Some surgeons inject saline into the subcutaneous plane (often with local anesthetic and/or adrenaline), to perhaps “hydrodissect” the breast off the skinflap if performed under pressure or at least to make the fascial plane thicker and easier to adhere to, while also purportedly minimizing blood loss and the use of diathermy. It is argued that the liquid finds the plane of least resistance between the subcutaneous fat and the fat of the glandular breast tissue below. Anecdot- ally, this approach seems quite popular and effective across different units. However, the literature reports contrasting experiences with tumescence. Two retrospective case series urge caution, reporting this as a risk factor for the develop- ment of postoperative skinflapnecrosis, while two more recent studies (one prospective) did not find tumescence to be a significant factor for MSFN. Chun et al 44 reported
According to the most recent NICE guidance, immediate breast reconstruction should be available to all women requiring a mastectomy for breast cancer in the UK . Skin sparing mastectomy (SSM) and nipple sparing mastectomy (NSM) are becoming more commonly per- formed and allow for cosmetically superior results. In 2011, 16,485 women underwent mastectomy in the UK . However, due to the delicate blood supply to the skin of the mastectomy skinflap, it is often susceptible to mastectomy skinflapnecrosis (MSFN). This can re- quire further surgical interventions, delayed recovery and an increased length of stay (LOS) in hospital, which can cause a delay in the delivery of adjuvant cancer treatment and compromise oncological outcomes. SSM and NSM with reconstruction are already costly proce- dures hence reducing the incidence of skinnecrosis to improve patient recovery and to reduce the financial burden to the NHS is of high interest.
Necrotizing fasciitis is a rapid progressive infection of the subcutaneous tissue or fascia that usually occurs in the groin and lower extremities . Early diagnosis with prompt surgical debridement is essential in management of this rapidly progressing disease [2,3]. However, even after proper management to control infection, a large open wound usually remains; to cover this, surgical intervention such as skin graft, local flap, or free flap is required [4-6]. A delay in coverage of this residual open wound may result in delayed infection, debilitating patient condition, and even generalized sepsis. However, surgical options are often limited as poor patient condi- tion restricts the use of time-requiring extensive surgeries such as local flap or free flap coverage. Skin grafting usually requires a long time to heal, as the wound bed is often dirty and unstable. Negative pressure wound therapy (NPWT) has been used to control chronic wounds as it increases tissue perfusion and decreases wound edema . Although NPWT can improve a wound’s condition, it cannot close it completely, so other operations are required for wound coverage . Dermatotraction is a surgical option that gradually approximates the margins of large wounds with a traction device. Successful derma- totraction can close fasciotomy wounds directly, and may restore the function and appearance of the fasciotomy wound site. Dermatotraction has been used to close open fasciotomy wounds in compartment syndrome [9,10]. Whereas the fasciotomy wound in compartment syndrome is supple, the fasciotomy wound in necrotizing fasciitis is usually scarred, and stiffer than the wound in compartment syndrome due to prolonged wound preparation. Dermato- traction in the necrotizing fasciitis patient may therefore be ineffective, and the traction can disturb circulation in the stiff skin flaps, resulting in skinnecrosis. Although it provides an attractive alternative for the necrotizing fasciitis patient in poor general condition, dermatotrac- tion has remained an alternative surgical option to date. To decrease the likelihood of skinflapnecrosis, and to facilitate skinflap mobilization for direct wound closure in the necrotizing fasciitis patient who had undergone dermatotraction, the authors applied extended NPWT over the dermatotraction device during treatment of the open wound. The authors present a report of clinical results of this practice, followed by a discussion of the clinical basis of extended NPWT-assisted dermatotraction in closing the large open wound of the necrotizing fasciitis patient.
created defects. The primary closure of the flap donor wound was further facilitated by the laxity of the skin of the elderly patients, who where the main patients affected by orofacial cancer in our study. The partial wound breakdown which was noted in our study was recorded in younger and obese patients and was dealt with by dressing and allowed to heal by secondary intention. The use of internal mammary artery perfo- rator-based deltopectoral flap is not useful for oral cancer reconstruction because it will not extend beyond the mandible. Therefore, reconstruction of only neck defects is possible with this type of deltopectoral flap with an added advantage of flap donor wound primary closure.
is the first study which assesses both serum and tissue peroxidation activity exclusively in human skin BCC. In our study, the serum MDA level was not increased sig- nificantly in patient with skin BCC. In contrast, Bekere- cioğlu et al. in their study, showed a significant higher serum MDA level in patients with non-melanoma skin carcinomas (NMSC); both SCC or BCC . Studies on SCC of oral cavity, also showed higher serum MDA lev- els than healthy groups [11,12]. In tumors of other organs, such as the liver, breast, lung, etc. the serum MDA was also significantly elevated [13-15]. In contrast to serum MDA levels in our study, it is suggested that sporadic skin BCC development is predominantly affected by ex- ogenous etiologic factors such as radiation rather than endogenous etiologies. In our study, the tissue MDA le- vel of the skin with BCC was significantly higher than non-affected skin tissue. In a study which considered the effect of antioxidants on photodamaged skin, vitamin E significantly decreased the tissue MDA . Another stu- dy on tumor of murine liver, tissue MDA level was in- creased significantly after radiation and decreased sig- nificantly after antioxidant therapy with melatonin . Other similar studies detected inhibitory effects of sev- eral antioxidants and even diet on incidence and progres- sion rates of different tumors [18-21]. According to sig- nificant increase of tissue MDA in BCC skin lesions in our study, it is suggested that the use of local or systemic
However, there are some disadvantages of split- thickness skin graft for reconstruction of scrotal and perineal defects. The appearance is not completely natural, since the new sac lacks redundant skin and the testicles are not freely floating. Instead, the testicles will remain in a low position due to loss of cremasteric function  . The graft may not take adequately when applying it on an uneven or concave wound surface. In addition, a split-thickness skin graft is not as
In middle-aged or younger patients, however, circular defects of the face after benign skin tumor excision represent a reconstructive challenge, even if the de- fects are small. Conspicuous scars on the face may have a significant impact on the quality of life of the patient . Several local flaps including M-plasty, transposition, and rotation have been attempted to minimize scar length, unfa- How to cite this paper: Ooshima, M., Ko-
circulation of the flap, there is a 13.7% risk of flap necro- sis when the perforator flap is applied for wound repair . Zhu et al. retrospecti- vely analyzed 78 cases of failed flap transplantation fr- om January 2010 to January 2018 . The results re- vealed that flapnecrosis is prone to occur 1 week after surgery, and infection was the main reason to bla- me. Repair surgery operated by professional microsurgery doctors was more conducive to reducing the necrosis rate. In this study, ultrasound ex- amination of the perforator flap in the observation group showed that the blood flow at shallow bleeding point of perforating artery in the flap survival group was higher than that in the flapnecrosis group, while there was no significant difference in dia- meter and velocity between the two groups. Further cor- relation analysis demonst- rated that flap survival was positively correlated with the blood flow at shallow bleed- ing point, but was not corre- lated with the diameter and the velocity of the perforat- ing artery. It may be because that the blood flow at shallow bleeding point of perforating artery directly affects the blood supply of the flap. As a result, higher blood flow le- ads to better blood supply and is more beneficial to the flap survival. Conversely, it easily leads to insufficient blood supply, poor local bl- ood supply and necrosis of the flap.
This study demonstrates that reduction of the dead space after mastectomy using flap fixation reduces seroma formation and seroma aspirations. For many decades, breast surgeons have used closed suction drainage to reduce dead space. However, seroma formation and its sequelae continued to cause postoperative problems in these patients, proving that wound drainage is insufficient in combating seroma. Flap fixation combined with low suction drainage significantly reduces seroma formation and the need for seroma aspiration after mastectomy.
Achilles tendon starts near the middle of the calf and ends at calcaneal tuberosity. The blood vessels of the Achilles tendon are concentrated near the endpoint of the tendon and where the muscles bind to the tendons. There are no ves- sels within the tendon, so the blood supply of the middle segment of the tendon is very scarce. Achilles tendon is mainly supplied by the peritendon tissues . The 2 to 6 cm proxi- mal end of the tendon is the most common site of rupture due to poor blood supply. The blood supply from the peritendon membrane will decrease with age , leading to calcifications and other degenerations. This further increas- es the risk of tendon rupture . The superficial fascia on the two sides of tendon contains much fat. Bursa is found between the endpoint of the tendon and the bone surface of the calcaneus, and bursa subcutanea calcanea exists between the tendon and the skin. Table 1. Comparison of the postoperative complications
Presentation of Case: Bone necrosis at donor site in closure of oroantral fistulas with palatal rotational flap is known to be very rare. We present a 57 years old female, rheumatoid arthritis patient under Methotrexate medication, with a chronic oroantral fistula in the left first molar region. Bone necrosis has been shown at the donor site after full thickness palatal rotational flap procedure. The treatment approach and alternative methods are discussed. Bone necrosis on the donor site has been treated with the re-rotation of the palatal rotational flap tissues, but this time with partial thickness to its original position. Successful healing has been achieved.
Introduction: Plastic surgery is used for restoring the form of the body. Acharya Sushruta, the ancient Indian Surgeon is recognised as a father of plastic surgery. Sushruta made important contributions to the field of plastic surgery. Treatments for the plastic repair of a broken nose are, some of the oldest known reconstructive surgery techniques were being carried out in India. Skin grafting is a surgical procedure that involves removing the skin from one area of the body and moving it, or transplanting it, to a different area of the body. Skin grafting is often used to treat extensive wounding or trauma, burn, after excising skin cancer where skin loss is more. Case Presentation: A sixty years male patient had come with non-healing ulcer at rt.inguinal region since two years. There was an ugly growth with unhealthy granulation tissue with slough and everted, rolled out edges, which bled on touching. Biopsy showed metastatic malignant growth. Its primary focus was unknown. Management and Outcome: wide local excision was done. The growth was excised along with skin and underlining muscle. And to cover the raw area pedicle graft of lateral aspect of the same thigh was used. This pedicle was selected along with skin and underling tissue allowing its vascular supply remained intact. It was sutured. To cover the raw area of this donor site split skin graft was performed. Discussion: This case report proved that after excision of malignant inguinal growth, when primary closure was not possible, skin grafting showed fast wound healing without any contracture.
Systemic involvements were evaluated by several ex- aminations. Skin biopsy was performed for establish the diagnosis. Arthritis indicated joint swelling with two or more of erythema, local heat, tenderness, or limited range of motion. In the peripheral and central nervous system (CNS), neuritis indicated peripheral neuropathy on nerve conduction velocity (NCV), while patients pre- sented with numbness, weakness, or pain. Brain and spine MRI, electromyogram (EMG), somato-sensory evoked po- tential (SSEP), brainstem auditory evoked potential (BAEP), and visual evoked potential (VEP) were performed accord- ing CNS symptoms and signs.
There was no lateralization observed in our circumferential technique because the graft placement was by underlay technique and supported by annulus all around the circumference and it was held firmly by tympanomeatal flap. Mishra et al reported graft lateralization of 1% where graft was placed by underlay technique after elevating circumferential tympanomeatal flap. 16 Mokhtarinejad et al stated that in case of chronic otitis media with normal ossicular mobility, the most important factor which decides the hearing outcome may be proper relationship of graft and ossicles, which means absence of blunting and lateralization. 15 Circumferential sub annular tympanoplasty has several distinct features that make it suitable for anterior and subtotal perforations. As the graft is placed directly onto the bony annulus anteriorly under microscopic vision and not tucked blindly under the tympanic membrane remnant,
can be performed with a pedicled radial forearm flap (RFF) or lateral arm flap (LAF). Supplied by a long vascular pedicle from the anterograde radial artery or retrograde palmar arch, the adipofascial to fasciocutaneous RFF is considerably resourceful. With traumatic elbow injuries often exposing bone, tendon, or neurovasculature, the RFF and LAF can effectively resurface the thin yet tenacious native tissue  . Although the latissimus dorsi muscle flap (LDF) is a more sizeable regional alternative for elbow
Case 1. A 50-year-old adipose (weight 157 kg) male was referred with a needle-biopsy verified grade 2 clear cell sarcoma and no signs of disseminated disease on a FDG PET/CT performed at a local hospital. The tumor was located in the left lower limb around the Achilles tendon with contact to the periosteal tissue of the calcaneus, and MRI could not exclude tumor invasion into the calcaneus (Figure 1). Limb- sparing surgery with tumor excision and reconstruction of the Achilles tendon and skin defect with a free flap was considered, and therefore a FDG PET/MRI was performed with the aim of evaluating potential tumor ingrowth to the bone. PET/MRI provided excellent metabolic information (SUVmean = 16, SUVmax = 21), suggesting no involvement of the bone (Figure 1). However, because of patient-related reasons (age and overweight), the patient and the surgeon settled for radical surgery with an amputation. Postoperative pathology examination revealed that the surgical margin was free of tumor and no ingrowth of tumor to the bone could be documented (Figures 2 and 3), thus matching the PET/MRI information obtained prior to surgery.
We used an embedded graft that included combined abdominal skin flaps, dorsalis pedis flaps, toe flaps, and toe-web flaps, which were naturally integrated. Abdominal skin flaps are elastic and soft, whereas foot-derived flaps are low in fatty tissues and do not roll or slide after healing with deep tissues, permitting good holding capacity in the grafted fingers. The two types of flaps integrated well, and resulted in satisfactory firmness and softness. The donor area of the abdominal skinflap was large and wide, providing enough capacity to cover the injured area on the hand. In the present study, the degloved fingers were embedded into the superficial layer of the skin fascia and laterally stabilized by abdominal tendons via the skin. This allowed one-time repair of most of the circumferential injuries of the hands. The abdominal thin skinflap was used mainly on the finger back and side, which have no critical function, and the dorsalis pedis flap, dorsal toe flap, and toe-web flaps, which were of good quality with good blood circulation and resulted in rapid return of skin sensation, were used to cover the finger-flexor side. Therefore, covering the common injured regions and reconstructing the key functions were effectively combined, so that flap resources were fully utilized. We followed our cases for 1 year, and found that sensation recovery in the palm
A 55-year-old man presented to our hospital with suspected carcinoma of the thyroid gland. The tumor in the center of the neck was large enough for us to suspect that the skin invasion had been present for many years, although the pa- tient had no remarkable symptoms. Based on needle biopsy findings, the tumor was diagnosed as papillary carcinoma. In addition to total thyroidectomy, we planned for an op- tional skin excision with bilateral neck dissection based on the CT findings (Fig. 1). We originally planned to use a local flap of the neck to cover the skin defect, but the size of the defect was too large and we had to make an extended skin incision (Fig. 2a). A DP flap was designed with substantial undermining to the pectoral region, followed by direct clos- ure of the surgical wound and donor site, using suction drains and without a skin graft (Fig. 2b-d). No adverse events occurred during hospitalization. The patient initially
Complications of tissue expansion in the mastoid skin have been described clearly. Hematoma, exposure of tissue expander, dehiscence of incision, skinnecrosis, extrusion of the stainless steel wire or sutures, infection, exposure of cartilage and hypertrophic scars have been mentioned in detail in many studies on microtia reconstruction with expansion, whose treatment modalities have also been well defined [7–10]. Although flap contraction is a well-known result of tissue expansion, its effect on the reconstructed ear has been less discussed in the studies among which only a few ones noted flap contraction in the texts [5–7]. There is no study including the cases of flap contraction after ear reconstruction in literature. In our opinion, flap contraction may be considered as a main factor being capable of changing the shape of ear with time, as it has a decreasing but continuous and long- term effect on the reconstructed ear. It has been shown that during expansion, although there is a 63% increase in expanded flap with a particular expander, this provides only a 30% increase after elevation and inset of the flap. This increase in flap dimensions can be provided for a three-month or four-month period. The 56% decrease in the flap probably results from contraction of the expanded skin . Tissue expansion in the mastoid area is performed by using the general principles of tissue expansion except for the slow inflation and static phase to obtain enough skin expansion to drape cartilage framework. Chen reconstructed microtia using the expansion technique in combination with one month of consolidation phase to reduce the severity of flap contraction . As a result, he did not note any signs of flap contraction. We used similar expansion method in which expander volume reached 135 ml, but encountered significant flap contracture decreasing the depth of cranioauricular sulcus.
Hyperbaric Oxygen Therapy (HBOT) is a medical procedure and therapeutic modality that utilizes 100% oxygen. HBOT has been used various medical conditions such as progressive necrotizing fasciitis, peripheral arterial insuffi- ciency, and diabetic wounds of the lower extremities. The case report reported here describes the usage of HBOT as an adjunctive “rescue” measure to sal- vage a patient’s cranioplasty scalp flap after flap ischemia was noted 2 days post-operatively. Patient is a 54 year-old caucasian female who presented to our facility with symptoms of a left MCA infarct. CT and MRI of her brain revealed a left MCA infarct with hemorrhagic stroke with significant cerebral edema, and midline shift. She was taken to the operating room for a left de- compressive hemi-craniectomy. She had cranioplasty utilizing native bone flap delayed fashion. She had wound infection after cranioplasty which re- quired removal of native bone. After appropriate treatment for infection, she had cranioplasty utilizing prosthetic Biomet implant. Post-cranioplasty, pa- tient developed ischemic cranial flap. This was recognized within 48 hrs and HBOT was implemented. She has a successful rescue of the ischemic cranial flap after she received 14 consecutive treatments over two weeks. In our knowledge, this is the first successful treatment of HBOT reported after pros- thetic cranioplasty for scalp flap ischemia.