can provide theoretical basis and helpful reference for the design of the drive mechanisms of flapping-wing air vehicles with different output flapping trajectories.

Lower Extremity Free Flaps for Breast Reconstruction.

PubMed

Dayan, Joseph H; Allen, Robert J

2017-11-01

Thigh-based flaps are typically a secondary option for breast reconstruction because of concerns regarding limited tissue volume and donor-site morbidity. In recent years, there have been a number of new techniques and insights that have resulted in greater flexibility and improved outcomes. This article reviews lessons learned from a large collective experience using the following 4 flaps: transverse upper gracilis also known as transverse myocutaneous gracilis, diagonal upper gracilis, profunda artery perforator, and lateral thigh perforator flaps. Flap selection considerations include the patient's fat distribution and skin laxity, perforator anatomy, and scar location. Pearls to minimize donor-site morbidity include avoiding major lymphatic collectors in the femoral triangle and along the greater saphenous vein and respecting the limits of flap dimension to reduce wound healing complications and distal ischemia. Limited flap volume may be addressed with stacking another flap from the contralateral thigh or primary fat grafting as opposed to overaggressive flap harvest from a single thigh. A detailed review of the benefits and disadvantages of each flap and strategies to improve results is discussed. With careful planning and selection, thigh-based flaps can provide a reliable option patients desiring autologous breast reconstruction.

A performance application study of a jet-flap helicopter rotor

NASA Technical Reports Server (NTRS)

Sullivan, R. J.; Laforge, S.; Holchin, B. W.

1972-01-01

A performance study was made of the application of a jet-flap to a reaction-drive rotor for a heavy-lift helicopter mission and for a high-speed-helicopter maneuverability (200 knots, 2g) mission. The results of the study are as follows: As a result of the increase in maximum airfoil lift coefficient achieved by the jet-flap, rotor solidity is reduced with the jet-flap to approximately 59% of a nonjet-flap rotor. As a result of the saving in rotor solidity, and hence in rotor weight, the jet-flap configuration had a 21% higher productivity than a nonjet-flap configuration. Of the three propulsion systems studied utilizing a jet-flap (hot cycle, warm cycle, cold cycle) the hot cycle gave the largest increase in productivity. The 200 knot 2g mission is performed best with a warm cycle propulsion system. The jet-flap permits designing for a rotor blade loading coefficient C sub T/sigma = .170 at 2g without encountering blade stall. The jet-flap rotor permits a 200 knot 2g maneuver without suffering the penalty of an unreasonable rotor solidity that would be required by a nonjet-flap rotor.

[A reverse vascular autograft finger island flap. A review of 15 cases and of the literature].

PubMed

Adani, R; Marcuzzi, A; Busa, R; Pancaldi, G; Bathia, A; Caroli, A

1995-01-01

The authors discuss the indications for homodigital island flap with a reverse vascular pedicle. This flap is based on the anastomoses between the radial and ulnar digital arteries. These anastomotic branches lie between the posterior wall of the tendon sheath and the periosteum to form an arch and are named the "digitopalmar arches". The vascularization of the reverse homodigital island flap is derived by using the middle transverse palmar arch. This flap was performed successfully in 14 patients involving 15 fingers to resurface amputation of the distal phalanx. In 6 cases the flap was used as an "artery" flap, and in 9 cases as a "sensitive" homodigital island flap. The pedicle in these cases was neurovascular also containing the digital nerve. The sensitivity of the flap was obtained by neurorraphy between the transposed digital nerve of the flap and the receiving digital nerve of the recipient finger. This technique achieves cover of the tactile pad in one operative stage and provides well vascularized skin allowing early mobilization. Sensation of the flap can be restored rapidly when neurorraphy of the transposed digital nerve is performed.

Reconstruction of pressure sores with perforator-based propeller flaps.

PubMed

Jakubietz, Rafael G; Jakubietz, Danni F; Zahn, Robert; Schmidt, Karsten; Meffert, Rainer H; Jakubietz, Michael G

2011-03-01

Perforator flaps have been successfully used for reconstruction of pressure sores. Although V-Y advancement flaps approximate debrided wound edges, perforator-based propeller flaps allow rotation of healthy tissue into the defect. Perforator-based propeller flaps were planned in 13 patients. Seven pressure sores were over the sacrum, five over the ischial tuberosity, and one on the tip of the scapula. Three patients were paraplegic, six were bedridden, and five were ambulatory. In three patients, no perforators were found. In 10 patients, propeller flaps were transferred. In two patients, total flap necrosis occurred, which was reconstructed with local advancement flaps. In two cases, a wound dehiscence occurred and had to be revised. One hematoma required evacuation. No further complications were noted. No recurrence at the flap site occurred. Local perforator flaps allow closure of pressure sores without harvesting muscle. The propeller version has the added benefit of transferring tissue from a distant site, avoiding reapproximation of original wound edges. Twisting of the pedicle may cause torsion and venous obstruction. This can be avoided by dissecting a pedicle of at least 3 cm. Propeller flaps are a safe option for soft tissue reconstruction of pressure sores. © Thieme Medical Publishers.

Low-Speed Wind-Tunnel Investigation of Blowing Boundary-Layer Control on Leading- and Trailing-Edge Flaps of a Large-Scale, Low-Aspect-Ratio, 45 Swept-wing Airplane Configuration

NASA Technical Reports Server (NTRS)

Maki, Ralph L.

1959-01-01

Blowing boundary-layer control was applied to the leading- and trailing-edge flaps of a 45 deg sweptback-wing complete model in a full-scale low-speed wind-tunnel study. The principal purpose of the study was to determine the effects of leading-edge flap deflection and boundary-layer control on maximum lift and longitudinal stability. Leading-edge flap deflection alone was sufficient to maintain static longitudinal stability without trailing-edge flaps. However, leading-edge flap blowing was required to maintain longitudinal stability by delaying leading-edge flow separation when trailing-edge flaps were deflected either with or without blowing. Partial-span leading-edge flaps deflected 60 deg with moderate blowing gave the major increase in maximum lift, although higher deflection and additional blowing gave some further increase. Inboard of 0.4 semispan leading-edge flap deflection could be reduced to 40 deg and/or blowing could be omitted with only small loss in maximum lift. Trailing-edge flap lift increments were increased by boundary-layer control for deflections greater than 45 deg. Maximum lift was not increased with deflected trailing-edge flaps with blowing.

The effect of partial-span split flaps on the aerodynamic characteristics of a Clark Y wing

NASA Technical Reports Server (NTRS)

Wenzinger, Carl J

1933-01-01

Aerodynamic force tests were made in the N.A.C.A. 7 by 10 foot wind tunnel on a model Clark Y wing with a 20 percent chord split flap deflected 60 degrees downward. The tests were made to determine the effect of partial-span split flaps, located at various positions along the wing span on the aerodynamic characteristics of the wing-and-flap combination. The different lengths and locations of the flaps were obtained by cutting off portions of a full-span flap, first from the tips and then from the center. The results are given in the form of curves of lift, drag, and center of pressure. They show that with partial-span split flaps both the lift and drag are less than with full-span flaps; that the lift for a given length of flap is somewhat greater when the partial span is located at the center of the wing than when it is located at the tip portion, and that the drag for a given length of flap is the same regardless of the location over the flap with respect to the wing span.

Effect of Krueger nose flaps on the experimental force and moment characteristics of an oblique wing

NASA Technical Reports Server (NTRS)

Hopkins, E. J.; Lovette, G. H.

1976-01-01

Experimental force and moment data are presented for an oblique wing mounted on a body of revolution and equipped with Krueger type nose flaps. The effectiveness of these flaps in making the moment curves more linear by controlling the flow separation on the downstream wing panel at high lift coefficients was determined. The investigation of the effects of the Krueger flaps covered two cases: (1) use of the flaps on the downstream wing panel only and (2) use of the flaps on both wing panels. For part of the tests, the Krueger flaps were mounted on nose flaps that were drooped either 5 deg or 10 deg. The wing was elliptical in planform, had an aspect ratio of 6.0 (based on the unswept span) and was tested at sweep angles of 0, 45 deg, and 50 deg. The Mach-number range covered was from 0.25 to 0.95. It was found that the most effective arrangement of the Krueger flaps for making the pitching-, rolling-, and yawing-moment curves more linear at high lift coefficients was having the Krueger flaps mounted on the nose flaps drooped 5 deg and only on the downstream wing panel.

A standardized model for predicting flap failure using indocyanine green dye

NASA Astrophysics Data System (ADS)

Zimmermann, Terence M.; Moore, Lindsay S.; Warram, Jason M.; Greene, Benjamin J.; Nakhmani, Arie; Korb, Melissa L.; Rosenthal, Eben L.

2016-03-01

Techniques that provide a non-invasive method for evaluation of intraoperative skin flap perfusion are currently available but underutilized. We hypothesize that intraoperative vascular imaging can be used to reliably assess skin flap perfusion and elucidate areas of future necrosis by means of a standardized critical perfusion threshold. Five animal groups (negative controls, n=4; positive controls, n=5; chemotherapy group, n=5; radiation group, n=5; chemoradiation group, n=5) underwent pre-flap treatments two weeks prior to undergoing random pattern dorsal fasciocutaneous flaps with a length to width ratio of 2:1 (3 x 1.5 cm). Flap perfusion was assessed via laser-assisted indocyanine green dye angiography and compared to standard clinical assessment for predictive accuracy of flap necrosis. For estimating flap-failure, clinical prediction achieved a sensitivity of 79.3% and a specificity of 90.5%. When average flap perfusion was more than three standard deviations below the average flap perfusion for the negative control group at the time of the flap procedure (144.3+/-17.05 absolute perfusion units), laser-assisted indocyanine green dye angiography achieved a sensitivity of 81.1% and a specificity of 97.3%. When absolute perfusion units were seven standard deviations below the average flap perfusion for the negative control group, specificity of necrosis prediction was 100%. Quantitative absolute perfusion units can improve specificity for intraoperative prediction of viable tissue. Using this strategy, a positive predictive threshold of flap failure can be standardized for clinical use.

[Reconstruction of ankle and foot with combination of free perforator flaps and skin graft].

PubMed

Yin, Lu; Gong, Ketong; Yin, Zhonggang; Zhang, Bo; Xu, Jianhua

2017-03-01

To evaluate the clinical outcomes of free perforator flaps combined with skin graft for reconstruction of ankle and foot soft tissue defects. Between June 2014 and October 2015, 20 cases of ankle and foot soft tissue defects were treated. There were 16 males and 4 females, aged from 19 to 61 years (mean, 43.3 years). Injury was caused by traffic accident in 7 cases, by crashing in 9 cases, and machine twist in 4 cases. The locations were the ankle in 6 cases, the heel in 3 cases, the dorsum pedis in 4 cases, and the plantar forefoot in 7 cases of avulsion injury after toes amputation. The size of wound ranged from 15 cm×10 cm to 27 cm×18 cm. The time from injury to treatment was from 11 to 52 days (mean, 27 days). The anterolateral thigh perforator flap was used in 11 cases, thoracodorsal antery perforator flap in 3 cases, medial sural artery perforator flap in 4 cases, deep inferior epigastric perforator flap in 1 case, and anteromedial thigh perforator flap in 1 case, including 5 chimeric perforator flaps, 5 polyfoliate perforator flaps, 3 flow-through perforator flaps, and 3 conjoined perforator flaps. The size of the perforator flap ranged from 10.0 cm×6.5 cm to 36.0 cm×8.0 cm, the size of skin graft from 5 cm×3 cm to 18 cm×12 cm. Venous crisis occurred in 2 flaps which survived after symptomatic treatment; 18 flaps survived successfully and skin grafting healed well. The follow-up time ranged 4-18 months (mean, 8.3 months). The flaps had good appearance, texture and color, without infection. The patients could walk normally and do daily activities. Only linear scars were observed at the donor sites. Free perforator flap can be used to reconstruct defects in the ankle and foot, especially in the weight-bearing area of the plantar forefoot. A combination of free perforator flap and skin graft is ideal in reconstruction of great soft tissue defects in the ankle and foot.

Omega "Ω" Pulley Plasty for Surgical Management of DeQuervain's Disease.

PubMed

Bakhach, Joseph; Chaya, Bachar; Papazian, Nazareth

2018-06-01

DeQuervain tenosynovitis, refractory to medical conservative treatment, has been traditionally treated by a simple division of the pulley, a procedure associated with several complications. Many authors attempted to prevent these complications by describing techniques of pulley reconstruction after its release necessitating suturing the different flaps and subsequently promoting extensor tendons adhesions. The authors present an alternative procedure for the first extensor compartment pulley decompression: "Omegaplasty". 25 Patients with 29 DeQuervain tenosynovitis cases were enrolled in a prospective, nonrandomized clinical trial from 2012 to 2016. At enrollment they were offered the option of Omegaplasty as a surgical treatment modality for their cases. The procedure is based on liberating the anterior attachment of the pulley from the anterior lip of the styloïd process while respecting its continuity with the periosteal flap as well as promoting expansion of the tunnel volume. All operated patients were evaluated using the "Opposition Kapandji Score". The authors present the results of 29 different "Omegaplasty" procedures. Based on the Kapandji opposition score, twenty cases scored 10/10 while the remaining nine cases yielded an 8/10 score each. The described technique is simple, reliable and respects the extensor tendons gliding physiology and biodynamics. By preserving the anatomical continuity of the first extensor compartment pulley at the wrist, the risk of adhesion formation is reduced. The preliminary results are encouraging and provide the "Ω" plasty the potential to be considered as a surgical option for treatment of De Quervain Tenosynovitis.

Incidence of lingual nerve paraesthesia following mandibular third molar surgery

PubMed Central

Lata, Jeevan; Tiwari, Arunesh K.

2011-01-01

Context: The surgical removal of impacted mandibular third molar is associated with minor but expected complications like pain, swelling, bruising and trismus. The lingual nerve damage sometimes occurs after the removal of mandibular third molar producing impaired sensation or permanent sensory loss. This complication is usually unexpected and unacceptable for the patients particularly if no prior warning has been given. Aims: The aim of the present clinical prospective study was to determine the clinical incidence of lingual nerve injury following mandibular third molar removal and to analyze possible factors for the lingual nerve injury. Settings and Design: Clinical prospective study in the Department of Oral Surgery, Punjab Government Dental College and Hospital, Amritsar. Materials and Methods: Ninety patients were selected randomly, amongst the patients, who reported to our department from January 2009 to December 2009 for the surgical removal of impacted mandibular third molar. To minimize the risk of lingual nerve injury, the standard terence wards incision was made in all cases and only buccal flap was raised. Statistical Analysis: The small number of paraesthesia precluded statistical analysis. Results: Out of 90 patients, six patients were diagnosed with lingual nerve paraesthesia. The overall incidence rate of lingual nerve injury was 6.6%. Conclusions: It can be concluded that lingual nerve paraesthesia can occur with or without reflection of lingual flap in spite of all the measures taken to protect it. It may be contributed to the fact of anatomical variations of lingual nerve. PMID:22639500

Comparative study of 2 commissural dorsal flap techniques for the treatment of congenital syndactyly.

PubMed

Mallet, Cindy; Ilharreborde, Brice; Jehanno, Pascal; Litzelmann, Estelle; Valenti, Philippe; Mazda, Keyvan; Penneçot, Georges-François; Fitoussi, Franck

2013-03-01

Many commissural reconstruction techniques have been described for the treatment of syndactyly. This study is the first to compare long-term results of 2 commissural dorsal flap procedures (T-flap and omega-flap). Fifty-nine web-spaces in 39 patients, operated on between 1991 and 2008, were retrospectively analyzed. Thirty-six T-flap and 23 omega-flap procedures were performed using full-thickness skin graft in every case for digital resurfacing. Factors that could affect the long-term outcome were collected, including development of web-creep, clinodactyly, and flexion contracture. Patients were reviewed with a mean follow-up of 5 years and 8 months. Preoperative complexity of syndactyly influenced the development of clinodactyly and flexion contracture. Among the patients who developed clinodactyly, 96% had surgery for complex syndactyly. No difference was found between the 2 flap methods concerning digital deformation and mobility. However, web-creep occurred more frequently after T-flap than after omega-flap procedures (17% vs. 5%). The combination of either dorsal commissural T-flaps or omega-flaps with full-thickness graft to resurface digits is a reliable technique for the treatment of syndactyly with satisfactory functional and cosmetic results. Long-term results are not influenced by the type of flap. Nevertheless, the omega-flap technique, using 2 triangular lateral-palmar flaps, avoids use of skin graft to cover lateral-palmar aspects of the new commissure, consequently reducing the incidence of web-creep. In cases of syndactyly, the primary prognostic factor is whether the patient has simple or complex syndactyly. In complex syndactyly, the risk of long-term unfavorable results is higher. When complex complicated syndactyly is involved, postoperative complication rates increase. Level III.

The effect of topical minoxidil pretreatment on nonsurgical delay of rat cutaneous flaps: further studies.

PubMed

Gümüş, Nazım; Odemiş, Yusuf; Tuncer, Ersin; Yılmaz, Sarper

2013-08-01

The purpose of this study was to determine the effectiveness of topically applied minoxidil in the pharmacological delay phenomenon and to demonstrate the comparable microscopic and macroscopic changes between minoxidil-pretreated flaps and surgically delayed flaps. A modified version of the McFarlane flap was used. Group 1 rats, in which a caudally based dorsal skin flap was raised and sutured back, were the control group. In group II, minoxidil solution was spread over the marked skin flap area for 7 days. On the 7th day, a caudally based dorsal skin flap was elevated and then sutured back. Group III rats underwent a surgical delay procedure alone. On the 7th day after flap elevation, evaluation was done by histologic examination and calculation of the flap survival areas in all groups. The lowest flap survival rate appeared in group I and was statistically different from groups II and III. The mean surviving skin flap area in the minoxidil-pretreated group was significantly larger than that in the control group. After histologic evaluation, moderate angiogenesis was also detected in group II. We also found that surgical delay significantly reduced flap necrosis when compared to the minoxidil pretreatment group. According to our study, minoxidil may be considered an effective vasoactive agent for the stimulation of angiogenesis in rat cutaneous flaps and capable of achieving pharmacological delay and increasing flap survival. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

The myocutaneous trapezius flap revisited: a treatment algorithm for optimal surgical outcomes based on 43 flap reconstructions.

PubMed

Can, Anil; Orgill, Dennis P; Dietmar Ulrich, J O; Mureau, Marc A M

2014-12-01

Because the vascular anatomy of the trapezius flap is highly variable, choosing the most appropriate flap type and design is essential to optimize outcomes and minimize postoperative complications. The aim of this study was to develop a surgical treatment algorithm for trapezius flap transfers. The medical files of all consecutive patients with a myocutaneous trapezius flap reconstruction of the head, neck, and upper back area treated at three different university medical centers between July 2001 and November 2012 were reviewed. There were 43 consecutive flaps performed in 38 patients with a mean follow-up time of 15 months (range, 1-48 months). Eleven patients had a mentosternal burn scar contracture (12 flaps), 12 patients (13 flaps) presented with cancer, and 15 patients (18 flaps) were suffering from chronic wounds due to failed previous reconstruction (n = 6), osteoradionecrosis (n = 1), chronic infection (n = 3), bronchopleural fistula (n = 3), and pressure sores (n = 2). The mean defect size was 152 cm(2). Sixteen flaps were based on the superficial cervical artery (SCA; type 2), 16 were based on the dorsal scapular artery (DSA; type 3), one was based on the intercostal arteries (type 4), and 10 flaps were based on both the DSA and SCA. Recipient-site complications requiring reoperation occurred in 16.3%, including one total flap failure (2.6%). The trapezius myocutaneous flap is a valuable option to reconstruct various head and neck and upper back defects. Based on our data, a surgical treatment algorithm was developed in an attempt to reduce variation in care and improve clinical outcomes. Copyright © 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

Efficacy of Liposuction as a Delay Method for Improving Flap Survival.

PubMed

Orhan, Erkan; Erol, Yağmur Reyyan; Deren, Orgun; Altun, Serdar; Erdoğan, Bülent

2016-12-01

Flaps are often used in repairing tissue defects and partial or full flap loss is still an important morbidity cause. Several techniques have been tried to increase flap circulation but none of these could replace the delay technique. Our goal in this study is to show the efficacy of liposuction in delay of dorsal rat cutaneous flaps and improvement in flap survival. Twenty-four Wistar rats were used. The rats in group 1 received 9 × 3-sized caudally-based random pattern skin flaps. In group 2, liposuction was done under the tissue island spotted as the flap and after 14 days, standard flap surgery was done. In group 3, surgical delay was done and after 14 days, standard flap surgery was done. In group 4, liposuction was done under the tissue island spotted as the flap and standard flap surgery was done right after the liposuction. The rate of necrotic tissue in group 3 (surgical delay; mean % 13.7) was less than the rate in group 2 (liposuction delay; mean % 15.1), although the difference was not statistically significant. The necrosis rates in group 3 (surgical delay) and group 2 (liposuction delay) were less than the rates in both group 1 (only flap; mean % 41.5) and group 4 (liposuction flap; mean % 40.0) and this difference was statistically significant (p < 0.0001). Liposuction can be an alternative to surgical delay as a less invasive method in the clinic. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

[Contribution of the scrotal flap for the coverage of ischial and perineal pressure ulcers].

PubMed

Vantomme, M; Viard, R; Aimard, R; Vincent, P-L; Comparin, J-P; Voulliaume, D

2018-04-11

The ischiatric pressure sore is a common pathology in rehabilitated spinal cord injured people, despite careful prevention. Medical treatment by discharge and directed healing is not always sufficient and surgery using local musculocutaneous flaps is often essential. Unfortunately, recidivism is frequent and the availability of local flaps is limited. The scrotal flap is an excellent complement to classic flaps, gluteal flaps or hamstrings. It can be used alone or in addition to another musculocutaneous flap, in first or second intention. The scrotal flap is a musculocutaneous flap, using the Dartos, the platys muscle of the scrotum. It is richly vascularized, extensible and resistant. Its great plasticity makes it adaptable to any form of loss of substance, with an arc of rotation that can reach the anal margin. It can also be desepidermized and buried to fill a deep defect. Ten cases of scrotal flaps and their different indications are reviewed: some are used in first intention, others in addition to musculocutaneous flaps. The removal of a scrotal flap is fast and extremely easy. The simple closure of the donor site allows the sampling of half of the scrotum due to the great local laxity. The scrotal flaps achieved quickly healed, as well as the donor sites. Only one recurrence was observed after an inappropriate treatment of underlying osteitis. No complications have occurred. The scrotal musculocutaneous flap, reliable, resistant, quick and easy to remove is an excellent means of coverage of the perineal region. It can be used for the treatment of any loss of perineal substance in humans, but remains particularly useful for the treatment of ischial or perineal pressure sores. Copyright © 2018 Elsevier Masson SAS. All rights reserved.

Defining the Role of Free Flaps in Partial Breast Reconstruction.

PubMed

Smith, Mark L; Molina, Bianca J; Dayan, Erez; Jablonka, Eric M; Okwali, Michelle; Kim, Julie N; Dayan, Joseph H

2018-03-01

 Free flaps have a well-established role in breast reconstruction after mastectomy; however, their role in partial breast reconstruction remains poorly defined. We reviewed our experience with partial breast reconstruction to better understand indications for free tissue transfer.  A retrospective review was performed of all patients undergoing partial breast reconstruction at our center between February 2009 and October 2015. We evaluated the characteristics of patients who underwent volume displacement procedures versus volume replacement procedures and free versus pedicled flap reconstruction.  There were 78 partial breast reconstructions, with 52 reductions/tissue rearrangements (displacement group) and 26 flaps (replacement group). Bra cup size and body mass index (BMI) were significantly smaller in the replacement group. Fifteen pedicled and 11 free flaps were performed. Most pedicled flaps (80.0%) were used for lateral or upper pole defects. Most free flaps (72.7%) were used for medial and inferior defects or when there was inadequate donor tissue for a pedicled flap. Complications included hematoma, cellulitis, and one aborted pedicled flap.  Free and pedicled flaps are useful for partial breast reconstruction, particularly in breast cancer patients with small breasts undergoing breast-conserving treatment (BCT). Flap selection depends on defect size, location, and donor tissue availability. Medial defects are difficult to reconstruct using pedicled flaps due to arc of rotation and intervening breast tissue. Free tissue transfer can overcome these obstacles. Confirming negative margins before flap reconstruction ensures harvest of adequate volume and avoids later re-operation. Judicious use of free flaps for oncoplastic reconstruction expands the possibility for breast conservation. Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Use of Autologous Scleral Graft in Ahmed Glaucoma Valve Surgery.

PubMed

Wolf, Alvit; Hod, Yair; Buckman, Gila; Stein, Nili; Geyer, Orna

2016-04-01

To compare the efficacy of an autoscleral free-flap graft versus an autoscleral rotational flap graft in Ahmed glaucoma valve (AGV) surgery. Medical records (2005 to 2012) of 51 consecutive patients (51 eyes) who underwent AGV surgery with the use of either an autoscleral free-flap graft or an autoscleral rotational flap graft to cover the external tube at the limbus were retrieved for review. The main outcome measure was the incidence of tube exposure associated with each surgical approach. Twenty-seven consecutive patients (27 eyes) received a free-flap graft and 24 consecutive patients (24 eyes) received a rotational flap graft. The mean follow-up time was 55.6 ± 18.3 months for the former and 24.2± 5 .0 months for the latter (P<0.0001). Two patients in the free-flap group (8.9%) developed tube exposure at 24 and 55 months postoperatively compared with none of the patients in the rotational flap group. Graft thinning without evidence of conjunctival erosion was observed in 15 patients (55%) in the free-flap group and in 7 patients (29.1%) in the rotational flap group. The use of an autoscleral rotational flap graft is an efficacious technique for primary tube patch grafting in routine AGV surgery, and yielded better results than an autoscleral free-flap graft. Its main advantages over donor graft material are availability and lower cost.

Effect of marking pens on femtosecond laser-assisted flap creation.

PubMed

Ide, Takeshi; Kymionis, George D; Abbey, Ashkan M; Yoo, Sonia H; Culbertson, William W; O'Brien, Terrence P

2009-06-01

To compare the ease of the flap lift after central corneal marking with 2 types of marking pens after femtosecond laser-assisted flap creation in laser in situ keratomileusis. Bascom Palmer Eye Institute, University of Miami, Miami, Florida, USA. Porcine eyes were prepared for flap creation with a femtosecond laser (IntraLase). The eyes were assigned to 1 of 4 groups. After the femtosecond laser treatment, the difficulty of flap lifting the 4 groups was compared. Twelve porcine eyes, 3 in each group, were evaluated. In the 2 groups in which an oil-based pen was used, the corneal flap could not be lifted. In the 2 groups in which a water-based pen was used, the corneal flap was easily lifted. Oil-based ink may reduce the ability of the femtosecond laser to penetrate the cornea. The resultant corneal flap may require aggressive manipulation to be lifted. When used to mark the center of the cornea before flap creation, water-based ink provided greater ease of corneal flap lifting than oil-based ink. Because the marking is located over the center of the pupil, any alteration of the cornea in this area from aggressive flap lifting may result in substantial visual loss. Therefore, the use of an oil-based ink to mark the central cornea must be avoided to prevent traumatic irregularities of the flap stroma.

Double transverse myocutaneous gracilis free flaps for unilateral breast reconstruction.

PubMed

Werdin, Frank; Haug, Daniel M; Amr, Amro; Schoeller, Thomas

2016-10-01

In cases were the deep inferior epigastric perforator flap (DIEP flap) is not available and unilateral transverse myocutaneous gracilis flap (TMG flap) is not sufficient for breast reconstruction, we perform double TMG flaps as a reconstructive method. In this report, we present our results of the use of double TMG free-flap-transfer for unilateral breast reconstruction. Between August 2004 and June 2012 we performed 58 TMG flaps in 29 patients for unilateral breast reconstruction. Patient data were analyzed and operative outcome (operation time, complication rate and aesthetic results) were investigated. Aesthetic outcome was evaluated retrospectively via photo documentation by an independent plastic surgeon. The results were classified in;unsatisfactory, satisfactory, good and very good. The average operating time was 6 hours 55 minutes (295 - 650 minutes). Of 58 TMG flaps, 57 (98.3%) were successful. Thrombosis occurred in seven (12%) cases (1 arterial, 6 venous). Flap salvage was successful in six cases and flap failure occurred in one (1.7%) case. The results of 25 patients were graded as good and very good. Three patients showed satisfying and one patient unsatisfying results. Double TMG flaps in unilateral breast reconstruction could lead to good operative results. This method further expands the range of options with autologous tissue in reconstructive breast surgery. © 2015 Wiley Periodicals, Inc. Microsurgery 36:539-545, 2016. © 2015 Wiley Periodicals, Inc.

Optimal placement of trailing-edge flaps for helicopter vibration reduction using response surface methods

NASA Astrophysics Data System (ADS)

Viswamurthy, S. R.; Ganguli, Ranjan

2007-03-01

This study aims to determine optimal locations of dual trailing-edge flaps to achieve minimum hub vibration levels in a helicopter, while incurring low penalty in terms of required trailing-edge flap control power. An aeroelastic analysis based on finite elements in space and time is used in conjunction with an optimal control algorithm to determine the flap time history for vibration minimization. The reduced hub vibration levels and required flap control power (due to flap motion) are the two objectives considered in this study and the flap locations along the blade are the design variables. It is found that second order polynomial response surfaces based on the central composite design of the theory of design of experiments describe both objectives adequately. Numerical studies for a four-bladed hingeless rotor show that both objectives are more sensitive to outboard flap location compared to the inboard flap location by an order of magnitude. Optimization results show a disjoint Pareto surface between the two objectives. Two interesting design points are obtained. The first design gives 77 percent vibration reduction from baseline conditions (no flap motion) with a 7 percent increase in flap power compared to the initial design. The second design yields 70 percent reduction in hub vibration with a 27 percent reduction in flap power from the initial design.

Instep island flaps.

PubMed

Reading, G

1984-12-01

The instep island flap is safe and useful. It is based on branches of the posterior tibial artery and can be a musculocutaneous or a direct fasciocutaneous island flap. Sensory branches of the digital nerves may be transposed with the flap. There is a wide arc of transposition and the flap has survived even in very difficult circumstances.

Effect of intradermal human recombinant copper-zinc superoxide dismutase on random pattern flaps in rats.

PubMed

Schein, Ophir; Westreich, Melvyn; Shalom, Avshalom

2013-09-01

Studies have focused on enhancing flap viability using superoxide dismutase (SOD), but only a few used SOD from human origin, and most gave the compound systemically. We evaluated the ability of SOD to improve random skin flap survival using human recombinant copper-zinc superoxide dismutase (Hr-CuZnSOD) in variable doses, injected intradermally into the flap. Seventy male Sprague Dawley rats were randomly assigned into 4 groups. Cephalic random pattern flaps were elevated on their backs and intradermal injections of different dosages of Hr-CuZnSOD were given 15 minutes before surgery. Flap survival was evaluated by fluorescein fluorescence. Analysis of variance (ANOVA) and t test statistical analyses were performed. Flap survival in all treated groups was significantly better than in the controls. The beneficial effect of HR-CuZnSOD on flap survival is attained when it is given intradermally into the flap tissue. Theoretically, Hr-CuZnSOD delivered with local anesthetics used in flap elevation may be a valuable clinical tool. Copyright © 2012 Wiley Periodicals, Inc.

Comparative study of functional and aesthetically outcomes of reverse digital artery and reverse dorsal homodigital island flaps for fingertip repair.

PubMed

Chen, Q Z; Sun, Y C; Chen, J; Kong, J; Gong, Y P; Mao, T

2015-11-01

This retrospective study was designed to compare functional and cosmetic outcomes of the reverse digital artery island flap and reverse dorsal homodigital island flap in fingertip repair. A total of 23 patients were followed for 24 to 30 months. The reverse digital artery island flap was used in 12 patients, and reverse dorsal homodigital island flap in another 11 patients. Flap sensibility was assessed using the Semmes-Weinstein monofilament test and static 2-point discrimination test. Patient satisfaction, active motion of the finger joints, complications and cold intolerance were evaluated. The static 2-point discrimination and Michigan Hand Outcomes Questionnaire (appearance) of the fingers treated with a reverse digital artery flap were significantly better than those with a reverse dorsal homodigital flap. The static 2-point discrimination of the skin-grafted donor sides after dorsal homodigital flap were poorer than that in the contralateral finger. No significant differences were found between the two flaps for pressure or touch sensibility, active ranges of digital motion, complications and cold intolerance. III. © The Author(s) 2015.

Dorsal Intercostal Artery Perforator Propeller Flaps: A Reliable Option in Reconstruction of Large Meningomyelocele Defects.

PubMed

Basterzi, Yavuz; Tenekeci, Goktekin

2016-04-01

Several options have been reported for the reconstruction of myelomeningocele defects. In this article, we present our experience on soft tissue reconstruction of myelomeningocele defects by using island propeller dorsal intercostal artery perforator (DIAP) flaps. Between January 2008 and February 2014, all newborns with large myelomeningocele defects (13 newborns) were reconstructed with island propeller DIAP flaps. All flaps survived completely. In 8 patients out of 13, venous insufficiency was observed which then resolved spontaneously. Flap donor sites were closed primarily. Myelomeningocele defects with a diameter larger than 5 cm require reconstruction with flaps. To mobilize a well-vascularized tissue over the defect without tension in which the suture lines will not overlap over the midline where the dura is repaired and over the meninges is one of the goals of reconstruction for such defects. Perforator propeller flaps enable us to reach those goals. Use of perforator flaps provides 2 important advantages, namely, more predictability and also more freedom in mobilizing flaps toward the defect. This study proves the reliability of DIAP propeller flaps in the reconstruction of myelomeningocele defects.

Biochemical analyses indicate that binding and cleavage specificities define the ordered processing of human Okazaki fragments by Dna2 and FEN1.

PubMed

Gloor, Jason W; Balakrishnan, Lata; Campbell, Judith L; Bambara, Robert A

2012-08-01

In eukaryotic Okazaki fragment processing, the RNA primer is displaced into a single-stranded flap prior to removal. Evidence suggests that some flaps become long before they are cleaved, and that this cleavage involves the sequential action of two nucleases. Strand displacement characteristics of the polymerase show that a short gap precedes the flap during synthesis. Using biochemical techniques, binding and cleavage assays presented here indicate that when the flap is ∼ 30 nt long the nuclease Dna2 can bind with high affinity to the flap and downstream double strand and begin cleavage. When the polymerase idles or dissociates the Dna2 can reorient for additional contacts with the upstream primer region, allowing the nuclease to remain stably bound as the flap is further shortened. The DNA can then equilibrate to a double flap that can bind Dna2 and flap endonuclease (FEN1) simultaneously. When Dna2 shortens the flap even more, FEN1 can displace the Dna2 and cleave at the flap base to make a nick for ligation.

[Modified pectoralis major myocutaneous flap in reconstruction of head and neck defects].

PubMed

Chen, Jie; Huang, Wenxiao; Li, Zan; Zhou, Xiao; Yu, Jianjun; Bao, Ronghua; Zhang, Hailin; Ling, Hang

2015-05-01

To report the experience of use of modified pectoralis major myocutaneous (PMMC) flaps in reconstruction of head and neck postoperative defects. A total of 107 patients who underwent head and neck defect reconstruction using modified PMMC flaps after tumor rescetion between Jan 2008 and Dec 2013 were analyzed retrospectively. The success rate of reconstruction with modified PMMC flaps was 94.4% (101/107). Five patients had partial flap necrosis and their wounds healed with dressing change. One patient (0.9%) had total flap necrosis, followed by the second reconstruction using contralateral PMMC flap. The modified falcate PMMC flap can obtain optimum quantity of the skin in the chest and decreasing the closing tension of the donnor site in favor of wound healing. The pedicle without muscle will not only maintain the partial function of the pectoralis major, but also help to avoid pressing the vascular pedicle within the subclavian tunnel. The muscular element the pedicled muscles of the PMMC flap can increase the ability of the flap to resist infection, which can use for covering an exposed carotid artery and improving the neck fibrosis of irradiated patients.

Optimal propulsive flapping in Stokes flows.

PubMed

Was, Loïc; Lauga, Eric

2014-03-01

Swimming fish and flying insects use the flapping of fins and wings to generate thrust. In contrast, microscopic organisms typically deform their appendages in a wavelike fashion. Since a flapping motion with two degrees of freedom is able, in theory, to produce net forces from a time-periodic actuation at all Reynolds numbers, we compute in this paper the optimal flapping kinematics of a rigid spheroid in a Stokes flow. The hydrodynamics for the force generation and energetics of the flapping motion is solved exactly. We then compute analytically the gradient of a flapping efficiency in the space of all flapping gaits and employ it to derive numerically the optimal flapping kinematics as a function of the shape of the flapper and the amplitude of the motion. The kinematics of optimal flapping are observed to depend weakly on the flapper shape and are very similar to the figure-eight motion observed in the motion of insect wings. Our results suggest that flapping could be a exploited experimentally as a propulsion mechanism valid across the whole range of Reynolds numbers.

Management of Dropped Skull Flaps.

PubMed

Abdelfatah, Mohamed AbdelRahman

2017-01-01

Dropping a skull flap on the floor is an uncommon and avoidable mistake in the neurosurgical operating theater. This study retrospectively reviewed all incidents of dropped skull flaps in Ain-Shams University hospitals during a 10-year period to show how to manage this problem and its outcome. Thirty-one incidents of dropped skull flaps occurred from January 2004 to January 2014 out of more than 10,000 craniotomies. Follow-up period varied from 20 to 44 months. The bone flap was dropped while elevating the bone (n = 16), while drilling the bone on the operating table (n = 5), and during insertion of the bone flap (n = 10). Treatment included re-insertion of the skull flap after soaking it in povidone iodine and antibiotic solution (n = 17) or after autoclaving (n = 11), or discarding the skull flap and replacing it with a mesh cranioplasty in the same operation (n = 3). No bone or wound infection was noted during the follow-up period. Management of dropped skull flap is its prevention. Replacement of the skull flap, after decontamination, is an option that avoids the expense and time of cranioplasty.

Near-Infrared Irradiation Increases Length of Axial Pattern Flap Survival in Rats.

PubMed

Yasunaga, Yoshichika; Matsuo, Kiyoshi; Tanaka, Yohei; Yuzuriha, Shunsuke

2017-01-01

Objective: We previously reported that near-infrared irradiation nonthermally induces long-lasting vasodilation of the subdermal plexus by causing apoptosis of vascular smooth muscle cells. To clarify the possible application of near-infrared irradiation to prevent skin flap necrosis, we evaluated the length of axial pattern flap survival in rats by near-infrared irradiation. Methods: A bilaterally symmetric island skin flap was elevated under the panniculus carnosus on the rat dorsum. Half of the flap was subjected to near-infrared irradiation just before flap elevation with a device that simulates solar radiation, which has a specialized contact cooling apparatus to avoid thermal effects. The length of flap survival of the near-infrared irradiated side was measured 7 days after flap elevation and compared with the nonirradiated side. Results: The irradiated side showed elongation of flap survival compared with the nonirradiated side (73.3 ± 11.7 mm vs 67.3 ± 14.9 mm, respectively, P = .03). Conclusions: Near-infrared irradiation increases the survival length of axial pattern flaps in rats.

Vortex leading edge flap assembly for supersonic airplanes

NASA Technical Reports Server (NTRS)

Rudolph, Peter K. C. (Inventor)

1997-01-01

A leading edge flap (16) for supersonic transport airplanes is disclosed. In its stowed position, the leading edge flap forms the lower surface of the wing leading edge up to the horizontal center of the leading edge radius. For low speed operation, the vortex leading edge flap moves forward and rotates down. The upward curve of the flap leading edge triggers flow separation on the flap and rotational flow on the upper surface of the flap (vortex). The rounded shape of the upper fixed leading edge provides the conditions for a controlled reattachment of the flow on the upper wing surface and therefore a stable vortex. The vortex generates lift and a nose-up pitching moment. This improves maximum lift at low speed, reduces attitude for a given lift coefficient and improves lift to drag ratio. The mechanism (27) to move the vortex flap consists of two spanwise supports (24) with two diverging straight tracks (64 and 68) each and a screw drive mechanism (62) in the center of the flap panel (29). The flap motion is essentially normal to the airloads and therefore requires only low actuation forces.

Biomimetic Beetle-Inspired Flapping Air Vehicle Actuated by Ionic Polymer-Metal Composite Actuator

PubMed Central

Zhao, Yang; Xu, Di; Sheng, Jiazheng; Meng, Qinglong; Wu, Dezhi; Wang, Lingyun; Xiao, Jingjing; Lv, Wenlong; Sun, Daoheng

2018-01-01

During the last decades, the ionic polymer-metal composite (IPMC) received much attention because of its potential capabilities, such as large displacement and flexible bending actuation. In this paper, a biomimetic flapping air vehicle was proposed by combining the superiority of ionic polymer metal composite with the bionic beetle flapping principle. The blocking force was compared between casted IPMC and IPMC. The flapping state of the wing was investigated and the maximum displacement and flapping angle were measured. The flapping displacement under different voltage and frequency was tested. The flapping displacement of the wing and the support reaction force were measured under different frequency by experiments. The experimental results indicate that the high voltage and low frequency would get large flapping displacement. PMID:29682006

Pressure investigation of NASA leading edge vortex flaps on a 60 deg Delta wing

NASA Technical Reports Server (NTRS)

Marchman, J. F., III; Donatelli, D. A.; Terry, J. E.

1983-01-01

Pressure distributions on a 60 deg Delta Wing with NASA designed leading edge vortex flaps (LEVF) were found in order to provide more pressure data for LEVF and to help verify NASA computer codes used in designing these flaps. These flaps were intended to be optimized designs based on these computer codes. However, the pressure distributions show that the flaps wre not optimum for the size and deflection specified. A second drag-producing vortex forming over the wing indicated that the flap was too large for the specified deflection. Also, it became apparent that flap thickness has a possible effect on the reattachment location of the vortex. Research is continuing to determine proper flap size and deflection relationships that provide well-behaved flowfields and acceptable hinge-moment characteristics.

Noise Reduction of Aircraft Flap

NASA Technical Reports Server (NTRS)

Hutcheson, Florence V. (Inventor); Brooks, Thomas F. (Inventor)

2009-01-01

A reduction in noise radiating from a side of a deployed aircraft flap is achieved by locating a slot adjacent the side of the flap, and then forcing air out through the slot with a suitable mechanism. One, two or even three or more slots are possible, where the slot is located at one;or more locations selected from a group of locations comprising a top surface of the flap, a bottom surface of the flap, an intersection of the top and side surface of the flap, an intersection of the bottom and side surfaces of the flap, and a side surface of the flap. In at least one embodiment the slot is substantially rectangular. A device for adjusting a rate of the air forced out through the slot can also be provided.

Experimental study on thrust and power of flapping-wing system based on rack-pinion mechanism.

PubMed

Nguyen, Tuan Anh; Vu Phan, Hoang; Au, Thi Kim Loan; Park, Hoon Cheol

2016-06-20

This experimental study investigates the effect of three parameters: wing aspect ratio (AR), wing offset, and flapping frequency, on thrust generation and power consumption of a flapping-wing system based on a rack-pinion mechanism. The new flapping-wing system is simple but robust, and is able to create a large flapping amplitude. The thrust measured by a load cell reveals that for a given power, the flapping-wing system using a higher wing AR produces larger thrust and higher flapping frequency at the wing offset of 0.15[Formula: see text] or 0.20[Formula: see text] ([Formula: see text] is the mean chord) than other wing offsets. Of the three parameters, the flapping frequency plays a more significant role on thrust generation than either the wing AR or the wing offset. Based on the measured thrusts, an empirical equation for thrust prediction is suggested, as a function of wing area, flapping frequency, flapping angle, and wing AR. The difference between the predicted and measured thrusts was less than 7%, which proved that the empirical equation for thrust prediction is reasonable. On average, the measured power consumption to flap the wings shows that 46.5% of the input power is spent to produce aerodynamic forces, 14.0% to overcome inertia force, 9.5% to drive the rack-pinion-based flapping mechanism, and 30.0% is wasted as the power loss of the installed motor. From the power analysis, it is found that the wing with an AR of 2.25 using a wing offset of 0.20[Formula: see text] showed the optimal power loading in the flapping-wing system. In addition, the flapping frequency of 25 Hz is recommended as the optimal frequency of the current flapping-wing system for high efficiency, which was 48.3%, using a wing with an AR of 2.25 and a wing offset of 0.20[Formula: see text] in the proposed design.

[Effects and related mechanism of bivalirudin on the survival of random skin flap on the back of rat].

PubMed

Cai, L Y; Wang, T; Lin, D S; Lu, D

2017-04-20

Objective: To investigate the effects and related mechanism of bivalirudin on the survival of random skin flap on the back of rat. Methods: Thirty SD rats were divided into bivalirudin group and normal saline group according to the random number table, with 15 rats in each group. The random flap model with size of 9 cm×3 cm was reproduced on the back of rats in two groups. Immediately post injury, rats in bivalirudin group were intraperitoneally injected with 5 mg/mL bivalirudin (0.8 mL/kg), while rats in normal saline group were intraperitoneally injected with normal saline (0.8 mL/kg) once a day. The continuous injection lasted for 7 days. The flap was divided into distal area, middle area and proximal area averagely based on the flap blood supply. On post injury day (PID) 1, 3, and 7, the overall survival of each area of flap was observed with naked eyes. On PID 7, the survival rate of flap was calculated, and then the morphology of skin tissue at the center of the three areas of flap was observed by HE staining, the microvessel density (MVD) of the middle area of flap was calculated, and the expression of vascular endothelial growth factor (VEGF) of the middle area of flap was detected with immunohistochemical staining. Data were processed with t test. Results: (1) On PID 1, flaps of rats in two groups had different degrees of swelling, mainly concentrated in distal area, but there was no obvious necrosis. The middle area and proximal area of flaps in two groups were survived. On PID 3, the necrosis of flaps of rats in two groups was concentrated in the middle area, while the proximal area of flap was still in survival state, and most distal area of flap was necrosis with a little scab. On PID 7, the necrosis of middle area of flaps of rats in two groups was gradually fused, and the survival area of flap of rats in bivalirudin group was larger than that in normal saline group. The distal area of flap was almost necrotic, and the proximal area of flap was almost survived. (2) On PID 7, the survival rate of flap of rats in bivalirudin group was (64±4)%, significantly higher than that in normal saline group [(45±3)%, t =13.49, P <0.01]. (3) On PID 7, the histological morphology of distal area of flap of rats in two groups was similar, the inflammatory cells were infiltrated abundantly, and tissue edema was obvious. A large number of new blood vessels appeared in the middle area of flap of rats in bivalirudin group, with the formation of collateral vessels, and basic dilation of new blood vessels was seen. There were fewer new blood vessels appeared in the middle area of flap of rats in normal saline group, and dilation of new blood vessels was not obvious. There was little inflammatory cells infiltration in the proximal area of flap of rats in two groups. Compared with that in normal saline group, tissue edema extent of proximal area of flap of rats in bivalirudin group was less, and expansion was observed in more blood vessels. (4) The MVD of middle area of flap of rats in bivalirudin group was (26±5)/mm(2,) significantly higher than that in normal saline group [(18±3)/mm(2,) t =5.43, P <0.05]. (5) The expression of VEGF of middle area of flap of rats in bivalirudin group was 6 534±384, significantly higher than that in normal saline group (4 659±448, t =12.31, P <0.05). Conclusions: Bivalirudin can promote the survival of random skin flap in rats, and the mechanisms may include reducing the formation of thrombosis, improving the blood supply of flap, and increasing the expression of VEGF, promoting the formation of new blood vessels.

Early experience with the free lumbar artery perforator flap for breast reconstruction.

PubMed

Peters, Kevin T; Blondeel, Phillip N; Lobo, Fernando; van Landuyt, Koenraad

2015-08-01

Autologous breast reconstruction has become a progressively more popular method of breast reconstruction. A wide variety of perforator flaps have been described and subsequently refined to decrease donor-site morbidity. Recently, the lumbar artery perforator (LAP) flap has been reported as an option for autologous breast reconstruction. This study summarises the prospectively gathered data of 35 free LAP flaps for breast reconstruction in 28 patients. The mean follow-up was 18 months. The internal mammary artery and the venae comitantes were used as recipient vessels in all reconstructions. In 80% of the reconstructions (28 flaps), an interposition graft was used. Six flaps (17%) had to be revised for venous thrombosis. Two of the revised flaps (5.7%) could not be salvaged, and total flap necrosis occurred. The mean operating time was 6 h and 15 min, 6 h and 39 min when an interposition graft was used and 5 h and 23 min when no interposition graft was necessary. The LAP flap should be considered as a further alternative for breast reconstruction in patients in whom a deep inferior epigastric artery perforator (DIEAP) flap is not possible or not desirable. Shaping of this flap is easier compared to any other flaps due to the quality of the lumbar fat and the gluteal extension. An interposition graft is frequently used to facilitate anastomosis, either to lengthen the pedicle or to resolve size mismatch. This is a disadvantage of the LAP flap. Copyright © 2015 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

Full-scale Wind-tunnel and Flight Tests of a Fairchild 22 Airplane Equipped with External-airfoil Flaps

NASA Technical Reports Server (NTRS)

Reed, Warren D; Clay, William C

1937-01-01

Wind-tunnel and flight tests have been made of a Fairchild 22 airplane equipped with a wing having external-airfoil flaps that also perform the function of ailerons. Lift, drag, and pitching-moment coefficients of the airplane with several flap settings, and the rolling- and yawing-moment coefficients with the flaps deflected as ailerons were measured in the full-scale tunnel with the horizontal tail surfaces and propeller removed. The effect of the flaps on the low speed and on the take-off and landing characteristics, the effectiveness of flaps when used as ailerons, and the forces required to operate them as ailerons were determined in flight. The wind-tunnel tests showed that the flaps increased the maximum lift coefficient of the airplane from 1.51 with the flap in the minimum drag position to 2.12 with the flap in the minimum drag position to 2.12 with the flap deflected 30 degrees. In the flight tests the minimum speed decreased from 46.8 miles per hour with the flaps up to 41.3 miles per hour with the flaps deflected. The required take-off run to attain a height of 50 feet was reduced from 820 to 750 feet and the landing run from a height of 50 feet was reduced from 930 to 480 feet. The flaps for this installation gave lateral control that was not entirely satisfactory. Their rolling action was good but the adverse yaw resulting from their use was greater than is considerable, and the stick forces required to operate them increased too rapidly with speed.

Lower Extremity Reconstruction with Free Gracilis Flaps

PubMed Central

Nicoson, Michael C; Parikh, Rajiv P; Tung, Thomas H

2017-01-01

Background There have been significant advancements in lower extremity reconstruction over the last several decades, and the plastic surgeon’s armamentarium has grown to include free muscle and fasciocutaneous flaps along with local perforator and propeller flaps. While we have found a use for a variety of techniques for lower extremity reconstruction, the free gracilis has been our workhorse flap due to the ease of harvest, reliability, and low donor site morbidity. Methods This is a retrospective review of a single surgeon’s series of free gracilis flaps utilized for lower extremity reconstruction. Demographic information, comorbidities, outcomes and secondary procedures were analyzed. Results We identified 24 free gracilis flaps. The duration from injury to free flap coverage was 7 days or less in 6 patients, 8–30 days in 11 patients, 31–90 days in 4 patients, and > 90 days in 3 patients. There were 22 (92%) successful flaps and an overall limb salvage rate of 92%. There was one partial flap loss. Two flaps underwent incision and drainage in the operating room for infection. Two patients developed donor site hematomas. Four patients underwent secondary procedures for contouring. Our subset of pediatric patients had 100% flap survival and no secondary procedures at a mean 30 month follow up. Conclusions This study demonstrates the utility of the free gracilis flap in reconstruction of small to medium sized defects of the lower extremity. This flap has a high success rate and low donor site morbidity. Atrophy of the denervated muscle over time allows for good shoe fit, often obviating the need for secondary contouring procedures. PMID:28024305

The First Dorsal Metatarsal Artery Perforator Propeller Flap.

PubMed

Hallock, Geoffrey G

2016-06-01

Distal foot and toe defects requiring a vascularized flap for coverage have very limited options, oftentimes justifying even a free flap. Perforator flaps in general and propeller flaps in particular have opened up an entirely new subset of local tissue transfer alternatives that can potentially avoid the difficulties that accompany microvascular tissue transfers. The first dorsal metatarsal artery (FDMA) perforator propeller flap represents another variation of this theme. A standard FDMA flap from the dorsum of the foot was raised in reversed fashion based on the distal communicating branch or "perforator" from the plantar foot circulation in 2 patients with great toe defects. All distal skin tissue between this perforator and the defect was kept with the FDMA flap as an attached minor blade, to thereby create an FDMA propeller flap. Salvage of the great toe in both patients was achieved. The benefit of the minor blade of the propeller was to fill a portion of the donor site defect of the traditional FDMA major blade, to permit tension-free donor site closure of the dorsal foot without sequela. The distal-based FDMA flap can be useful as a local flap for coverage of distal foot and toe wounds, but direct donor site closure can be problematic as mirrored by its relative the dorsalis pedis flap. The FDMA perforator propeller flap variation can achieve the same reconstructive goals while simultaneously transferring vascularized tissue into the dorsal foot donor site to thereby minimize the tension if direct closure is possible or minimize the need for a skin graft in this notoriously difficult region.

Internal limiting membrane flap transposition for surgical repair of macular holes in primary surgery and in persistent macular holes.

PubMed

Leisser, Christoph; Hirnschall, Nino; Döller, Birgit; Varsits, Ralph; Ullrich, Marlies; Kefer, Katharina; Findl, Oliver

2018-03-01

Classical or temporal internal limiting membrane (ILM) flap transposition with air or gas tamponade are current trends with the potential to improve surgical results, especially in cases with large macular holes. A prospective case series included patients with idiopathic macular holes or persistent macular holes after 23-G pars plana vitrectomy (PPV) and ILM peeling with gas tamponade. In all patients, 23-G PPV and ILM peeling with ILM flap transposition with gas tamponade and postoperative face-down position was performed. In 7 of 9 eyes, temporal ILM flap transposition combined with pedicle ILM flap could be successfully performed and macular holes were closed in all eyes after surgery. The remaining 2 eyes were converted to pedicle ILM flap transposition with macular hole closure after surgery. Three eyes were scheduled as pedicle ILM flap transposition due to previous ILM peeling. In 2 of these eyes, the macular hole could be closed with pedicle ILM flap transposition. In 3 eyes, free ILM flap transposition was performed and in 2 of these eyes macular hole could be closed after surgery, whereas in 1 eye a second surgery, performed as pedicle ILM flap transposition, was performed and led to successful macular hole closure. Use of ILM flaps in surgical repair of macular hole surgery is a new option of treatment with excellent results independent of the diameter of macular holes. For patients with persistent macular holes, pedicle ILM flap transposition or free ILM flap transposition are surgical options.

My First 100 Consecutive Microvascular Free Flaps: Pearls and Lessons Learned in First Year of Practice

PubMed Central

2013-01-01

Background: Microvascular reconstruction for oncologic defects is a challenging and rewarding endeavor, and successful outcomes are dependent on a multitude of factors. This study represents lessons learned from a personal prospective experience with 100 consecutive free flaps. Methods: All patients’ medical records were reviewed for demographics, operative notes, and complications. Results: Overall 100 flaps were performed in 84 consecutive patients for reconstruction of breast, head and neck, trunk, and extremity defects. Nineteen patients underwent free flap breast reconstruction with 10 patients undergoing bilateral reconstruction and 2 patients receiving a bipedicle flap for reconstruction of a unilateral breast defect. Sixty-five free flaps were performed in 61 patients with 3 patients receiving 2 free flaps for reconstruction of extensive head and neck defects and 1 patient who required a second flap for partial flap loss. Trunk and extremity reconstruction was less common with 2 free flaps performed in each group. Overall, 19 patients (22.6%) developed complications and 14 required a return to the operating room. There were no flap losses in this cohort. Thorough preoperative evaluation and workup, meticulous surgical technique and intraoperative planning, and diligent postoperative monitoring and prompt intervention are critical for flap success. Conclusions: As a young plastic surgeon embarking in reconstructive plastic surgery at an academic institution, the challenges and dilemmas presented in the first year of practice have been daunting but also represent opportunities for learning and improvement. Skills and knowledge acquired from time, experience, and mentors are invaluable in optimizing outcomes in microvascular free flap reconstruction. PMID:25289221

[Pedicled versus free TRAM flap for breast reconstruction].

PubMed

Galla, T J; Lukas, B; Feller, A M

1999-03-01

In breast reconstruction, the free TRAM-flap offers many advantages over the pedicled TRAM-flap. Due to its superior perfusion, the free flap rarely develops necrosis. Shaping of the flap is easier due to the lack of the thick muscle pedicle. Because the rectus muscle is spared, there is minimal donor site morbidity. However, the necessary microvascular anastomoses reduced the acceptance of the free TRAM-flap. During a 13-months period, 51 breast reconstructions were performed in 41 patients, 31 unilateral and ten bilateral. 45 flaps served for delayed reconstruction and six flaps for immediate reconstruction. The operations were performed by two teams working simultaneously. The average operating time was 3.9 hours for unilateral and 6.9 hours for bilateral delayed reconstruction. For immediate reconstruction, 6.2 and 6.3 hours were required for uni- and bilateral procedures, respectively. In 38 flaps, the thoracodorsal vessels served as recipient vessels; 13 flaps were anastomosed to the internal mammary artery and vein. Postoperative complications were observed in 13 patients. Three vessel anastomoses had to be revised. In one flap, a partial necrosis occurred; in two flaps hematoma evacuation was necessary. Two patients suffered from fat necroses at the abdomen and one umbilicus was lost. Skin irritations and seromas at the abdomen occurred in five patients. Pulmonary embolism was diagnosed in one patient three weeks postoperatively. Abdominal hernias or bulging in the epigastric area were not observed up to 15 months after reconstruction. These results reveal a low complication rate for breast reconstruction with the free TRAM-flap. The advantages of this technique as compared to the pedicled technique are discussed.

Reproducibility of flap thickness with IntraLase FS and Moria LSK-1 and M2 microkeratomes.

PubMed

Talamo, Jonathan H; Meltzer, Jeremy; Gardner, John

2006-06-01

To compare flap thickness reproducibility of the femtosecond laser and two mechanical microkeratomes. Flap thickness for all eyes was measured as the difference between the preoperative (day of surgery) full corneal thickness and post-flap creation central stromal bed thickness using ultrasonic pachymetry. Flap thickness values produced by three different microkeratome systems were compared for accuracy and reproducibility. For 99 flaps created using the IntraLase FS laser with an intended thickness of 110 microm, the mean achieved thickness was 119 +/- 12 microm (range: 82 to 149 microm). In 100 eyes treated with the Moria LSK-1 microkeratome with an intended flap thickness of 160 microm, the mean achieved thickness was 130 +/- 19 microm (range: 71 to 186 microm). In 135 eyes treated with the Moria M2 microkeratome with an intended flap thickness of 130 microm, mean thickness was 142 +/- 24 microm (range: 84 to 203 microm). The standard deviation and range of corneal flap thickness created with the IntraLase FS laser was significantly smaller than either mechanical microkeratome (P < .0001). When compared to two commonly used mechanical microkeratomes, mean achieved flap thickness was more reproducible with the IntraLase FS laser, reducing the comparative risk of overly thick flaps.

Propeller flaps in eyelid reconstruction.

PubMed

Rajak, Saul N; Huilgol, Shyamala C; Murakami, Masahiro; Selva, Dinesh

2018-03-14

Propeller flaps are island flaps that reach the recipient site through an axial rotation. The flap has a subcutaneous pedicle on which it pivots, thereby resembling a helicopter propeller. We present our series of propeller flaps for the reconstruction of large eyelid defects. This is a retrospective review of the clinical case notes of eight patients that underwent tumour excision with reconstruction with a cutaneous propeller flap supplied by a non-perforator orbicularis pedicle between July and December 2016. Propeller flaps were used in the reconstruction of five lower lid defects (size range 19 × 5 mm to 25 × 8 mm), one medial canthus defect (13 mm diameter), one complete upper lid defect (42 × 19 mm diameter) and one lid sparing extenteration defect. The flaps were recruited from nasolabial, lateral canthal, temple or medial upper cheek skin. Post-operatively one case had 'trapdooring' which required flap revision at 4 months and one had persistent oedema that settled without intervention. The reconstruction of large eyelid defects is challenging in part because of the paucity of locally available skin. Propeller flaps are a paradigm shift in periocular reconstruction in which the subcutaneous pedicle enables the recruitment of large and highly mobile skin flaps from a wide area of regional tissue.

A simple concept for covering pressure sores: wound edge-based propeller perforator flap.

PubMed

Kelahmetoglu, Osman; Van Landuyt, Koenraad; Yagmur, Caglayan; Sommeling, Casper E; Keles, Musa K; Tayfur, Volkan; Simsek, Tekin; Demirtas, Yener; Guneren, Ethem

2017-12-01

We present a new surgical modification to allow propeller perforator flaps to cover pressure sores at various locations. We used a propeller perforator flap concept based on the detection of newly formed perforator vessels located 1 cm from the wound margin and stimulated by the chronic inflammation process. Between January 2009 and January 2017, 33 wound edge-based propeller perforator flaps were used to cover pressure sores at various locations in 28 patients. In four cases more than one flap was used on the same patient. The patients comprised 18 males and 10 females with a mean age of 41·25 (range, 16-70) years. All patients underwent follow-up for 0-12 months. The mean follow-up duration was 5·03 months. Venous congestion was observed in three flaps that were rotated by 180° (9·1%). However, there was a significant difference between flaps rotated by 90° and 180° according to the complication rate (P = 0·034). Out of 33 flaps, 29 flaps healed uneventfully. Patients were able to sit and lie on their flaps three weeks after surgery. In our study, we were able to obtain satisfying final results using these novel flaps. © 2017 Medicalhelplines.com Inc and John Wiley & Sons Ltd.

Latissimus dorsi myocutaneous flap for breast reconstruction: bad rap or good flap?

PubMed

Perdikis, Galen; Koonce, Stephanie; Collis, George; Eck, Dustin

2011-01-01

This article serves to review latissimus dorsi myocutaneous flap as an option for breast reconstruction postmastectomy. Since the introduction of the latissimus dorsi myocutaneous flap in the late 1970s, its use has always been as a secondary technique, particularly after the development of the transverse rectus abdominus myocutaneous flap in the 1980s. A literature review of the history of latissimus dorsi myocutaneous flap utilized for breast reconstruction as well as a review of our institution's experience with latissimus dorsi myocutaneous flap and tissue expander placement was performed. There remains a paucity of published studies investigating latissimus dorsi myocutaneous flap for breast reconstruction. Most studies have small numbers and do not utilize tissue expanders. More recently several small studies have been published that show acceptably low complication rates with aesthetically pleasing outcomes when latissimus dorsi myocutaneous flap is employed with a tissue expander. At our institution, we have employed latissimus dorsi myocutaneous flap with tissue expander placement for both delayed and immediate reconstruction with subsequent replacement with a permanent implant with a capsular contraction rate of 10.5%. Our data and others more recently published demonstrate very acceptable capsular contracture rates and aesthetic outcomes, particularly when an expander is utilized. The latissimus dorsi myocutaneous flap remains an excellent choice for breast reconstruction with a low risk of complications.

[Aesthetic reconstruction strategy for postburn facial scar and its clinical effect].

PubMed

Ma, X J; Li, W Y; Liu, C H; Li, Y

2016-08-20

To explore the aesthetic reconstruction strategy for postburn facial scar and its clinical effect. Three hundred and forty-two patients with postburn facial scars were hospitalized from January 2000 to December 2015. Local expanded flap or deltopectoral expanded flap was used for reconstruction according to the location and size of the facial scar. The forehead expanded flap could be chosen for the scar in dorsum nasi or inferior eyelid. The local expanded flap was chosen when the scar width was smaller than 5 cm in cheek, chin, and marginal mandible region. The expanded deltopectoral flap was chosen when the scar width was larger than 5 cm in cheek, chin, and marginal mandible region or the scar contracture was too serious to cause displacement of lips, nose, or eyelid, and the wound width was larger than 5 cm after release. The facial scars of 82 patients, with size ranged from 6.0 cm×2.5 cm to 15.0 cm×10.0 cm, were reconstructed with expanded local flaps. The facial scars of 260 patients, with size ranged from 8.0 cm×7.0 cm to 38.0 cm×13.0 cm, were reconstructed with expanded deltopectoral flaps. After expansion of 2 to 6 months, the facial scars were excised and completely released first of all. The transfer way of local flap and size of deltopectoral flap with pedicle were designed according to the size and shape of the wound. Three weeks after transfer of deltopectoral flap, flap delay procedure was conducted. One week later, the pedicle was severed from the flap to reconstruct the remaining scar. Anti-scar medicine, laser therapy, and elasticized fabric were used postoperatively on the scars in both donor and recipient sites. During the postoperative follow-up for 3 to 12 months, the flaps of 40 out of 82 cases reconstructed with expanded local flaps were in good color and texture. Before 2008, mild scar hyperplasia was observed in the incision of 19 patients; with application of laser after 2008, the number of patients with scar hyperplasia was decreased. During the postoperative follow-up for 3 to 12 months, the flaps of 90 out of 260 cases reconstructed with expanded deltopectoral flaps were in good color and texture. The expander was exposed from the incision in 15 patients, while it did not affect the later treatment. Nine unilateral flaps showed poor blood circulation at the distal end, and they were healed after dressing change. In the early phase, necrosis was observed in one flap after transfer, and it was healed after transplantation of free skin graft. Scar hyperplasia was observed in the chest donor site of one patient, and it was improved after laser therapy. Postburn facial scar could be reconstructed with local or deltopectoral flaps, following the principle of similarity. The expansion could increase the size of the flaps, reduce the thickness of the flaps, and lower the donor site damage.