Experience with various reconstructive techniques for meningomyelocele defect closure in India

Background

The estimated incidence of spina bifida is 1–2 cases per 1000 population. In earlier literature, the global prevalence of meningomyelocele (MMC) is reported as 0.8–1.0 per 1000 live births. This retrospective study analyses the outcome of various surgical procedures performed for the closure of MMC defects.

Method

A total of 22 patients with MMC defects who underwent repair at our institute from July 2016 to August 2018 were included in the study. A retrospective review of all the cases operated was completed to analyse patient demography including defect size, defect location, surgical procedures, complications and the final outcome.

Results

Out of 22 cases, wherein the neurosurgery department sought help from the plastic surgery department, 11 defects were closed using the Limberg flap technique, 4 defects were closed with either primary closure or the double flap rotation flaps, one defect was closed using the triple rotation flap and 2 defects were closed using the local transposition flap cover technique. Complications were noted in only three cases. One patient had a local wound infection, while in two other cases, wound dehiscence was observed. All 3 cases were managed conservatively. On average, it takes approximately 70 days in India to close such defects.

Conclusion

MMC defects can be effectively managed with local flap options such as Limberg flap, local transposition flap or rotation flaps. Various reasons for the delay in closure were reported in patients late to our centre, when the first point of contact was with other departments.

Pedicled and Free Tissue Transfers

Tissue defects that result from diabetic foot infections are often complex and necessitate reconstructive soft-tissue surgery to achieve closure. Intrinsic muscle flaps of the foot require attention to major vascular pedicles and are useful for closing smaller ulcerations. Microvascular free flaps are beneficial for large defects and provide long-term survivability. Perioperative planning is an important aspect of caring for diabetic patients requiring reconstructive surgery. These techniques are valuable tools for use in efforts to preserve a functional limb in this patient population.

Anatomical and functional outcomes of ILM interposition in surgery for large macular holes: A retrospective study

INTRODUCTION

While surgery for small macular holes (<400μm) is well-described, the results are not as clear-cut for larger holes (>400μm). Our purpose is to demonstrate the difference in terms of closure and final visual acuity between 3 techniques: the classical technique, the FLAP technique and internal limiting membrane (ILM) transfer.

METHODS

This retrospective non-randomized study included consecutive patients with a macular hole greater than 400μm. Myopic eyes (>26.5mm or >6.50D) and eyes with other retinal comorbidities were excluded. All patients underwent pars plana vitrectomy in combination with one of the 3 techniques.

RESULTS

We included 84 eyes of 77 patients between 2005 and 2018; 57 in the classic group (A), 13 in the FLAP group (B) and 14 in the ILM transfer group (C). The closure rate at 3 months was 70.18 % in group A, 100 % in group B and 92.86 % in group C. The closure rate was significantly higher in group B and C compared to group A. There was no significant improvement between pre- and post-operative best corrected visual acuity in any group. The gain in BCVA was 2.90 lines (±2.98) in group A, 3.40 lines (±2.40) in group B, and 1.07 lines (±1.04) in group C. The gain was significantly lower in group C compared to group A and B.

CONCLUSION

ILM interposition appears to offer a true anatomical advantage for closing large holes, but the functional recovery does not appear to be better or worse.

Endoscopic near infrared and indocyanine green to verify the viability of the subcutaneous flap for vulvar cancer

INTRODUCTION

Vulvar cancer often requires radical vulvectomy with subsequent vulvar flap. Approximately in 20-60% of cases, there are post-operative complications ranging from infection to flap necrosis that often require reoperation. Several methods have been described to verify the vitality of the flap, but these are often expensive and require specific machinery that is not generally present in a gynecological clinic. In this case report, we present a viability verification of VY fasciocutaneous advancement flap for vulvar reconstruction by Endoscopic Near-Infrared and Indocyanine Green.

METHODOLOGY

The patient was a 67-year-old woman with FIGO IB ≤ 4 cm squamous cell vulvar cancer with absence of inguinal lymphadenopathy. The lesion appeared about 35 mm from the lateral margin of the large left lip and extended to the left inguinocrural fold. The patient underwent left inguinal lymphadenectomy and left radical hemivulvectomy with a left fasciocutaneous medial-thigh advancement flap. For the flap evaluation, we endovenous administered 50 mg of Indocyanine Green diluted in 10 ml of saline solution. After 10 min we visualized the flap margin with a near-infrared laparoscopic view. The evaluation was repeated at the end of the surgical procedure and we confirmed the good vascularization of the flap.

RESULTS

No early or late post-operative complications were obtained. There was no wound dehiscence, marginal necrosis or surgical site infection.

CONCLUSIONS

Verifying the viability of the vulvar flap using near-infrared laparoscopic optics was easy to use, reproducible and highly economical technique. This could be a reproducible alternative to other more expensive techniques.

Treatment of large avulsion injury in perianal, sacral, and perineal regions by island flaps or skin graft combined with vacuum assisted closure

BACKGROUND

Traumatic avulsion injuries to the anus, although uncommon, can result in serious complications and even death. Management of anal avulsion injuries remains controversial and challenging. This study aimed to investigate the clinical effects of treating large skin and subcutaneous tissue avulsion injuries in the perianal, sacral, and perineal regions with island flaps or skin graft combined with vacuum assisted closure.

METHODS

Island flaps or skin graft combined with vacuum assisted closure, diverting ileostomy, the rectum packed with double-lumen tubes around Vaseline gauze, negative pressure drainage with continuous distal washing, wounds with skin grafting as well as specialized treatment were performed.

RESULTS

The injuries healed in all patients. Six cases had incomplete perianal avulsion without wound infection. Wound infection was seen in four cases with annular perianal avulsion and was controlled, and the separated prowl lacuna was closed. The survival rate in 10 patients who underwent skin grafting was higher than 90%. No anal stenosis was observed after surgery, and ileostomy closure was performed at 3 months (six cases) and 6 months (four cases) after surgery, respectively.

CONCLUSIONS

Covering a wound with an island flap or skin graft combined with vacuum assisted closure is successful in solving technical problems, protects the function of the anus and rapidly seals the wound at the same time.

[Surgical treatment of recurrent pressure ulcers in spinal cord injured patients]

Not to burn one's bridges. This is the basic principle that comes immediately to the mind of the plastic surgeon when one brings up the secondary surgery of pressure ulcers, which is a common pathology in the spinal cord injured patients. Which ones are good candidates for surgical treatment? When? What preoperative, infectious, rehabilitative management is most likely to minimize the number of failures and recurrences? Which operative technique to prefer in first intention? And in case of secondary surgery, how to choose the best strategy? We will see that some cases can be treated by primarily closing or flap remobilization but, in case of greater loss of substance the realization of a flap from another anatomical region will be essential.

Extensor digiti minimi muscular flap: From a clinical case to an anatomical study

We present a case report of a failed posterior interosseous flap with distal pedicle rescued by an extensor digiti minimi (EDM) island pedicle flap supplied by the posterior interosseous artery (PIOA) in reverse flow to cover a soft tissue defect in the hand of a 25-year-old man. We subsequently performed an anatomical study on 5 cadaver limbs to determine the EDM muscle's vascularization: it was segmental, multiple and came from the PIOA. The rotation arc reached the dorsal side of the metacarpophalangeal (MCP) joints, as well as the distal part of the thumb. The indications selected are the same as those of the distal pedicle flap: defect on dorsal side of the hand and MCP joints, coverage of carpal tunnel, failure of posterior interosseous flap. This study describes a new flap and adds to our understanding of the EDM muscle's vascularization.

[Vaginal repair of vesico-vaginal fistula: Experience at a tertiary care center in Venezuela.]

Vesico-vaginal fistula (VVF) is a pathology with serious social repercussions; its resolution can be achieved through multiple surgical, abdominal or vaginal techniques, the choice of which will generally depend on the characteristics of the fistula and the experience of the surgeon.OBJETIVE: We describe our experience with vaginal approach to treat VVF using different flap interpositions. METHODS: A retrospective review of the charts of VVF patients attended at University Hospital of Caracas (UHC) during the 2009 - 2016 period was undertaken. The follow up period ranged from 3 months to 7 years, with an average of 2 years and 6 months. RESULTS: Of a total of 22 cases of VVF, most had a single orifice, retrotrigonal position, with an average diameter of 9.5 mm. A peritoneal flap was used in 77.27 % of the cases, Martius flap in 13.63 %, and omentum and vaginal mucosa each in 4.54 % of the cases. Success rate was 90.91%. Failure occurred in 2 cases (9.09%), due to relapse of the pathology. Morbidity rate was 13.64%, mainly due to urinary tract infections. CONCLUSION: The vaginal technique for the treatment of VVF is safe and effective with low recurrence rate and complications.

Measuring Flap Oxygen Using Electron Paramagnetic Resonance Oximetry

OBJECTIVES/HYPOTHESIS

To determine if electron paramagnetic resonance (EPR) oximetry is a viable technology to aid in flap monitoring.

STUDY DESIGN

Prospective cohort.

METHODS

This was a cohort study assessing accuracy and speed of EPR oximetry in detecting ischemia of a saphenous artery-based flap in a rat model, using transcutaneous oximetry as a control. Measurements were obtained under both resting and ischemic conditions for nine Sprague Dawley rats (18 flaps), for 3 postoperative days following flap elevation.

RESULTS

The mean partial pressure of oxygen prior to tourniquet application was 66.9 ± 8.9 mm Hg with EPR oximetry and 64.7 ± 5.2 mm Hg with transcutaneous oximetry (P = .45). Mean partial pressures of oxygen during tourniquet application were 8.9 ± 3.2 mm Hg and 8.5 ± 2.9 mm Hg for EPR oximetry and transcutaneous oximetry, respectively (P = .48), and 67.2 ± 6.9 mm Hg and 65.3 ± 6.1 mm Hg after tourniquet release for EPR oximetry and transcutaneous oximetry, respectively (P = .44). The mean ischemia detection time of EPR oximetry was 49 ± 21 seconds.

CONCLUSIONS

Offering timely, accurate, and noninvasive tissue oxygen measurements, EPR oximetry is a promising adjunct in flap monitoring.

LEVEL OF EVIDENCE

NA Laryngoscope, 129:E415-E419, 2019.

Intraoperative partial pressure of oxygen measurement to predict flap survival

Introduction:

Flap monitoring using partial pressure of oxygen (pO₂) is a proven modality. Instruments needed are expensive and are not readily available to a clinician. Here, pO₂ of flap has been determined using readily available and cheap methods, and a cut-off value is calculated which helps in predicting flap outcome.

Methods and Results:

Total 235 points on 84 skin flaps were studied. Capillary blood was collected from flap and fingertip using 1-ml syringes after at least 30 min of flap inset, and pO₂ analysed using blood gas analyser. Fall/change of pO₂ (difference of mean of pO₂ [diff-pO₂]) was also calculated by subtracting the flap pO₂ from the finger pO₂. Flap was monitored clinically in post-operative period and divided into two groups depending on its survival with Group 1 – dead points and Group 2 – alive points. pO₂ and diff-pO₂ amongst both the groups were compared and found to be statistically different (P = 0.0001). Cut-off value calculated for pO₂ was found to be <86.3 mmHg with a sensitivity of 100% and specificity of 89.05%. The difference of >68.503 mmHg of flap pO₂ compared from finger pO₂ was calculated as a cut-off with sensitivity of 94.12 and specificity of 79.60%.

Conclusions:

Flap areas having intra-operative pO₂ value <86.3 mmHG have higher chances (60.71%) of getting necrosis later. Similarly, if diff-pO₂ compared to fingertip is >68.5 mmHg, chances of those points getting necrosed in post-operative period are high.

Flap Related Complications Requiring Secondary Surgery in a Series of 851 Local Flaps Used for Fingertip Reconstruction

BACKGROUND

Local flaps are widely used to cover fingertip defects. Errors in design or technical execution of the flap may lead to morbidity and additional surgical procedure. The purpose of this study was to review flap related complications requiring unplanned secondary surgery to characterize preventable issues.

METHODS

851 local flaps were used to reconstruct fingertip defects during a 9-year period. Patients requiring unplanned secondary surgery to address flap related complications were subjected to analysis.

RESULTS

31 of 851 flaps (3.6%) required unplanned secondary surgery because of flap related complications. The most reliable flap was VY advancement flap with only one (0.3%) re-operation. The reverse vascular island flap, cross finger flap, and neurovascular island flap were associated with the comparable number of complications (8.0%; 6.3%; and 3.8% respectively). Total or partial necrosis was the cause for re-operation in 6 patients (0.7%). The typical reason for secondary surgery was inadequate soft tissue cover of the tip with homodigital neurovascular island flap and flexion contracture with reverse vascular island flap. Cross finger flaps were revised because of poor graft take at the donor site, bulky flap or flap necrosis.

CONCLUSIONS

Local flaps are reliable operations to cover fingertip defects. Each flap has potential pitfalls, which may be avoided if the surgeon is aware of them.

Should we pay attention to the aberrant nerve communication between the lingual and mylohyoid nerves?

An unusual communication between the lingual and mylohyoid nerves has been identified as one reason for incomplete mandibular anaesthesia, and for neuropathy. However, its anatomical features and function are poorly understood and its relations with neighbouring structures, which are valuable in reducing the side effects of surgical operations, have not been sufficiently described. The aim of this study, therefore, was to describe the communication between the nerves and to assess the implications for oral and maxillofacial surgery. We explored the communication between the mylohyoid nerves of 62 embalmed, and 16 fresh, hemifaces. The diameter, length of the communication, and other variables were measured, and the junctions with the two nerves microdissected. The nervous communications of fresh specimens and relative nerves were stained histochemically for acetylcholinesterase. Of the 62 embalmed specimens, 19 had a communication that pierced the mylohyoid muscle, and staining showed that this was a sensory nerve. Our results suggest that the sensory communication between the lingual and mylohyoid nerves pierces the mylohyoid muscle and connects these otherwise unrelated nerves, thereby contributing to the likelihood of operative side effects.

Free Style Perforator Flaps for Aesthetic Facial Reconstruction

BACKGROUND

Functional and cosmetic outcomes affect reconstruction of the face more than any region of the body. To use a predetermined perforator flap freely designed allowing a wide range of movement and manipulation can give us an optimum outcome. We present our clinical experience with free style facial perforator flaps, surgical technique, and complications.

METHODS

Thirty patients with post-tumor resection of the face were reconstructed with free style local perforator flaps between January 2014 and November 2016. Doppler was used to identify the perforator vessels preoperatively.

RESULTS

Twenty-two clinical cases had no complications. Four had venous congestion that resolved spontaneously, three had a distal 1/3 superficial necrosis, and one suffered from hematoma.

CONCLUSION

Freestyle perforator flaps were applied to get better cosmetic facial reconstruction, allowing one stage procedure and decreasing donor site morbidity. Modern anatomical understanding, good planning, and meticulous surgical technique can affect clinical results.

Soft Tissue Mandibula and Tongue Reconstruction Using A Suprafascial, Folded, Deepithelialized Antero-Lateral Thigh Perforator Free Flap

Head and neck squamous cell carcinoma (HNSCC) is the most frequent carcinoma of the head and neck region. For coverage of an entire resected mandible with floor of the mouth, 3/4 of the tongue and soft tissue of cheeks and neck bony reconstruction of the mandible and soft tissue reconstruction of tongue, cheeks and a neck large flap are needed. A patient with a superinfected T4 HNSCC was presented to our outpatient clinic. Complete resection of the mandible, bilateral neck dissection and 3/4 resection of the tongue were performed. A complex reconstruction using two free flaps was not feasable, so a large, folded, suprafascial Antero Lateral Thigh Perforator (ALTP) flap for immediate soft tissue reconstruction was used. Because of the anatomy, no reconstruction plate was inserted. On postop day 11, an understandable speaking was possible using a speach canula. Swallowing was possible without regurgitation. Eight months postoperatively, the patients mimic and closure of the mouth were satisfactory. The flap was viable throughout the entire time. It was shown that the suprafascial ALTP flap was a versatile part in the armamentarium for complex mandible soft tissue reconstruction.

Calcaneal lengthening for partial traumatic loss of the calcaneus

BACKGROUND

The purpose of this article was to introduce calcaneal lengthening for partial traumatic loss of the calcaneus. Effectiveness with the use of the technique was also assessed.

METHODS

From January 2013 to May 2016, calcaneal lengthening was performed in 15 patients who sustained a partial traumatic loss of the tuberosity portion of calcaneus. There were 13 men and 2 women with an average age of 36 years (range, 19-53 years). Combined Achilles tendon rupture was noted in 7 patients, and the tendon was reinserted to the calcaneus before calcaneal lengthening. Calcaneal lengthening was performed using an Ilizarov frame. Clinical outcome was assessed based on the American Orthopedic Foot and Ankle score.

RESULTS

The mean loss of calcaneus was 27% (range, 19%-35%). Calcaneal lengthening (mean total time is157 days; range, 111-226 days) included three periods, i.e., latency (mean 7 days; range, 7-9 days), distraction (mean 43 days; range, 32-57 days), and consolidation (mean 108 days; range, 84-162 days). The mean amount of lengthening was 28% (range, 19%-38%). The mean follow-up duration was 25 months (range, 24-27 months). Based on the American Orthopaedic Foot and Ankle, there were 8 excellent, 6 good, and 1 fair result.

CONCLUSIONS

For the treatment of partial traumatic loss of the calcaneus, calcaneal lengthening using an Ilizarov frame is a preferable technique to restore the length of calcaneus and foot function.

A modified reconstructive technique for paediatric congenital alar rim deformity

Alar subunit retraction or notching whether acquired or congenital, can be challenging to reconstruct. Congenital cysts and benign lumps involving the nasal alar region can also result in acquired alar deformity once resected. Published reports describe different surgical methods, but we demonstrate a simple and highly satisfying technique. We present four paediatric cases with alar rim defects and demonstrate our modified surgical technique. All patients had an unremarkable recovery. Our outcomes demonstrate a minimal yet effective one-stage technique for correction of alar defects in paediatric patients that results in high patient satisfaction and allows for future secondary surgery if required.

Extending Applications of Local Anesthesia Without Tourniquet to Flap Harvest and Transfer in the Hand

The authors' experience demonstrates that wide-awake flap surgery in the hand is safe. The authors used this approach in 4 commonly used flaps in the hand in 27 patients: the extended Segmuller flap, the homo-digital reverse digital artery flap, the dorsal metacarpal artery perforator flap, and the Atasoy advancement flap. Wide-awake flap surgery works very well and safely achieved excellent anesthetic and vasoconstrictive effects in the authors' cases. The authors found that vasoconstriction caused by epinephrine mainly affects the capillaries and does not affect digital arteries and their major branches in the hand.

Breast Reduction: The Superolateral Dermoglandular Pedicle Revisited

BACKGROUND

Breast hypertrophy, generally found in association with ptosis, is a common problem in postadolescent women. Beyond the psychological burden of excessively heavy, droopy breasts, physical symptoms compound the condition, with neck, shoulder and back pain. Reduction mammaplasty is one of the most common cosmetic operations, especially to improve patient's musculoskeletal symptoms, with proven benefits in patient satisfaction and self-esteem postoperatively. Multiple techniques exist for breast reduction, with no clear evidence of benefit of one over another.

METHODS

We review the senior author's experience in using a superolateral pedicle for breast reduction in 726 patients over the past 40 years. Over the past 10 years, the technique has also been adapted for simultaneous augmentation-mastopexy, especially in post-bariatric surgery patients. Benefits include recruitment of lateral breast tissue to fill the upper pole and correct axillary fullness. The technique has the advantages of ease of execution and a low complication rate.

RESULTS

Complete data were available for 397 patients. Resection weights varied from 380 to 1248 g, and mean sternal notch-nipple distance was 25.3 cm. Mean follow-up was 22 months. Complications were uncommon: four cases of partial nipple-areola complex loss, dehiscence in 14 patients, three hematomas and seven cases of superficial surgical site infection. Nipple sensitivity was decreased in eight patients, and three patients were unable to breastfeed following surgery. Revision surgery was requested by 14 patients.

CONCLUSIONS

Breast reduction using the superolateral dermoglandular flap is easy to execute, versatile, safe and effective, preserving physiological functions, and is an excellent option when treating patients with medium-to-large breasts.

LEVEL OF EVIDENCE IV

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 .

A curative-intent endoscopic surgery for postradiation nasopharyngeal necrosis in patients with nasopharyngeal carcinoma

Background

Postradiation nasopharyngeal necrosis (PRNN) is a severe complication after radiotherapy in patients with nasopharyngeal carcinoma (NPC), which can severely affect the quality of life and threaten the patient’s life. Only 13.4%–28.6% of patients can be cured by traditional repeated endoscopic debridement. Here, we introduced an innovative curative-intent endoscopic surgery for PRNN patients and evaluated its clinical efficacy.

Methods

Clinical data of 72 PRNN patients who underwent radical endoscopic necrectomy, followed by reconstruction using a posterior pedicle nasal septum and floor mucoperiosteum flap were analyzed to determine the efficacy of this surgery. The endpoints were complete re-epithelialization of the nasopharyngeal defect, relief of headache, and overall survival (OS).

Results

All surgeries were successfully performed without any severe postoperative complications or death. The median value of numeric rating scales of pain decreased from 8 before surgery to 0 after surgery (P < 0.001). Fifty-one patients (70.8%) achieved complete re-epithelialization of the nasopharyngeal defect. The number of cycles of radiotherapy (odds ratio [OR], 7.254; 95% confidence interval [CI] 1.035–50.821; P = 0.046), postoperative pathological result (OR, 34.087; 95% CI 3.168–366.746; P = 0.004), and survival status of flap (OR, 261.179; 95% CI 17.176–3971.599; P < 0.001) were independent risk factors of re-epithelialization of the nasopharyngeal defects. Postoperative pathological result (hazard ratio [HR], 5.018; 95% CI 1.970–12.782; P = 0.001) was an independent prognostic factor for OS. The 2-year OS rate of the entire cohort was 77.9%.

Conclusion

Curative-intent endoscopic necrectomy followed by construction using the posterior pedicle nasal septum and floor mucoperiosteum flap is a novel, safe, and effective treatment of PRNN in patients with NPC.

The Reach of the Gastrocnemius Musculocutaneous Flap: How High Is High?

BACKGROUND

Gastrocnemius muscle and musculocutaneous flaps are very versatile and one of the commonly used flaps for lower extremity reconstruction. There is significant literature available on the use of these flaps. However, we feel that the potential of the gastrocnemius musculocutaneous (GMC) flaps has not yet been fully explored in terms of increasing their reach, viability and arc of rotation. An attempt is made to refine the technique of flap harvestation to optimize outcomes of this versatile flap.

METHODS

Six patients of complex lower limb defects were managed using the GMC flaps. Harvesting of the flap was always initiated from the posterior midline to include the proximal sural pedicle, sural nerve, short saphenous vein and the muscle belly of either the medial or the lateral gastrocnemius muscle along with the cutaneous paddle. All the flaps were islanded and denervated. The origin of the gastrocnemius muscle was detached in all cases to increase the reach of this flap.

RESULTS

The flap can reliably and comfortably cover defects from middle third-lower third junction of thigh and the entire posterior aspect of the thigh. Such a local option offers relatively simple but more cost-effective approach to complex clinical problem with tolerable impairment of the donor site.

CONCLUSION

The GMC flap can be considered as a worthwhile alternative to free-tissue transfer for limb salvage.

[Radical treatment of hidradenitis suppurativa: Comparison of the use of the artificial dermis and pedicled perforator flaps]

OBJECTIVES

The objective of this study was to compare the use of artificial dermal and perforator flap after radical surgery of severe axillary and perineal hidradenitis suppurativa disease.

PATIENTS AND METHODS

The data on postoperative outcomes, scar assessment (POSAS) and quality of life (DLQI, SF-36) were collected during consultation or by phone call. Forty-seven patients were included in our study between January 2015 and September 2017, including 27 patients in the artificial dermal group and 20 patients in the perforator flap group.

RESULTS

The quality of life assessment by the SF-36 questionnaire showed a significant increase in quality of life in both groups (P<0.05), higher in the perforating flap group (P<0.001). The DLQI questionnaire showed a decrease in the impact of MV on quality of life in both groups, which was greater in the perforator flap group (P<0.05). The scarring assessment by the POSAS patient and observer questionnaire showed a better overall opinion in the perforator flap group (P<0.001). In the perforator flap group, the total hospital stay and healing time was shorter (P<0.001) and the return to work was faster (P<0.001).

CONCLUSION

The artificial dermis and the perforator flaps are very useful coverage solutions after radical surgery of hidradenitis suppurativa. The use of perforator flaps, however, seems more interesting while simplifying the post-operative course.

Analysis of prognostic factors affecting poor outcomes in 41 cases of Fournier gangrene

Purpose

We present our experience involving the management of this disease, identifying prognostic factors affecting treatment outcomes.

Methods

The patients treated for Fournier gangrene at our institution were retrospectively reviewed. Data collected included demographics, extent of soft tissue necrosis, predisposing factors, etiological factors, laboratory values, and treatment outcomes. The severity index and score were calculated. Multivariate regression analysis was used to determine the association between potential predictors and clinical outcomes.

Results

A total of 41 patients (male:female = 33:8) were studied. The mean age was 54.4 years (range, 24-79 years). The most common predisposing factor was diabetes mellitus (n = 19, 46.3%). Sixteen patients (39.0%) were current smokers. Seven patients had chronic kidney disease. The most frequent etiology was urogenital lesion (41.5%). The mortality rate was 22.0% (n = 9). Multivariate regression analyses showed that extension of necrosis beyond perineal/inguinal area and pre-existing chronic kidney disease were significant and independent predictors of mortality. Extension of necrosis beyond perineal/inguinal area was a significant predictor of increased duration in the intensive care unit and hospital stay. In addition, pre-existing chronic kidney disease was a significant predictor of flap reconstruction in the wound.

Conclusion

Fournier gangrene with extensive soft tissue necrosis and pre-existing chronic kidney disease was associated with poor prognosis and complexity of patient management. Early recognition of dissemination and premorbid renal function is essential to reduce mortality and establish a management plan for this disease.

Early ambulation after colorectal oncologic resection with perineal reconstruction is safe and effective

BACKGROUND

Post-operative bedrest is common following perineal reconstruction despite little supporting data. We sought to determine the safety of early ambulation following colorectal oncologic resection and flap-based perineal reconstruction.

METHODS

A retrospective cohort study was conducted with two cohorts: standard bedrest (BC) and early ambulation (EAC). Ambulation capacity was objectively assessed. Regression analysis was performed to determine the effects of ambulation timing on 60-day reoperations or readmissions and other surgical outcomes.

RESULTS

There were 57 participants. Those in the EAC were significantly more ambulatory on post-operative days one through three (p < 0.0001). There was no significant difference in 60-day reoperations (25% BC versus 9% EAC, p = 0.14) or readmissions (33% BC versus 15% EAC, p = 0.12). Early ambulation significantly reduced minor complication rates (38% BC versus 9% EAC, p = 0.02).

CONCLUSIONS

Early ambulation following perineal reconstruction is safe and may potentially decrease wound complications.

SUMMARY AND KEYWORDS

Institution of early ambulation protocols is rapidly becoming the standard of care for many oncological surgery patients. In cases requiring perineal reconstruction with vascularized flaps, however, there is no data to uproot the historical practice of mandatory bedrest. Our study demonstrates that the benefits of early ambulation are attainable in these patients without compromising reconstructive outcomes.

Reconstruction of Lateral Mandibular Defects with Soft Tissue Loss: The Role of the Submental Flap

INTRODUCTION

Mandibular continuity defects after pathologic resections or traumatic events are difficult cases for reconstruction. Defects involving both hard and soft tissue loss are more challenging, because of problems in soft tissue coverage^. The role of the submental flap in this regard is presented.

MATERIALS AND METHODS

In a retrospective study from the archived files of Ghaem Hospital, Mashhad, Iran between 2007-2016, lateral mandibular defects that were managed with submental flap for soft tissue coverage were selected.

RESULTS

Ten patients had been treated, of whom four cases were due to trauma/gunshot events and six cases were defined as pathologic resection; five patients with malignant lesions and one with benign intraosseous pathology, but with soft tissue invasion. There was one complication overall, concerning orocutaneous fistula formation.

CONCLUSION

Submental flap is indicated for coverage of the reconstruction plate when the lateral mandible is resected/avulsed with soft tissue loss limited to the oral cavity or due to through and through defects in the lower third of the face.