Christoph Papp

Definite surgical treatment of complicated recurrent pilonidal disease with a modified fasciocutaneous V-Y advancement flap

BACKGROUND Different methods for managing pilonidal disease have been described in the literature. Recurrence impairs the success of all forms of therapy, but the lowest rates have been reported for reconstructions involving local flaps. Nevertheless, treatment of pilonidal disease with a fasciocutaneous V-Y flap is not a well-established procedure. We have modified the surgical technique and used it selectively for complicated recurrent cases. Our experience with this method is analyzed, and its validity is evaluated. METHODS Twenty-four patients with recurrent pilonidal sinus undergoing radical excision and reconstruction with our modified fasciocutaneous V-Y advancement flap between 1986 and 1993 were studied retrospectively. RESULTS Except for two minor transient wound dehiscences, in all cases primary healing was achieved. Furthermore, an excellent functional result and acceptable scar pattern were obtained in all twenty-four patients, with a mean follow-up of 4.5 years. Neither evidence of recurrence nor impairment of daily life activity was noted. CONCLUSIONS Treatment of complicated recurrent pilonidal sinus with the described technique offers a safe but demanding method for definite reconstruction, and we support a more common application.

Partial and complete reconstruction of Achilles tendon defects with the fasciocutaneous infragluteal free flap

Multiple attempts to repair the Achilles tendon can be associated with major soft-tissue defects of skin and tendon necessitating reconstruction with free flaps. In view of its specific anatomical characteristics, the fasciocutaneous infragluteal free flap is best suited for restoring sensibility and achieving nearly full function, including resumption of sporting activities, with minimum donor-site morbidity. The anatomy, dissection technique, and results of 100 percent successful skin and tendon defect reconstruction in seven patients are presented.

autologous Breast Reconstruction after Breast-conserving Cancer Surgery

&NA; Breast‐conserving therapy, which aims to reduce trauma by preserving as much of a patients natural appearance as possible, does not necessarily lead to an optimal cosmesis. We hypothesized that combining plastic and oncologic surgeries would greatly reduce the physical and psychological traumas and produce an optimal cosmesis without impairing the oncologic outcome. We performed breast reconstruction on 40 cancer patients. Of those 40 patients, 15 received combined plastic and oncologic surgeries. Procedures depended on breast size: mammareduction plasty in cases with sufficient volume, and reconstruction using myocutaneous latissimus dorsi flaps for those with less volume. Cosmetic results were rated good to poor. Of the 15 primary reconstruction patients, 86.7 percent of the cases showed good results and 13.3 percent fair; in the secondary cases, 68 percent were good, 16 percent fair, and 16 percent poor. Through a follow‐up and cosmetic evaluations by both surgeons and patients, the study showed that combining aesthetic improvements and oncologic surgery does not compromise patient safety, reduces mental and physical trauma, and frequently results in superior cosmesis, thereby improving the patients overall health. (Plast. Reconstr. Surg. 102: 1932, 1998.)

Breast reconstruction with the fasciocutaneous infragluteal free flap (FCI)

Thin patients who will not accept breast reconstruction with foreign material may not have enough tissue associated with the TRAM or latissimus muscle to achieve an acceptable reconstruction. We feel the next choice is tissue from the infragluteal region raised and moved as a free fasciocutaneous flap (FCI) based on the descending branch of the inferior gluteal artery. This (FCI) has not been described for this to our knowledge. Thirty-five FCI flaps were done for 28 patients between 1998 and 2005 for autologous breast reconstruction, as well as simultaneous augmentation of the contralateral breast in 4 of these patients. There was no flap loss. Complications include seroma, scar pain, and fat necrosis and are reported and discussed. We suggest that the FCI flap be considered as a worthy alternative for autologous breast reconstruction in thin patients.

Reconstruction of Soft Tissue Defects Overlying the Achilles Tendon Using the Super Extended Abductor Hallucis Muscle Flap

BACKGROUND Soft tissue defects overlying the Achilles tendon often occur after traumatic ruptures of the Achilles tendon or because of pressure ulcers in patients suffering from circulatory problems. Ideally, reconstruction should be achieved in as few stages as possible. Currently, there are different methods used to treat these defects. Here, we examined whether reconstruction of this region could benefit from the super extended abductor hallucis muscle flap. METHODS In 12 cadaver feet, the vascular supply and mobilization radius of the abductor hallucis muscle were studied to clarify the possible clinical utilization of this flap. A technique for Achilles defect reconstruction using this flap, along with the functional and cosmetic results in six patients are presented. RESULTS Our anatomic findings agree with those available in the literature and the adaptation in pedicle preparation allowed an increase in rotation of the flap for successful coverage of defects overlying the Achilles tendon. Using the super extended abductor hallucis muscle flap, the functionality and the anatomic shape were successfully reconstructed. Six weeks after surgery all patients were fully mobile, unless they suffered from Achilles tendon ruptures then they were mobile after 12 weeks. CONCLUSIONS The super extended abductor hallucis muscle flap might represent an alternative to established methods because of ease of handling and a shorter anesthesia compared with a free flap procedure.

Perineal reconstruction after rectal and anal disease using the local fascio-cutaneous-infragluteal flap: A new and reliable technique

BACKGROUND Significant morbidity can result from perineal wounds, particularly if the tissue has been partially devitalized after radiotherapy and extensive resection for cancer or chronic inflammation which may occur in Crohns disease. Many different types of flaps have been used to improve healing of perineal tissue defects. The purpose of this study was to evaluate the morbidity and outcomes of reconstruction using the local fasciocutaneous infragluteal (FCI) flap. METHODS Fourteen consecutive patients undergoing local FCI flap reconstruction for perineal wounds and defects were included in the study. In 5 female patients, the defect included the dorsal wall of the vagina, which was reconstructed in 1 step. Ten patients underwent operations for anal or low rectal cancer, 3 suffered from Crohns disease and extensive local fistula formation, and 1 young girl presented with a defect after resection of a perineal synovial sarcoma. Eleven of these patients underwent preoperative chemotherapy and either pre- or intra-operative radiotherapy. RESULTS Complete healing of perineal wounds occurred in 13 of the 14 patients. There were 4 flap-related complications, including 3 patients with delayed wound healing and wound dehiscence and 1 patient with partial flap necrosis. The last patient required a second local flap for wound closure. In 2 patients, a second FCI flap was necessary because of a second tumor and a local tumor recurrence. Ambulation and normal mobility were possible after the flap procedure in all patients without restriction of activity. Four patients died during the follow-up period (median, 42.5 months) from tumor metastasis. CONCLUSION Local FCI flap for reconstruction of large perineal defects achieves good wound healing with only moderate morbidity in most patients after extensive resection owing to cancer or Crohns disease.

Pectus excavatum and free fasciocutaneous infragluteal flap: a new technique for the correction of congenital asymptomatic chest wall deformities in adults.

Background: Pectus excavatum is typically a cosmetic congenital chest wall deformity. In most cases, it does not affect heart and lung function; therefore, because of their high rate of complications, extensive procedures need not be performed. Various alternative techniques (e.g., reconstruction with silicone prosthesis or the transverse rectus abdominis musculocutaneous flap) were introduced in asymptomatic pectus excavatum. All of these methods have their advantages but also limitations. Thus, the authors used a free fasciocutaneous infragluteal flap for reconstruction of asymptomatic pectus excavatum in selected patients. Methods: Between 2001 and 2007, six patients suffering from asymptomatic pectus excavatum underwent correction with the free fasciocutaneous infragluteal flap. The fasciocutaneous infragluteal flap is based on a constant end artery of the inferior gluteal artery. After raising of the flap and wound closure in the buttock region, the flap was adjusted to the defect using a small skin incision in the inframammary fold, and the vessels were anastomosed. Results: There were no flap losses and no major complications. One patient suffered from a sensory change at the posterior thigh in the early postoperative period that resolved completely within 2 weeks. In four cases, flap shaping or liposuction was performed to improve the aesthetic result. In the authors’ final evaluation, all patients were very satisfied with the result and would undergo the procedure again. Conclusions: The authors have demonstrated for the first time the reconstruction of asymptomatic pectus excavatum with the free fasciocutaneous infragluteal flap. It is the authors’ opinion that, in selected patients, this flap offers an excellent alternative to established techniques for this problem.

Local fasciocutaneous infragluteal (FCI) flap for vulvar and vaginal reconstruction: a new technique in cancer surgery.

Introduction Soft tissue reconstruction after vulvar, vaginal, or anal cancer resection poses a formidable task for reconstructive surgeons because of the functional, locational, and cosmetic importance of this region. Although numerous flaps have been designed for vulvar reconstruction, each has its disadvantages. Methods The authors introduce the local fasciocutaneous infragluteal (FCI) flap for vulvar and vaginal reconstruction after tumor resection, vaginal scar obliteration, and vulvar ulceration in 15 patients operated on between 1999 and 2007. The FCI flap is supplied by the cutaneous branch of the descending branch of the inferior gluteal artery. The sensory supply of this flap comes from side branches of the posterior cutaneous nerve of the thigh. A total of 17 flaps were performed in 15 patients. Results Except for one, all flaps survived. One flap necrosis occurred because of false postoperative position with compression and tension to the vascular pedicle. In the remaining patients, we found one local cancer recurrence with necessity of a second flap from the contralateral side. The patients report satisfaction with reconstruction, without one having pain at donor site and recurrent vaginal ulceration. Conclusions This article discusses the expanding indications of this versatile flap and the operative technique of the local FCI flap for reconstruction of vulvar and partial vaginal defects. It can be raised in different volume and dimension out of possible irradiated area with an inconspicuous scar.

Autologous Breast Augmentation With the Deepithelialized Fasciocutaneous Infragluteal Free Flap: A 10-year Experience

Introduction:Breast augmentation with silicone implants is frequently performed, a daily procedure in plastic surgery. Nevertheless, there are well-known risks of capsular formation and contraction leading to pain, displacement, and rupture after breast augmentation. Thus, the frequency of augmentation with autologous tissue is increasing. Most frequently used are the transverse rectus abdominis muscle flap, the deep inferior epigastric artery perforator flap, and the gracilis free flap, but in some cases, these flaps are not the first choice. Therefore, we present our experience with the free fasciocutaneous infragluteal (FCI) flap. Methods:The FCI flap is based on a constant end artery of the inferior gluteal artery and has frequently been used for various indications at our department for many years. Since 1998, 17 patients suffering from breast hypoplasia, congenital breast asymmetry, or consecutive capsular fibrosis were treated with 25 FCI flaps. Results:In this series, no complete or partial flap loss was clinically detected. The only complaint was a discomfort at the donor site in the early postoperative period. As revealed by a final questionnaire, all patients were satisfied with the result. Conclusion:Our results suggest that the FCI flap should be considered as a worthy alternative for autologous breast augmentation, especially in thin patients suffering from breast hypoplasia, congenital asymmetry, or consecutive capsular formations.

Temporary closure of full-thickness abdominal-wall defects with mesh grafts

Introduction: A simple technique is presented here for temporarily covering massive, full-thickness, abdominal-wall defects, when they cannot be closed directly. Methods: The exposed viscera can be covered with a meshed split-thickness skin graft to close the wound and seal off the abdominal cavity from the outside. Once the patients general condition improves, the epidermal layer of the mesh graft should be removed by dermabrasion to minimize the risk of epidermal cysts, and the defect should be closed either by primary closure or by a local or free flap, depending on the defect size.