The distally based posterior tibial arterial adipofascial flap

A distally based posterior tibial artery adipofascial flap with skin graft was used for the reconstruction of soft tissue defects over the Achilles tendon in three cases and over the heel in three cases. Good resurfacing with protective sensation of these wounds was achieved. There was no breakdown of the graft or morbidity of donor sites, which were closed primarily. We believe there were many advantages to this adipofascial flap and that it is an ideal choice for the reconstruction of soft tissue defects in the lower third of the leg and foot, especially over the Achilles tendon.

Microsurgical replantation of avulsed scalp--two cases report

Two female patients with scalp avulsion were treated successfully by microsurgical replantation. The first patient suffered an avulsion of the right half of scalp and which survived fully after replantation. The second patient suffered avulsion of the entire scalp as well as the forehead skin and nape of the neck. Almost all of the avulsed part survived except partial skin loss in the posterior neck and left occipital area. Only one temporal artery and one vein was anastomosed in each case. Near normal hair growth recurred in both cases.

[Treatment of large skin defect with 6:1 meshed skin autograft and 1.5:1 meshed fresh porcine skin overlay]

The use of expanded mesh skin graft from limited donor sites has greatly increased wound coverage. However, grafts with an expansion size of 6:1 or greater often heal slowly or are lost because of local infection. Three patients with large skin defects in lower extremity have been treated with 6:1 mesh autograft overlayed by 1.5:1 fresh porcine skin mesh graft. Epithelium grown from both grafts could be found. The autografts continuously expanded under the xenografts. The outer xenografts gradually separated and desquamated, on an average, in 14 days. This technique enables resurfacing of a large area of skin defect from smaller donor sites.

The adipofascial turnover flap for elbow coverage

Closure of soft tissue defects in the vicinity of the elbow with exposed bone or joint remains a difficult problem. Local adipofascial turnover flaps covered by a skin graft were successfully used to reconstruct two elbow defects. The flap's base was placed 1.5 to 2.0 cm from the wound edge. The flap-to-base area ratio, which is an important index of flap survival, in addition to the traditional length-to-width ratio were 3.25 and 3.3, respectively. The undermined skin of the flap donor site was preserved rather than discarded as in the conventional deepithelialized turnover flap. The primary benefits of this flap are that it is an easy and rapid one-stage procedure, it requires limited immobilization of the involved joint, and it leaves an inconspicuous donor site scar. The motion of the elbow joint was not impeded because the adiposal component of the flap faced the exposed vital structures. The padding is not thick, but is sufficient to cover and protect the elbow. The flap is especially indicated for small- to medium-sized, complicated elbow wounds.

Microskin grafting of rabbits with pigskin xenograft overlay

Pigskin xenografts were used to replace allografts in microskin grafting (10:1 expansion ratio) on 15 rabbits. Rabbits were selected randomly for the removal of the overlaid pigskin at days 7, 10 or 14 for the evaluation of the degree of epithelialization. Histological examination of the removed pigskin 7 days after application showed obvious eosinophilic changes in the epidermal cells and pyknotic changes of the nuclei, however in some areas newly formed epidermis could be found. The pigskin became an eschar or slough on day 14. The microskin autografts proliferated and expanded actively under the protection of this overlaid pigskin. The epidermis increased in thickness and with increasing differentiation. The dermal layer was well vascularized with a large number of capillaries and fibroblasts. The wound was covered by the neoepithelium with almost normal skin texture on day 14, by which time the overlaid pigskin became a dry eschar. In areas where the overlaid pigskin was sloughing, the epithelialization of the underlying microskin grafts was not complete at the same time. In these animal studies of microskin grafting, these overlaid pigskin xenografts showed the same effects as those of allografts.

Use of a cross-leg free muscle flap to reconstruct an extensive burn wound involving a lower extremity

A young patient sustained a high-voltage burn with extensive destruction of the soft tissue in his left lower extremity. Occlusion of the anterior and posterior tibial arteries, loss of toe extensors and the superficial and deep peroneal nerves were noted, besides the exposure of the lower end of the tibia and metatarsal bones. In the absence of proper recipient vessels, a cross-leg free latissimus dorsi muscle flap with overlying skin and depending on the vessels of the contralateral foot was used successfully for reconstruction of the defect. The pedicle was divided 3 weeks after microvascular anastomosis and the flap survived completely. This technique permits transfer of free flaps to compromised wounds without available recipient vessels, and the latissimus dorsi muscle flap, with its characteristics of large size and copious vascularity, could be split to cover exposed bones in different areas simultaneously.

[Surgical treatment of diffuse scrotal epidermal cysts: case report]

Epidermal cysts are common, benign skin tumors that are found mainly on the face, neck, and trunk. This case was a 53-year-old male bus driver who had suffered from multiple papules on his scrotum for 7 years. This affliction had caused intractable itching and responded poorly to medical treatment. The patient received an excision of these papules (total 32) 3 years ago. According to the pathological reports, these papules were epidermal cysts; unfortunately, these papules recurred within 3 months after the operation and then resulted in itching more severe than before. The patient was again admitted to the hospital ward and received an operation in Oct. 1990. The diseased tissue (14cm x 8cm) was then excised and the defective scrotal skin was covered with a meshed, split-thickness skin graft. The cosmetic result was enhanced by the rugate appearance of the healed meshed graft. The patient was satisfied with both the functional and cosmetic results. The itching sensation on the scrotum improved and there was no recurrence of epidermal cysts within the graft area during the 9 month follow-up period. With this simple and safe operation, the result gave a satisfying improvement in both symptoms and appearance; so this case is offered for reference.

Management of hypertrophic scars on the pubic area with an iliac flap

Postburn hypertrophic scars on the pubic area are rare. A local iliac flap has been used in four female patients for covering the raw areas after total excision of these scars. The largest flap in this series was 7 x 13 cm. Although bilateral flaps could be used simultaneously, only a unilateral flap was used in each patient. All the donor sites were closed primarily. The postoperative course was uneventful in each patient. Itching subsided completely in all patients and distortions of the genitalia were corrected. There was no recurrence of the scar formation in the follow-up period from 2 to 7 years. The only drawback of this flap for coverage of the symphysis pubis is that it is hairless. The experience with the present patients proved that this is an easy, quick and reliable method for removing hypertrophic scars on the pubic area.

The adipofascial turn-over flap for complicated dorsal skin defects of the hand and finger

Six cases of complicated dorsal skin defects of hands and two in fingers were successfully resurfaced with local adipofascial turn-over flaps. Flaps with a base-to-length ratio of 1:1.0 to 1:1.5 survived completely. The width of the attached base was 1.0 to 1.5 cm in hands and 0.5 cm in fingers.

Adipofascial turn-over flap for reconstruction of the dorsum of the foot

Local adipofascial turn-over flaps with skin grafts were successfully used to reconstruct complicated skin defects over the dorsum of the foot in 7 patients. The blood supply of the flap comes from perforators in the base and from the surrounding subcutaneous and fascial plexuses. A new concept of base-to-flap area ratio is proposed to predict the survival of the turn-over flaps in addition to the conventional base-to-length ratio. This appears to be a valuable technique for difficult wounds of the dorsum of the foot.

Limb salvage of infected diabetic foot ulcers with microsurgical free-muscle transfer

This study was comprised of 9 diabetic patients with 10 infected foot ulcers, including osteomyelitis in 4 limbs and gangrene in 3 limbs. Adequate debridement of these complicated wounds inevitably resulted in exposure of bones or tendons. All defects were successfully reconstructed with free gracilis muscle flaps covered with split-thickness skin grafts. No recurrence of ulcer or infection was noted in the muscle-transplanted area during the follow-up period. Laser Doppler perfusion monitor measurement showed that the perfusion unit of the denervated free muscle flap increased to a peak at the second week after transplantation; the neovascularization of the grafted skin, the progressive decrease of the muscle swelling, and the decreased interstitial pressure may be the main contributing factors. The perfusion unit of the muscle flap reached equilibrium with the surrounding tissue at about 8 weeks after microsurgical transfer. Lower extremity amputation is a major health problem in the diabetic population. The microvascular free-muscle transfer was proved to play an effective and important role in limb salvage in diabetic patients with infected foot ulcers. The gracilis muscle flap was recommended due to its lack of bulkiness and minimal donor site deformity.

Reconstruction of plantar heel defect using reinnervated, skin-grafted flexor digitorum brevis flap

Two cases with extensive plantar avulsion injuries had their heel defects resurfaced initially with full thickness skin grafts. Two months later, reinnervation presented in areas of grafted skin innervated by medial and lateral plantar nerves. No reinnervation was found in the plantar heel region originally innervated by the medial calcaneal nerve. Heel ulceration in the non-sensate, grafted skin occurred in the first case. Reinnervated, skin-grafted flexor digitorum brevis muscle flaps were then used for reconstructing the non-sensate plantar heels. There was no breakdown of skin during the follow-up period of 8 months and 6 months respectively. This method provides sensate and durable cover for extensive plantar heel defects.

Immediate reconstruction of the penis with an iliac flap

Immediate reconstruction of the penis can save time and significantly reduce postoperative psychological morbidity. A patient suffered a cancerous lesion in his glans penis. After total amputation, an iliac flap based on the superficial circumflex iliac artery was used to reconstruct the penis. The subcutaneous tissue around the vascular pedicle was carefully preserved for enhancing the venous drainage of the new penis. A self-sculptured silicone implant was inserted later to increase the penile rigidity. The advantages of this technique include ready availability, easy mobilisation, hairlessness, elimination of multi-staged procedures, and saving time. The patient is pleased with the operative results.

An unusually-formed appearance epidermoid cyst of the plantar region--a case report

A rare site for an epidermoid cyst is herein reported. A 40-year-old female was admitted for treatment of a right plantar tumor. The tumor was multiloculated, soft, nodular and in the range of about seven by seven centimeters. We initially diagnosed it as a saccular hemangioma, but it was finally diagnosed as an epidermoid cyst with foreign body reaction from the surgical specimen. Epidermoid cysts can occur in various parts of the body. Trauma is regarded to be the chief cause of them. Due to their various locations and appearance, they are sometimes difficult to diagnose. In such cases, however, it is generally agreed that pathological study is mandatory for a correct diagnosis.

Surgical treatment of the penoscrotal Paget's disease

Data from six cases of penoscrotal Paget's disease were collected. Erythematous, indurated, and pruritic skin lesions that failed to respond to the topical therapy were the main complaints. Symptoms had been observed for three to seven years before correct diagnosis. Extensive diagnostic studies revealed negative findings of subjacent adenocarcinoma, but 1 patient had concurrent skin cancer of nasal ala. In treating penoscrotal Paget's disease, our policy is to (1) resect 3 cm or more skin beyond the margin of the cutaneous lesion, (2) resect deeply to the subcutaneous fat, (3) use intraoperative frozen sections to confirm the free margin and (4) reconstruct the wound with the local iliac flap. No local recurrence was noted during the follow-up period of two to seven years. The iliac flap is thin and pliable; it precluded scar contracture and painful penile erection, which are the common sequelae of free skin graft in the penoscrotal area. Patients enjoyed normal sexual activity after surgery.

The reverse digital artery flap for fingertip reconstruction

Reverse digital artery flaps were performed successfully to resurface the major fingertip defect in 10 patients and the volar defect of the middle phalanx in 1. This thin flap with its long vascular pedicle containing a digital artery and its perivascular cuff tissue has a wide arc of transposition. It can be used to reconstruct the defect located from the proximal phalanx to the fingertip of all fingers. No loss of the flap in this series was noted. The procedure is a time-saving, one-stage operation. Patients who received this procedure had no uncomfortable immobilization of the hand or long hospitalization. It also causes no disfigurement and no functional loss of the involved digit. Our clinical experience showed favorable results.

Replantation of the testis by microsurgical technique

Microsurgical replantation of amputated testes were performed in two patients. Both were caused by trauma to the genitoperineal regions. These reconstructed testes are viable and not atrophic grossly. The patients are satisfied with these operations.

Amnion overlay meshed skin autograft

Meshed skin autografts are conventionally dressed with fine petrolatum gauzes. Pain and haemorrhage are a frequent sequel to changing dressings in the early days after grafting. We have explored the use of amnion to overlay the meshed autograft (3:1) in addition to the fine petrolatum gauze. Eleven patients with 24 burn wounds were treated. The amnion provided good protection to the underlying meshed autograft and the neoepithelium. It did not block the re-epithelialization and may have promoted the healing process. Most of the grafts had healed completely by 7 days after application. Pain and haemorrhage were markedly reduced. The non-antigenic nature, adherent quality and inexpensive cost makes amnion a promising biological dressing for meshed autografts.

Venous drainage in the reverse forearm flap

Venograms were performed in three cases of reverse forearm flap. The "crossover pattern" of the communicating branches between the two venae comitantes and the "bypass pattern" of the collateral branches of each vein have been demonstrated. These factors may explain the reverse drainage of venous blood, even though the valves of the vein are intact. Notably, the cephalic vein also shows a good communication with the deep venous system. Thus it can contribute another route for venous drainage in this flap.

Nasal alar reconstruction with free "accessory auricle"

A case of basal cell epithelioma of the nasal ala is presented that was managed by local excision of the tumor. The alar defect was reconstructed by a microvascular accessory auricle with excellent outcome.

Membrane filter method for recovery of fecal coliforms in chlorinated sewage effluents

The standard one-step M-FC broth-membrane-filter procedure for recovery of fecal coliforms from chlorinated sewage effluents is much less effective than the multiple-tube (most-probable-number) technique. A two-step membrane-filter method, using a pre-enrichment technique with phenol red lactose broth and incubation at 35 degrees C for 4 h, followether 18+/-2 h, enhanced fecal coliform recovery from chlorinated effluents. The results of 126 comparisons using chlorinated effluents from five wastewater plants showed that fecal coliform recovery by using the two-step membrane-filter method is comparable to that using the multiple-tube procedure.

Evaluation of millipore HA and HC membrane filters for the enumeration of indicator bacteria

Millipore type HA and HC membrane filters were compared for recoveries of total coliforms, fecal coliforms and fecal streptococci from natural waters and wastewater effluents. Bacterial and fecal coliform recovery was better on HC than on HA filters.