Lloyd Nanhekhan

Fat necrosis in deep inferior epigastric perforator flaps: an ultrasound-based review of 202 cases.

Background: In autologous breast reconstruction after mastectomy, fat necrosis is a rather common complication that may lead to secondary corrective surgery. The understanding of fat necrosis until now has been limited because previous studies were based exclusively on physical examination and used diverse definitions. Methods: The authors retrospectively reviewed the incidence of fat necrosis and the correlation of several risk factors in 202 deep inferior epigastric perforator (DIEP) flaps for breast reconstruction. The incidence of fat necrosis was based on both physical examination and ultrasound imaging. The following risk factors were studied: age, smoking, body mass index, timing of reconstruction, and timing and extent of radiation therapy fields. Results: Physical examination revealed a palpable mass or nodule in 14 percent of the DIEP flaps (28 of 202). Ultrasound examination added another 21 percent of DIEP flaps (42 of 202) with a firm area of scar tissue (diameter ≥5 mm). The overall ultrasound incidence of fat necrosis in this study was 35 percent (71 of 202). Although the overall ultrasound incidence of fat necrosis was very high, only 7 percent of the DIEP flaps (15 of 202) needed to undergo an extra surgical procedure for removal of this area. In contrast to previous studies, none of the risk factors studied was statistically significant for the occurrence of fat necrosis. Conclusions: These results suggest that there is no significant association between previously suspected risk factors and fat necrosis. The overall incidence of fat necrosis, however, is much higher than previously accepted, even though the need for corrective surgery is limited.

The role of free flaps in the treatment of persistent scalp osteomyelitis.

OBJECTIVE: To evaluate the efficacy of the combination of an extensive surgical debridement and simultaneous free flap repair in case of troublesome cranial osteomyelitis. METHODS: Five patients with persistent, frontal bone osteomyelitis were treated with surgical debridement of the infected bone and reconstruction with a free flap. In all patients, osteomyelitis occurred after neurosurgical procedures and lasted from 1 to 7 years. A latissimus dorsi muscle flap with a split skin graft has been performed. RESULTS: No flap failure occurred and donor site morbidity was negligible. No signs of osteomyelitis or soft tissue infection were observed during the mean follow-up period of 3.2 years. Furthermore, the contour of the cranium could be preserved without a need for bone grafts or implants. CONCLUSION: In our experience, the combination of an extensive surgical debridement and a free flap transfer is demonstrated to be an effective treatment for “chronic” osteomyelitis of the cranium.

Initial reconstruction of sustained neck and facial burns.

Approximately 50% of burn injuries involve the neck and head region. Because both appearance and function must be taken into account with burns of this area, several consecutive reconstructions will be performed. With a focus on improving outcome after burn injury, we underline the method of grafting as a very important element in primary surgery. With our special excision and grafting technique, we aim to achieve a reconstruction that deals with mobility and aesthetics. Consequently, necessary reconstructive procedures may be fewer and of less magnitude. We describe this surgical technique in detail. In this study we surgically treated 39 patients with sustained facial and neck burns. For 22 patients this surgical treatment circumvented the need to perform any secondary reconstructions. The proposed treatment involves a special grafting technique after pretreatment with a topical agent in combination with early pressure therapy.

Minimizing limb amputations in meningococcal sepsis by early microsurgical arteriolysis.

PURPOSE Surgical treatment of children with meningococcal sepsis has mainly involved debridement of necrotic skin and amputation of limbs. This resulted in major functional impairment. On the contrary, when early microsurgical arteriolysis was performed, freeing up the blood vessels, the impaired blood flow could be restored, thereby significantly reducing the amputation levels. METHODS We prospectively evaluated 14 patients affected by meningococcal sepsis. In 7 patients, microsurgical arteriolysis was performed; standard sepsis treatment was performed on the remaining 7. Ischemia levels on admission were compared with permanent amputation levels after 1 year. RESULTS Statistically significant decreases (P = .005) in ischemia values were achieved by the arteriolysis, in comparison with final amputation percentages. The functional impairment of the affected limbs was highly reduced compared with the probable loss of function observed on admission. CONCLUSIONS Our findings show that early microsurgical arteriolysis is a reliable method to reduce the devastating amputations normally found in patients with meningococcal sepsis. This significantly improves the functional outcome in severely ischemic limbs in meningococcal induced septic children.

The unilateral deep inferior epigastric perforator flap: Comparing university to community hospital.

Abstract The deep inferior epigastric perforator (DIEP) flap is considered to be the gold standard for autologous breast reconstruction. This study evaluates the outcome of unilateral DIEP flap reconstructions, comparing university with a community hospital setting. A total of 77 unilateral DIEP flaps were performed at one university hospital and two community hospitals by the same two surgeons. Outcome parameters were: hospital stay, operating time, wound infection, wound dehiscence, fat necrosis, haematoma, (partial) flap necrosis and the need for surgical intervention. Forty-nine unilateral DIEP flaps were performed in the university hospital and 28 in the community hospitals. Baseline characteristics were equal. No significant difference was found in total complication rate, flap loss or need for surgical intervention. Although wound dehiscence occurred more often in the community hospitals, unilateral DIEP flap breast reconstructions can be performed with a comparable degree of safety and complication risk in both university and community hospital settings.

An old flap for a new child

Sir: Spina bifida is a posterior fusion failure of neural tissue affecting approximately 1 of 850 live births [1]. Three different types of spina bifida are well known: aperta (with a bony defect of posterior vertebral arches accompanied by herniation of neural tissue), cystica (the most common type in which either meninges or neural tissue is exposed to the environment) and occulta (asymptomatic and often undetected) [2]. When confronted with this type of pathology, our task as plastic surgeons consists of finding a suitable solution to cover the lumbosacral cutaneous defect and, above all, keeping in mind the timing of repair, which is of utmost importance. Closure of the back defect soon after birth is mandatory to decrease the risk of mortality and central nervous system infections, which can hamper mental development. Prolonged delay may be associated with neurological deficit due to desiccation of the exposed cord elements and the possibility of infections increasing with time [1, 3]. Many techniques to repair wide defects have been described in literature such as skin grafts, myocutaneous flaps and local fasciocutaneous flaps [3–5]. Fasciocutaneous flaps provide an adequate soft tissue pad over the repaired dura and conform well to the areas which are important because these children are often confined to wheelchairs. Indeed, the alteration or removal of normally functioning back muscles (e.g. latissimus dorsi) carries the risk of functional loss in the maintenance of trunk posture and ambulation [1, 3, 5]. In January 2004, a 4-day-old newborn, with a length of 47 cm and a weight of 2.55 kg, with spina bifida aperta was brought to our department. The cutaneous defect measured 9×6 cm and covered 36% of the total surface of the back (Fig. 1). The patient was treated using the standard fourflap technique. This method, described by Lanigan in 1993, consists of elevation and medial transposition of two inferiorly based flaps to cover the central defect. The resulting lateral defects were covered by two laterally based flaps. In this way, nearly all of the skin of the back is redistributed without involving the underlying muscles. Our flaps covered Eur J Plast Surg (2008) 31:87–88 DOI 10.1007/s00238-007-0211-1

Preservation of rat cremaster muscle microcirculation after prolonged cold storage and transplantation

BACKGROUND Microvascular surgery for the reconstruction of complex defects involves an ischemic period, which may cause flap failure as the result of ischemia/reperfusion injury. We assessed the microvascular consequences of rat cremaster muscle transplantation after prolonged periods of cold storage in HTK-Bretschneider solution (HTK). MATERIALS AND METHODS Cremaster muscle transplantations were performed immediately or after 8 or 24 h of cold storage (4 degrees C) in HTK or saline. Intravital microscopy was used to quantify capillary perfusion and venular leukocyte-endothelium interactions following transplantation. RESULTS The transplantation procedure itself resulted in 50-65 min of ischemia. After direct transplantation, capillary perfusion was 90% of control. Transplantation after 8 h of cold storage in either HTK or saline did not deteriorate capillary perfusion. When the tissue was stored for 24 h, HTK was superior to saline in preserving capillary perfusion (HTK: 76-83% of control, saline: 30%). Immediate transplantation induced a small increase in leukocyte adhesion. Prolonged cold storage in either fluid resulted in reduced flow velocities (qualitative observations) and edema formation, which hampered quantification of leukocyte-endothelium interactions. CONCLUSIONS Even after 8 or 24 h of cold storage in HTK, transplantation of rat cremaster muscle was successful with good capillary perfusion. Capillary perfusion was better preserved in HTK than in saline.