M. Hamdi

Creation of a neovagina with use of a pudendal thigh fasciocutaneous flap and restoration of uterovaginal continuity

OBJECTIVE To create a neovagina and an endocervival canal in two patients with vaginal aplasia and a functioning uterus. DESIGN Technique and instrumentations. SETTING University hospital. PATIENT(S) A 31-year-old woman with vaginal aplasia and a double noncommunicating uterus (classified as Mayer-Rokitansky-Kuster-Hauser syndrome) and a 19-year-old woman with partial vaginal aplasia and a functional uterus. INTERVENTION(S) Creation of a neovagina by using the bilateral pudendal thigh fasciocutaneous flap procedure and laparotomy to establish uterovaginal continuity. MAIN OUTCOME MEASURE(S) Clinical follow-up evaluation of restoration of outflow of menstrual blood and coital satisfaction. RESULT(S) Uterovaginal continuity was established in both patients, resulting in normal menstruation. Granulomatous polyps occurred in one patient, and stenosis at the site of anastomosis occurred in the other patient; these conditions were successfully managed. Unimpeded menstrual flow continued after 1 year of follow-up in one patient and 3 years of follow-up in the other patient. CONCLUSION(S) Bilateral fasciocutaneous pudendal thigh flaps permit vaginal reconstruction and a uterovaginal connection in patients with vaginal agenesis and a functional uterus. The main advantages of this technique are that postoperative dilatation is not necessary, sensation is maintained, and the resulting scar is inconspicuous. The main disadvantage is the presence of some sebaceous vaginal secretion and hair in the vaginal lining; the latter can be managed by preoperative and postoperative laser depilation.

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.

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.

Ball lightning burn

Ball lightning is a rare physical phenomenon, which is not yet completely explained. It is similar to lightning but with different, peculiar characteristics. It can be considered a mix of fire and electricity, concentrated in a fireball with a diameter of 20-cm that most commonly appears suddenly, even in indoor conditions, during a thunderstorm. It moves quickly for several meters, can change direction, and ultimately disappears. During a great storm, a 28-year-old man and his 5-year-old daughter sustained burn wounds after ball lightning came from the outdoors through a chimney. These two patients demonstrated signs of fire and electrical injuries. The father, who lost consciousness, sustained superficial second-degree burn wounds bilaterally on the zygomatic area and deep second-degree burn wounds on his right hand (total body surface area, 4%). His daughter demonstrated superficial second-degree burn wounds on the left part of the face and deep second-degree and third-degree burn wounds (total body surface area, 30%) on the left neck, both upper arms, and the back. In this article, the authors report the first two cases of burn injuries resulting from ball lightning contact indoors. The literature on this rare phenomenon is reviewed to elucidate the nature of ball lightning. Emphasis is placed on the nature of injuries after ball lightning contact, the therapy used, and the long-term complications.

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.