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

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

Using 2-step PCR and restriction endonuclease digestion to detect K-ras mutation in paraffin-embedded tissues: is it reliable?

BACKGROUND: Among the myocutaneous island flaps applied for reconstruction of large soft-tissue defects after ablative surgery for malignomas, the pectoralis major flap is the one most frequently used. In comparison, the sternocleidomastoid myocutaneous island flap is not as popular. METHODS: We report on our experiences with the superiorly based sternocleidomastoid myocutaneous (SCM) island flap (cutaneous island of 6-8 cm in diameter) in seven consecutive cases after resection of malignomas of the oral cavity and the pharynx. The vascularization from the occipital artery is additionally supplied by preserving the platysma during preparation of the SCM flap. RESULTS: Only one total cutaneous necrosis was observed in a patient who had received prior radiation. In the other 6 cases no major complications (necrosis or fistula) occurred. CONCLUSION: When the preservation of the sternocleidoid muscle does not compromise oncologic principles as in cases with limited lymphe node involvement (N0-N1), the SCM flap appears to be a useful and simple technique, particularly in female patients compared with the pectoralis major flap, in addition to others.     

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

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

A severe reaction to carbamazepine: consequences for patient monitoring

Surgical reconstruction of ischial pressure sores is technically complex and presents a significant problem. Although there is consensus about the use of muscle or myocutaneous flaps in the closure of these sores, there is still dispute about which muscle or myocutaneous flap to use. This evaluation describes the use of the gracilis myocutaneous flap for the treatment of wide and chronic ischial pressure sores. Details of 14 cases are presented and compared with those described in the literature.     

Use of a nitric oxide precursor to protect pig myocutaneous flaps from ischemia-reperfusion injury

Nitric oxide is a radical with vasodilating properties that protects tissues from neutrophil-mediated ischemia-reperfusion injury in the heart and intestine. Previous studies in our laboratory suggested that L-arginine, a nitric oxide precursor, can protect skin flaps from ischemia-reperfusion injury. In this study, we examined the effects of L-arginine on the survival of myocutaneous flaps in a large animal model and established whether this effect was mediated by nitric oxide and neutrophils. Two superiorly based 15 x 7.5 cm epigastric myocutaneous island flaps were dissected in 15 Yorkshire pigs weighing 45 to 50 kg. One of the flaps was subjected to 6 hours of arterial ischemia and then reperfused for 4 hours (ischemia-reperfusion flaps), whereas the other flap was used as a non-ischemic control (non-ischemia-reperfusion flaps). The flaps were divided into four groups: control non-ischemia-reperfusion flaps that received only saline (group I); ischemia-reperfusion flaps that were treated with saline (group II); and flaps treated with either L-arginine (group III) or Nomega-nitro-L-arginine methylester (L-NAME), a nitric oxide synthase competitive inhibitor, plus L-arginine in equimolar amounts (group IV). These drugs were administered as an intravenous bolus 10 minutes before the onset of reperfusion, followed by a 1-hour continuous intravenous infusion. Full-thickness muscle biopsies were taken at baseline, 3 and 6 hours of ischemia, and 1 and 4 hours of reperfusion. The biopsies were evaluated by counting neutrophils and measuring myelo-peroxidase activity. At the end of the experiment, skeletal muscle necrosis was quantified using the nitroblue tetrazolium staining technique, and a full-thickness biopsy of each flap was used for determination of water content. Statistical analysis was performed using analysis of variance and the Newman-Keuls test. Non-ischemia-reperfusion flaps showed no muscle necrosis. Ischemia-reperfusion flaps treated with saline had 68.7 +/- 9.1 percent necrosis, which was reduced to 21.9 +/- 13.6 percent with L-arginine (p < 0.05). L-NAME administered concomitantly with L-arginine demonstrated a necrosis rate similar to that of saline-treated ischemia-reperfusion flaps (61.0 +/- 17.6 percent). Neutrophil counts and myeloperoxidase activity after 4 hours of reperfusion were significantly higher in ischemia-reperfusion flaps treated with L-NAME and L-arginine as compared with the other three groups (p < 0.05). Flap water content increased significantly in ischemia-reperfusion flaps treated with saline and L-NAME plus L-arginine versus non-ischemia-reperfusion flaps (p < 0.02) and L-arginine-treated ischemia-reperfusion flaps (p < 0.05). There was no difference in flap water content between ischemia-reperfusion flaps treated with L-arginine and non-ischemia-reperfusion flaps. Administration of L-arginine before and during the initial hour of reperfusion significantly reduced the extent of flap necrosis, neutrophil accumulation, and edema due to ischemia-reperfusion injury in a large animal model. This protective effect is completely negated by the use of the nitric oxide synthase blocker L-NAME. The mechanism of action seems to be related to nitric oxide-mediated suppression of ischemia-reperfusion injury through neutrophil activity inhibition.     

A method that preserves circulation during preparation of the pectoralis major myocutaneous flap in head and neck reconstruction

The present article describes a method that preserves circulation during the preparation of the pectoralis major myocutaneous flap used in head and neck reconstruction. The major disadvantage of this flap is its poor circulation and consequent partial necrosis. To solve this problem, we analyzed the circulation and hemodynamics of the pectoralis major myocutaneous flap (the perforator of the anterior intercostal branch located about 1 to 2 cm medial to the areola in the fourth intercostal space is important), evaluated the safe donor sites in the chest wall for a skin island (the perforator is included on the skin island's central axis), improved the surgical procedure for elevating flaps (for preventing perforator injuries), and devised a means to transfer flaps, thereby increasing the range of the flaps (the transfer route is under the clavicle). Using this technique, head and neck reconstruction was performed on 62 patients. The diagnosis included oral cancer (21), oropharyngeal carcinoma (10), parotid carcinoma (10), hypopharyngeal carcinoma (9), and other head and neck malignant tumors (12). Of these, partial or marginal necrosis of the flap caused by circulatory problems was detected in three patients (5 percent). Using our method, the problems associated with inadequate circulation in the pectoralis major myocutaneous flap were greatly alleviated, thus reconfirming the usefulness of this flap in head and neck reconstruction.     

The distally based forearm island flap in hand reconstruction

The distally based forearm island flap is vascularized by the perforators of the distal radial artery. The skin flap is along the axis of the radial artery, and the pivot point of its subcutaneous pedicle is about 2 to 4 cm above the radial styloid process. We have treated 12 patients with 12 flaps for soft-tissue defects of the hand. Of these recipient sites, seven were in dorsal hands, two were in thumbs, two were in forearms, and one was in the palmar area. The donor-tissue variants included eight skin flaps, two adipofascial flaps, and two sensate flaps. The sizes of the flaps ranged from 6 x 4 cm to 14 x 6 cm. The donor site wound could be closed primarily in five patients. Two sensate flaps, innervated by the lateral antebrachial cutaneous nerve, could provide sensation for thumb reconstruction. The advantage of this flap is its constant and reliable blood supply without sacrifice of the main radial artery. The elevation of the flap is simple and rapid. There is the potential that this flap can be used as an innervated flap, and there is no need of microsurgical technique.     

Postoperative sensitivity of vascular pedicles latissimus dorso transplant without neural anastomosis

It is still a matter of controversy whether anastomosis of the sensory nerves is necessary in free transplants of microvascular reanastomosed myocutaneous latissimus dorsi flaps in the oral cavity and oropharynx. Some surgeons perform this routinely because they expect fewer complications in skin with a sensory nerve supply. We clinically examined 30 patients in order to assess the sensory innervation of the transplant tissue. All patients received free transplants of microvascular reanastomosed latissimus dorsi flaps during a tumor operation in the oral cavity. Sensation was determined clinically according to pain, temperature, pressure, two point discrimination and vibration. In most patients sensation in the Latissimus dorsi flap does not return. These findings suggest that reinnervation in the myocutaneous latissimus dorsi flap mostly does not occur, indicating that there is a need for anastomosis of a sensory nerve during transplant surgery with a myocutaneous latissimus dorsi flap to reinnervate it.     

Stimulation of angiogenesis to improve the viability of prefabricated flaps

The cutaneous area in a prefabricated myocutaneous flap surviving after elevation is dependent on the rate and amount of vascular ingrowth that occurs from the underlying muscle. Two modalities, basic fibroblast growth factor and hyperbaric oxygen, were used separately and together in a prefabricated myocutaneous flap animal model to improve flap survival. The semimembranous muscle, based on the saphenous vessels of 40 female Wistar rats weighing between 250 and 325 grams, was tunneled under the ipsilateral abdominal skin and sutured in place. A 3 x 5-cm silicone sheet was placed beneath the muscle flap, and the ipsilateral epigastric vessels were ligated. Four groups of 10 animals each received one of the following treatment regimes: a 1-ml normal saline infusion into the saphenous arterial pedicle, a 1-ml infusion of basic fibroblast growth factor (1.0 microg/gm of muscle), a 1-ml normal saline infusion and 14 hyperbaric oxygen treatments, or a 1-ml basic fibroblast growth factor infusion and 14 hyperbaric oxygen treatments. After 1 week, the muscle, still based on the saphenous vessels, was elevated with a 3 x 5-cm abdominal skin paddle. The flap was sutured back in place, leaving the silicone sheet intact. The surviving area of each flap was measured 1 week later after it had demarcated into viable and necrotic regions. Laser Doppler skin perfusion measurements were taken before and after flap elevation and before animal euthanasia. Sixteen flaps, 4 in each group, were examined histologically for vascularity by means of hematoxylin and eosin staining. There was a statistically significant increase in flap survival area when either basic fibroblast growth factor or hyperbaric oxygen was used alone. Further improvement was noted with combination therapy. Histology confirmed improved vascularity in the basic fibroblast growth factor and hyperbaric oxygen-treated flaps. This study shows a significant and reliable increase in the area of prefabricated myocutaneous flap survival using either basic fibroblast growth factor or hyperbaric oxygen. There is a further complementary effect when these two modalities are combined, leading to near complete flap survival through improved vascularity.     

Magnetic resonance imaging of nonhealing pressure ulcers and myocutaneous flaps

OBJECTIVE: To evaluate the use of magnetic resonance imaging (MRI) in making clinical decisions when assessing nonhealing pressure ulcers and nonhealing myocutaneous flaps for the presence of an abscess, osteomyelitis, sinus tracts, and fluid collections. DESIGN: Retrospective review of patient charts and radiographic studies. SETTING: Regional spinal cord injury center. SUBJECTS: Twelve patients who had MRI as part of their evaluation for a nonhealing pressure ulcer or myocutaneous flap. RESULTS: Seven patients had MRI for preoperative evaluation, four with a previous flap that had recurrent breakdown and three with a new grade III or IV ulcer. Five patients had MRI for postoperative evaluation of myocutaneous flaps with delayed healing. MRI was useful in identifying osteomyelitis in three patients and sinus tracts that required surgical revision in six patients. MRI was also used in two patients to assess the size of fluid collections postoperatively in determining whether the patients should be mobilized after surgery. These chronic nonhealing wounds resulted in multiple admissions and lengthy hospital stays and required multiple surgical revisions. Patients who did poorly with healing or had repeated breakdown tended to have concurrent issues such as poor self care, increased age, increased time of spinal cord injury, poor nutrition, or other medical problems. CONCLUSION: Chronic nonhealing pressure ulcers and myocutaneous flaps can be difficult to treat and evaluate with conventional methods. There are multiple reasons for failure to heal. MRI can be a useful tool for identifying some of these factors including osteomyelitis, fluid collections, abcesses, and sinus tracts in the perioperative period. Identifying the appropriate patient populations and clinical indications for the optimal use of MRI should be subject of further study.     

The application of distally based fascial pedicled island flap to rapair wound of the extremities]

In order to preserve the major vessels of the extremities in the repair and reconstruction of wounds of the extremities, the distally based fascial pedicled island flap was applied clinically. Its axis and rotatary point were designed along orientation of the major arteries, and the blood supply was from the abundant vascular networks in the deep fascia. Twenty-two cases with exposure of tendon and bone including 10 upper limbs and 12 lower limbs were treated. The flap area of forearm ranged from 7 cm x 8 cm to 12 cm x 9 cm and the ratio of the length to width of the pedicle was 1: 1-2. The flap area of the calf ranged from 10 cm x 6 cm to 16.5 cm x 12 cm and the ratio of the length to width of the pedicle was 2:1. The rotatary angle was 130 degrees-170 degrees. After operation, 18 flaps were survived completely, 2 cases had partial necrosis on the margin, 2 failures received cross-leg flap in the second operation. The patients were followed up with an average of 13.5 months (ranged from 3 months to 2 years). The conclusions were as follows: 1. the blood supply of this type of flap was reliable and the major arteries of the extremities needed not to be sacrificed; 2. the preparation of the flap was easy and the survival rate was satisfactory; 3. the shortcomings of this flap were unsightly incision scar and the limited size of flap and; 4. during the operation, the compression of the pedicle must be avoided.     

Reconstruction of the head and neck

The collaboration of surgeons, radiation oncologists, chemotherapists, dentists, oral surgeons, prosthodontists, and speech therapists has led to major advances in the management of the difficult cancers of the head and neck area. The advent of myocutaneous flaps and the facilitation of microsurgical free flaps have ushered in an era of one-stage reconstructions to shorten the hospital stay and improve the overall therapeutic, functional, and cosmetic results.     

Minor and major lip reconstruction

Lip reconstruction has made significant advances over the past two decades with refinement of some old techniques and the introduction of new innovative methods. Small and medium defects can be repaired in a variety of ways with similar results. Local lip switch flaps are far superior to any distant tissue. Total lip loss is probably best handled with nasolabial flaps. Extensive resections including the lip, premaxilla, mandible, and skin of the chin and upper neck remain a challenge with all modern techniques, including myocutaneous flaps and free flaps, having little advantage over the standard visor forehead flap.     

Surgical management of pressure ulcers

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

The use of platysmal myocutaneous flaps in laryngeal reconstruction

Vertical frontal subtotal laryngectomy, a procedure that can remove as much as 90% of the larynx, was used to produce a functionally acceptable neolarynx with platysmal myocutaneous flaps. Thirty-two patients with laryngeal carcinoma underwent this operation. All flaps survived and there was no necrosis after operation. With the exception of one patient who require nasal feeding because of an irritating cough when swallowing food, all the other patients regain breathing, swallowing and phonating of laryngeal function. The operative methods, advantages and experiences are discussed in this paper.     

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

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

Clinical application of the distally based medial adipofascial flap for soft tissue defects on the lower half of the leg

OBJECTIVE: Reconstruction of soft tissue defects on the lower half of the leg. DESIGN: The distally based medial adipofascial flap nourished by the lower perforator originating from the posterior tibial artery was harvested, and the pivot point of flap transposition is 9 to 12 cm above the tip of the medial malleolus. MATERIALS AND METHODS: Twelve cases of open tibial fracture associated with soft tissue defects on the lower half of the leg were reconstructed with this flap. The cases consisted of ten males and two females, and their ages ranged from 16 to 71 (averaging 41 years). MEASUREMENTS AND MAIN RESULTS: Size of the flap varied from 4 x 7 cm to 5 x 18 cm. Eleven flaps had good perfusion and survived completely. Tip necrosis of the flap occurred in one case. In the early postoperative period, take of the meshed split-thickness skin graft on the flap was not complete. All wounds, however, were resurfaced completely without the need of a second grafting. Discharging sinuses occurred in one case, which was managed by removal of infected bony fragments. All the donor sites were closed primarily, and desquamation of wound edges occurred occasionally. CONCLUSIONS: The distally based medial adipofascial flap was a reliable and effect local flap for the reconstruction of soft tissue defects on the lower half of the leg.     

Oral hygiene in the control of occlusal caries

In order to be able to objectively evaluate capillary perfusion of venous flaps, we created arterialised venous flaps, venous flow-through flaps, and unilateral pedicled venous island flaps in the epigastric vascular system of Wistar rats and determined their oxygen supply with two different methods. Interstitial pO2 was polarographically measured with a probe placed intracutaneously in the center of the 4 x 2.5 cm flaps and continuously recorded on a connected computer. Moreover, we also noninvasively determined the oxygenation of the intracapillary haemoglobin with a micro-lightguide spectrophotometer. The statistical evaluation showed comparable results for both measurement methods: Arterialised venous flaps had a better oxygen supply with a pO2 of 16 mmHg and an Hb oxygenation of 23% than the other types of venous flaps, but they have a poorer oxygen supply than conventionally perfused flaps (pO2: 24 mmHg, Hb oxygenation: 30%). Venous flow-through flaps (pO2: 9 mmHg, Hb oxygenation: 17%) and unilateral pedicled venous island flaps had a significant better oxygen supply than skin flaps without any vascular connection. The results show that the capillary system in all types of venous flaps is reached by some of the inflowing oxygenated haemoglobin over the entire flap surface to different degrees.     

Impact of imported beverages on fluoridated and nonfluoridated communities

In the last 10 years an increasing number of cases of group A streptococcal toxic shock syndrome have appeared in various clinical settings. The manifestation of this syndrome includes rapidly progressive multiorgan failure and soft-tissue necrosis. This report presents a case of streptococcal toxic shock syndrome caused by Streptococcus pyogenes with severe necrotizing fasciitis of the abdominal wall following hysterectomy. Aggressive surgical intervention with debridement of all necrotic tissue necessitated resection of the complete abdominal wall (skin, subcutaneous tissue, muscle and peritoneum). The abdominal wall defect was covered with free myocutaneous flaps and split-skin grafts. Optimal treatment, including adequate antibiotic therapy and radical surgical intervention, is an indispensable prerequisite of successful outcome.     

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

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