Nima P. Patel

Current management of venous ulceration.

Summary: It has been estimated that chronic venous insufficiency affects 10 to 35 percent of the entire U.S. population and that 4 percent of people older than 65 have active venous ulcers. The high prevalence of the disease results in an annual expenditure of more than

Outcomes of delayed abdominal-based autologous reconstruction versus latissimus dorsi flap plus implant reconstruction in previously irradiated patients.

1 billion a year to the U.S. health care system. To have a rational approach toward patients with venous ulcers, it is important to understand the pathophysiology and clinical characteristics of the disease process, in order to initiate appropriate treatment and prevent venous ulcer recurrence.

The use of the multi-island vertical rectus abdominis myocutaneous flap in head and neck reconstruction.

BackgroundLocal recurrence after breast conservation therapy is usually managed with salvage mastectomy. Multiple methods of reconstruction are possible, although delayed autologous reconstruction provides the most reliable results. MethodsWe compared complications in delayed abdominal-based [transverse rectus abdominis muscle (TRAM)/deep inferior epigastric perforator (DIEP)] reconstruction with delayed latissimus dorsi plus implant-based reconstruction in previously irradiated breasts. The authors reviewed 133 consecutive cases of delayed breast reconstructions performed in patients who had postmastectomy radiation therapy and reconstruction with abdominal-based methods (single-pedicle TRAM, supercharged pedicle TRAM, muscle-sparing TRAM free flap, DIEP flap, and superficial inferior epigastric artery flap) or a pedicled latissimus dorsi flap plus implant. Complications for donor and recipient sites were recorded including infection, seroma, hematoma, and partial flap loss. ResultsSeventy-five patients were reconstructed with abdominal-based flaps (37 muscle-sparing TRAMs, 19 pedicled TRAMs, 12 DIEPs, 6 supercharged pedicled TRAMs, and 1 superficial inferior epigastric artery). Their median age was 50 years and mean follow-up was 22.7 months. Three (4.0%) patients required reoperation during the same hospital visit for vascular compromise that resulted in 2 (2.7%) flap failures. Three (4.0%) patients had partial flap loss that ultimately required debridement and primary closure. Seventeen (22.7%) patients had minor complications including seroma, small hematoma, cellulitis, and abdominal bulge. Fifty-six patients were reconstructed with latissimus dorsi flaps plus implants. Their median age was 47 years and mean follow-up was 32 months. Three (5.4%) patients developed infections resulting in implant loss. Four (7.1%) patients had partial flap loss that required debridement and primary closure. Thirteen (23.2%) patients had minor complications including seroma (12 patients) and hematoma (1 patient) that required drainage. Fisher exact test was used to determine statistical significance of complication and failure rates between the 2 types of reconstruction. In patients who had postmastectomy radiation therapy, those with abdominal-based reconstructions had fewer complications compared with latissimus dorsi flap plus implant reconstructions (28.0% vs 30.4%, P = 0.846). Also, fewer reconstructions failed in patients with abdominal-based reconstruction (2.7% vs 5.4%, P = 0.650). ConclusionsAbdominal-based autologous reconstruction had fewer complications and fewer reconstruction failures than latissimus dorsi flap plus implant reconstructions in patients with postmastectomy radiation therapy in our series; however, these rates were not statistically significant.

Uncommon leg ulcers in the lower extremity

BackgroundHead and neck cancer extirpation frequently creates complex 3-dimensional defects involving both intraoral and external tissues. Reconstruction can be accomplished either with 2 free flaps, a simultaneous free and pedicle flap, or a single double-island folded free flap. Herein, the outcomes and rationale for reconstruction of multilaminar head and neck defects using the multi-island vertical rectus abdominis myocutaneous (MI-VRAM) flap are reported. MethodsA retrospective review was performed of a prospectively collected database of all head and neck reconstructions completed by a single surgeon between 1992 and 2011. Forty-six patients were identified who underwent reconstruction of composite defects using MI-VRAM flaps. Oncologic defects were classified into 3 categories based on anatomic location, namely, the midface, lower face, and neck. Indications and outcomes were reviewed. ResultsPatients’ ages ranged from 7 to 84 years with two thirds being male; 45% received preoperative radiation. Average MI-VRAM skin paddle size was 9 × 25.5 cm. Of the 46 reconstructions, 27 (59%) were performed in the midface, 14 (30%) in the lower face, and 5 (11%) in the neck region. There were no complete flap loses; however, 1 patient lost the external skin island, requiring pectoralis flap coverage. Of these cases, 15% had surgically related complications. Ten patients required secondary contouring procedures to revise bulky flaps. ConclusionsThe MI-VRAM flap is a safe and reliable technique for reconstruction of complex defects throughout the head and neck region. Compared to 2 simultaneous free flaps or a free flap combined with a regional flap, it saves time and eliminates a second donor site. Level of EvidenceLevel IV. Clinical question addressed in this paper is whether a multi-island VRAM flap is a safe technique in head and neck reconstruction.