K. Van Landuyt

The donor site morbidity of free DIEP flaps and free TRAM flaps for breast reconstruction

This study was undertaken to demonstrate that the deep inferior epigastric perforator (DIEP) flap can provide the well-known advantages of autologous breast reconstruction with lower abdominal tissue while avoiding the abdominal wall complications of the transverse rectus abdominis myocutaneous (TRAM) flap. Eighteen unilateral free DIEP flap breast reconstruction patients were assessed 12-30 months (mean 17.8 months) after surgery. Clinical examination, physical exercises and isokinetic dynamometry were performed preoperatively and two months and one year postoperatively. Intraoperative segmental nerve stimulation, visual evaluation and postoperative CT scans were also used to quantify the damage to the rectus muscle. The 18 patients were then compared with 20 free TRAM flap patients and 20 non-operated controls. Two DIEP flap patients presented with abdominal asymmetry. A limited decrease of trunk flexing strength was noticed but rotatory function was intact. Ten of the TRAM flap patients had umbilical or abdominal asymmetry, bulging or hernias. TRAM flap patients showed a statistically significant reduction in strength to flex and to rotate the upper trunk compared to both the one year postoperative DIEP flap group and the control group. The answers to a questionnaire revealed impairment of activities of daily living for some TRAM flap patients while the activities of all DIEP flap patients were unaffected. Our data demonstrate that the free DIEP flap can limit the surgical damage to the rectus abdominis and oblique muscles to an absolute minimum. We believe it is worthwhile to spend extra operative time, the main disadvantage of this technique, to limit late postoperative weakness of the lower abdominal wall.

The role of iodine in antisepsis and wound management: A reappraisal

Abstract For more than 150 years, iodine has been used for the prevention of infection and for the treatment of wounds. Nowadays a large amount of published evidence is available and, although it is generally in support of the use of iodine product, it is confused by being a mixture of laboratory, animals and human studies, often using different preparations. This makes interpretation and comparison difficult. After new developments and publications, the role of iodine in antisepsis and in wound management needs to be reevaluated. We mainly focused our review on the following problems: the role of the newly developed formulations of iodine preparations, its antimicrobial activity, the possibility of impairing the wound healing process, the role of iodine in the problem of growing resistance against antibiotics and antiseptics. New formulations seem to keep the same clinical efficacy, avoiding the problem of toxicity; it seems that the antibacterial activity of iodine is superior compared to other products and, in contrast with antibiotics and other antiseptics, it seems to have no resistance problem. It seems that povidone-iodine has all the characteristics to become the first choice antiseptic in wound treatment.

Allogeneic cultured keratinocytes vs. cadaveric skin to cover wide-mesh autogenous split-thickness skin grafts

Improved shock therapy has extended the limits of survival in patients with massive burns, and nowadays skin coverage has become the major problem in burn management. The use of mesh skin grafts is still the simplest technique to expand the amount of available donor skin. However, very wide-mesh skin grafts take a very long time to heal, often resulting in unaesthetic scar formation. On the other hand, allogeneic cultured keratinocytes have been reported as a natural source of growth factors and thus could be useful to improve wound healing of these wide-mesh grafts. A clinical study was performed to compare the use of cryopreserved allogeneic cultured keratinocytes vs. the traditional cadaveric skin as a double layer over widely expanded autogenous skin grafts. This procedure was performed in 18 pairs of full-thickness burn wounds (with similar depth and location) in 11 severely burned patients. Early clinical evaluation was made at 2, 3, and 4 to 5 weeks. Parameters such as epithelialization, granulation tissue formation, infection, and scar formation were evaluated. Biopsies were taken to compare the histological characteristics of the epidermis, the epidermal-dermal junction, and the dermis. Late evaluations were performed at 6 and 12 months regarding color, softness, thickness, and subjective feeling of the scar tissue. Aside from a faster (p < 0.05) epithelialization in the keratinocyte group at 2 weeks, there were no statistically different results in any of the early evaluated parameters, neither clinically nor histologically. At long-term follow-up, clinical results and scar characteristics were not significantly different in the two compared groups. It is concluded from the results of this study that, during the early phase, epithelialization was faster with allogeneic cultured keratinocytes compared with cadaveric skin. However, taking into account the substantial difference in costs, the described use of cryopreserved allogeneic cultured keratinocytes as a double layer on meshed autogenous split-thickness skin grafts can hardly be advocated.

Biocompatibility and oxidative stability of radiolucent breast implants.

Currently available mammary implants filled with either silicone gel, saline, or both are radiopaque on x-ray film and make mammographic screening less reliable. In women who have had augmentation mammaplasty, modifications of the mammography technique are necessary to maximize the amount of breast tissue visualized.1 These special techniques require additional effort, expertise, and x-ray views, adding to the expense of the procedure. A new implant (Trilucent, Lipomatrix, Inc., Neufchateau, Switzerland), filled with medicalgrade triglycerides derived from 100% USP soybean oil, recently became available on the market. The filler has a radiolucency equal to that of breast tissue and is reported to greatly simplify mammography in patients who have undergone augmentation.2– 4 Because breast cancer is expected to develop in about 10 percent of women who have undergone breast implantation and because mammography is the best diagnostic tool to detect breast carcinoma in its earliest stage (before the mass becomes palpable), this new filler might become increasingly important, even more so with the aging of women who have undergone breast augmentation.5,6 Although silicone gel and saline have been traditionally used as implant fillers, triglycerides are by no means a novel material. In fact, they have a much longer history of use in human medicine (as intravenous nutrition and intramuscular drug carriers), and their biocompatibility has been demonstrated in several animal experiments.2 The manufacturer states that the triglyceride filler of the Trilucent implant has several properties that make it even more desirable than normal saline as an implant filler: It is biodegradable, excretable, a lubricant, a normal dietary component, more viscous than saline, osmotically neutral, as radiolucent as breast fat, and nonallergenic. However, little is known about the effects of aging on the content of the breast implant in a biological environment, which may be associated with oxidation of the fatty acid moiety. To our knowledge, this report is the first to describe what happens when late deflation of a triglyceride-filled implant occurs.

Complete survival of a free flap after early pseudoaneurysm formation and pedicle thrombosis.

A microsurgical pseudoaneurysm is a very rare complication after free flap surgery. The authors report a case of a free thoracodorsal artery perforator flap transferred to a degloving wound on the dorsum of the foot and ankle. The patient developed pedicle thrombosis caused by a septic pseudoaneurysm, which was treated by conservative means. Sufficient vascularization developed within 15 days after surgery and the flap survived completely. This is in sharp contrast to other reported cases of pseudoaneurysm formation, all of which were treated surgically and resulted in flap failure, except in one case. A critical review of the literature is presented and the factors influencing flap survival are discussed.

The inframammary extending lateral intercostal artery perforator flap for reconstruction of axillary contractures: a case report

SUMMARY Release and reconstruction of axillary scar contractures can be challenging due to the specific anatomic site and contouring of the axillary region. Pliable and unscarred skin coverage of resulting defects after scar release is needed which enhances the postoperative recovery and revalidation. When traditional donor regions of fasciocutaneous flaps are involved in the scarred area, options are few. We describe the design and versatility of an inframammary extended lateral intercostal artery perforator (LICAP) flap to reconstruct an axillary defect after wide scar release and debridement. The postoperative recovery was uneventful with restoration of the range of motion of the shoulder joint.

Single-stage revascularization and free flap coverage in the treatment of ischemic lower limb lesions.

Old age, diabetes and atherosclerotic disease all have been considered to be relative contraindications for microsurgery. As such, gangrenous lesions of the lower limb traditionally resulted in staged amputations. A more aggressive approach, combining revascularization and free tissue transfer, allowed us to limit the level of amputation and to start early ambulation and rehabilitation, without the need for major orthotic help. Performing the vascular procedure, debridement, and free tissue transfer in one single intervention greatly reduces the number of operative procedures without substantial increase in operative time. Twenty consecutive patients underwent a combined free flap and revascularization procedure, two patients died perioperatively. One free flap was lost and needed replacement. All surviving patients were ambulating postoperatively.

The pyramidalis muscle free flap

The pyramidalis muscle is introduced as a new small muscle free flap, with description of its anatomy, the surgical technique and the clinical results in five different cases in which this flap was used to treat small recalcitrant wounds in the foot/ankle region. The pyramidalis muscle can be an alternative option in selective cases to reduce donor site morbidity as compared with more traditional free flaps.

Therapy resistant traumatic fungal infection necessitating arm amputation after free flap coverage

The indication for microvascular free tissue transfer is usually exposure of vital structures, bone defect, or loss of function. Radical debridement and control of infection is a prerequisite for any kind of reconstructive procedure. This is especially true for untidy wounds in industrial or agricultural settings; in these, one should not hesitate to debride any tissue which is not obviously viable. Aggressive surgical debridement should be performed before flap coverage. Some organisms, however, fail to be eradicated by mechanical debridement as they are particularly pathogenic or embedded in the tissues. Perforator flaps are currently recommended for soft tissue coverage of the upper limb, for their pliability and the low morbidity of the donor site. A case of traumatic deglovement injury of an upper arm is presented. After free flap coverage, it was complicated by a rare and highly pathogenic fungal infection. Successful soft tissue reconstruction obtained with a chimeric free flap was compromised by an expanding fungal infection ultimately leading to limb amputation.