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1.  Skull Base Reconstruction in the Pediatric Patient 
Skull Base  2007;17(1):39-51.
ABSTRACT
Tumors of the skull base are rare in children and adolescents and present a complicated management problem for oncologists and surgeons alike. Surgical resection is an integral component of the management of many pediatric neoplasms, especially those that are benign or, though not frankly malignant, are locally invasive. The general principles of skull base reconstruction following tumor ablation are applicable to nearly all patients; the reconstructive algorithm, however, is particularly complex in the pediatric population and the potential benefits of therapy must be balanced against the cumulative impact on craniofacial growth and maturity and the donor site morbidity. A retrospective analysis of all patients less than 19 years of age who underwent resection of a skull base tumor was performed. Particular emphasis was placed on the 12 patients who required complex reconstruction by the plastic surgical service. This represents approximately a third of the operated patients. Data were recorded on patient age, tumor pathology and location, prior therapies, surgical approach, extent of resection, margin status, defect components, details of reconstructive methods employed, complications, additional procedures or interventions, and the use and timing of adjuvant therapies. Patient outcome at most recent follow-up was recorded. All patients were followed clinically and by MRI and/or CT scan of the skull base. The reconstructive details recorded included flap choice, recipient vessels, and any concomitant procedures performed. The indications for and details of any staged surgical revisions or prosthetics were also noted. Complications recorded included partial or total flap loss, cerebrospinal fluid leakage, meningitis, infection, abscess, hematoma or seroma formation, delayed healing, and donor site dysfunction. The vertical rectus abdominis myocutaneous free flap was the most common means of reconstruction utilized in this series. Three of 12 patients had reconstruction related complications. Delayed reconstructive procedures or prosthetic interventions have been performed in 6 of the 12 patients who underwent complex reconstructions. On the basis of our experience and previous reports in the literature, we offer the following guidelines for the successful multidisciplinary care of children and adolescents undergoing skull base reconstruction after tumor resection: (1) skull base reconstruction may be safely performed in children and adolescents using free tissue transfer or local flaps; (2) larger defects and those involving more than one anatomic region of the skull base should be repaired with soft-tissue free flaps; and (3) because of the versatility and reliability of free flaps, pedicled flaps should be reserved for limited defects. Because of the potentially synergistic effects of multimodality treatment for skull base malignancies on craniofacial growth and development, we advocate soft-tissue reconstruction as the primary technique, reserving bony flaps for definitive procedures in survivors who have reached skeletal maturity.
doi:10.1055/s-2006-959334
PMCID: PMC1852573  PMID: 17603643
Skull base; pediatric; microvascular; reconstruction
2.  Perineal Wound Complications after Abdominoperineal Resection 
ABSTRACT
Perineal wound complications following abdominoperineal resection (APR) is a common occurrence. Risk factors such as operative technique, preoperative radiation therapy, and indication for surgery (i.e., rectal cancer, anal cancer, or inflammatory bowel disease [IBD]) are strong predictors of these complications. Patient risk factors include diabetes, obesity, and smoking. Intraoperative perineal wound management has evolved from open wound packing to primary closure with closed suctioned transabdominal pelvic drains. Wide excision is used to gain local control in cancer patients, and coupled with the increased use of pelvic radiation therapy, we have experienced increased challenges with primary closure of the perineal wound. Tissue transfer techniques such as omental pedicle flaps, and vertical rectus abdominis and gracilis muscle or myocutaneous flaps are being used to reconstruct large perineal defects and decrease the incidence of perineal wound complications. Wound failure is frequently managed by wet to dry dressing changes, but can result in prolonged hospital stay, hospital readmission, home nursing wound care needs, and the expenditure of significant medical costs. Adjuvant therapies to conservative wound care have been suggested, but evidence is still lacking. The use of the vacuum-assisted closure device has shown promise in chronic soft tissue wounds; however, experience is lacking, and is likely due to the difficulty in application techniques.
doi:10.1055/s-2008-1055325
PMCID: PMC2780192  PMID: 20011400
Abdominoperineal resection; perineal wound complication; wound management; tissue transfer; vacuum-assisted closure device
3.  Management of a complex recurrent perineal hernia 
Journal of Surgical Case Reports  2013;2013(8):rjt056.
Symptomatic perineal hernias following abdomino-perineal excision of rectum have been reported to occur uncommonly. We present the case of a 79-year-old gentleman who developed a perineal hernia after laparoscopic-assisted extralevator abdomino-perineal excision (ELAPE) of the rectum. Despite initial myocutaneous flap repair, there was further symptomatic recurrence. Magnetic resonance imaging demonstrated non-compromised bowel extending beneath the gracilis flap with extension into the adductor compartment of the left thigh. Given the recurrent nature, a rectus flap repair was performed and after 15 months, he remains hernia free. There is currently no consensus as to the optimal operative technique in the prevention and management of these hernias; however, primary reconstruction at the time of ELAPE may be preferable. Symptomatic perineal hernias can be severely debilitating and require operative repair. We suggest that surgical options should be discussed and carried out with the input of a Plastic surgeon.
doi:10.1093/jscr/rjt056
PMCID: PMC3813553  PMID: 24964466
4.  Use of the Anterolateral Thigh and Vertical Rectus Abdominis Musculocutaneous Flaps as Utility Flaps in Reconstructing Large Groin Defects 
Archives of Plastic Surgery  2014;41(5):556-561.
Background
Groin dissections result in large wounds with exposed femoral vessels requiring soft tissue coverage, and the reconstructive options are diverse. In this study we reviewed our experience with the use of the pedicled anterolateral thigh and vertical rectus abdominis musculocutaneous flaps in the reconstruction of large groin wounds.
Methods
Groin reconstructions performed over a period of 10 years were evaluated, with a mean follow up of two years. We included all cases with large or complex (involving perineum) defects, which were reconstructed with the pedicled anterolateral thigh musculocutaneous or the vertical rectus abdominis musculocutaneous (VRAM) flaps. Smaller wounds which were covered with skin grafts, locally based flaps and pedicled muscle flaps were excluded.
Results
Twenty-three reconstructions were performed for large or complex groin defects, utilising the anterolateral thigh (n=10) and the vertical rectus abdominis (n=13) pedicled musculocutaneous flaps. Femoral vein reconstruction with a prosthetic graft was required in one patient, and a combination flap (VRAM and gracilis muscle flap) was performed in another. Satisfactory coverage was achieved in all cases without major complications. No free flaps were used in our series.
Conclusions
The anterolateral thigh and vertical rectus abdominis pedicled musculocutaneous flaps yielded consistent results with little morbidity in the reconstruction of large and complex groin defects. A combination of flaps can be used in cases requiring extensive cover.
doi:10.5999/aps.2014.41.5.556
PMCID: PMC4179361  PMID: 25276649
Groins; Surgical flap; Pedicled flap; Musculocutaneous flap
5.  Reconstruction of Groin Defects Following Radical Inguinal Lymphadenectomy: An Evidence Based Review 
Inguinal lymph node involvement is an important prognostic and predictive factor in various neoplasms of the genitalia and lower limb. As part of the multimodality approach, these patients undergo surgery and adjuvant radiotherapy. Morbidity of inguinal lymphadenectomy includes lymphedema, lymphorrhea and infection; however the most common distressing complication is skin necrosis. Myocutaneous flaps have been the most popular form of primary or delayed groin reconstruction. This paper aims to critically review the different myocutaneous flaps used in groin reconstruction, discuss evidence based data on the versatility and utility of these flaps and discuss ways in which modifications maybe incorporated in treatment and radiation planning following groin reconstruction. A comprehensive search of the scientific literature was carried out using PubMed to access all publications related to groin reconstruction. The search focused specifically on current management, technique, safety and complications of these procedures. Keywords searched included “inguinal lymphadenectomy”, “primary reconstruction”, “musculocutaneus flap”, “myocutaneous flap”, “tensor fascia lata flap”, “anterolateral thigh flap”, “rectus abdominis flap”. Low to middle income countries witness a huge burden of locally advanced genital malignancies and melanoma of the lower extremity. Higher tumor burden both at the primary site as well as the inguinal basin requires surgery as the primary modality of treatment. Groin reconstruction is required not only to prevent femoral blowouts but also for early administration of adjuvant radiation. The versatility of tensor fascia lata, anterolateral thigh, and rectus abdominis flaps is useful to cover the defect, provide radiation, eradicate pain and achieve good palliation. Assessment of aesthetic and functional outcomes of one flap over the other and the “ideal” form of reconstruction for groin defects needs additional investigation.
doi:10.1007/s13193-012-0145-3
PMCID: PMC3392480  PMID: 23730102
Inguinal lymphadenectomy; Primary reconstruction; Musculocutaneus flap
6.  Unilateral and Bilateral Breast Reconstruction with Pedicled TRAM Flaps: An Outcomes Analysis of 188 Consecutive Patients 
Background:
The abdomen remains a popular donor site for autologous tissue breast reconstruction. Recently, however, some authors have questioned whether the pedicled transverse rectus abdominis myocutaneous (TRAM) flap should remain a first-line reconstruction option.
Methods:
Between 1998 and 2009, 188 women underwent breast reconstruction with pedicled TRAM flaps by the senior author (J.A.A.). All TRAM flaps involved reinforcement of the abdominal wall repair with polypropylene mesh. Reconstruction was unilateral in 164 patients and bilateral in 24 patients, yielding a total of 212 flaps.
Results:
The mean follow-up period was 36 months. There were no complete flap losses. Overall hernia rate for the series was 1.6%, and overall abdominal bulge rate was 0.5%. When combining all types of morbidity, 38 unilateral (23.2%) and zero bilateral TRAM flap patients experienced flap site complications (P = 0.005), and 16 unilateral (9.8%) and 5 bilateral patients (20.8%) experienced donor site complications (P = 0.155). For morbidity that required a return to the operating room, the overall rate was 4.3% for unilateral TRAM flap patients and 4.2% for bilateral TRAM flap patients. Flap site morbidity was significantly associated with obesity, former or active smoking, and receiving 2 or more adjuvant therapies. Donor site morbidity was significantly associated with obesity.
Conclusions:
The pedicled TRAM flap continues to be an excellent option for breast reconstruction. Complication rates for both unilateral and bilateral TRAM flaps were low in this series, with no complete flap losses and just 4.3% of patients requiring a return to the operating room secondary to morbidity.
doi:10.1097/GOX.0b013e3182944595
PMCID: PMC4184052  PMID: 25289209
7.  Latissimus Dorsi Myocutaneous Flap for Breast Reconstruction: Bad Rap or Good Flap? 
Eplasty  2011;11:e39.
Objective: This article serves to review latissimus dorsi myocutaneous flap as an option for breast reconstruction postmastectomy. Since the introduction of the latissimus dorsi myocutaneous flap in the late 1970s, its use has always been as a secondary technique, particularly after the development of the transverse rectus abdominus myocutaneous flap in the 1980s. Methods: A literature review of the history of latissimus dorsi myocutaneous flap utilized for breast reconstruction as well as a review of our institution's experience with latissimus dorsi myocutaneous flap and tissue expander placement was performed. Results: There remains a paucity of published studies investigating latissimus dorsi myocutaneous flap for breast reconstruction. Most studies have small numbers and do not utilize tissue expanders. More recently several small studies have been published that show acceptably low complication rates with aesthetically pleasing outcomes when latissimus dorsi myocutaneous flap is employed with a tissue expander. At our institution, we have employed latissimus dorsi myocutaneous flap with tissue expander placement for both delayed and immediate reconstruction with subsequent replacement with a permanent implant with a capsular contraction rate of 10.5%. Our data and others more recently published demonstrate very acceptable capsular contracture rates and aesthetic outcomes, particularly when an expander is utilized. Conclusion: The latissimus dorsi myocutaneous flap remains an excellent choice for breast reconstruction with a low risk of complications.
PMCID: PMC3196917  PMID: 22031843
8.  Perineal care 
Clinical Evidence  2011;2011:1401.
Introduction
Over 85% of women having a vaginal birth suffer some perineal trauma. Spontaneous tears requiring suturing are estimated to occur in at least a third of women in the UK and US, with anal sphincter tears in 0.5% to 7% of women. Perineal trauma can lead to long-term physical and psychological problems.
Methods and outcomes
We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of intrapartum surgical and non-surgical interventions on rates of perineal trauma? What are the effects of different methods and materials for primary repair of first- and second-degree tears and episiotomies? What are the effects of different methods and materials for primary repair of obstetric anal sphincter injuries (third- and fourth-degree tears)? We searched: Medline, Embase, The Cochrane Library, and other important databases up to March 2010 (Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).
Results
We found 38 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.
Conclusions
In this systematic review we present information relating to the effectiveness and safety of the following interventions: active pushing, spontaneous pushing, and sustained breath-holding (Valsalva) method of pushing; continuous support during labour; conventional suturing; different methods and materials for primary repair of obstetric anal sphincter injuries; episiotomies (midline and mediolateral incisions); epidural analgesia; forceps; methods of delivery ("hands-on" method, "hands poised"); water births; non-suturing of muscle and skin (or perineal skin alone); passive descent in the second stage of labour; positions (supine or lithotomy positions, upright position during delivery); restrictive or routine use of episiotomy; sutures (absorbable synthetic sutures, catgut sutures, continuous sutures, interrupted sutures); and vacuum extraction.
Key Points
Over 85% of women having a vaginal birth suffer some perineal trauma. Spontaneous tears requiring suturing are estimated to occur in at least one third of women in the UK and US, with anal sphincter tears in 0.5% to 7% of women.Risk factors include first vaginal delivery, large or malpositioned baby, older or white mother, abnormal collagen synthesis, poor nutritional state, and forceps delivery.
Perineal trauma can lead to long-term physical and psychological problems. Up to 10% of women continue to have long-term perineal pain; up to 25% will have dyspareunia or urinary problems, and up to 10% will report faecal incontinence.
Restricting routine use of episiotomy reduces the risk of posterior perineal trauma. Using episiotomies only when there are clear maternal or fetal indications increases the likelihood of maintaining an intact perineum, and does not increase the risk of third-degree tears.
We don't know whether pain or wound dehiscence are less likely to occur with midline episiotomy compared with mediolateral incision. Midline incisions may be more likely to result in severe tears, although we can't be sure about this.
Instrumental delivery increases the risk of perineal trauma. The risk of instrumental delivery is increased after epidural analgesia. Vacuum extraction reduces the rate of severe perineal trauma compared with forceps delivery, but increases the risk of cephalhaematoma and retinal haemorrhage in the newborn.
Continuous support during labour reduces the rate of assisted vaginal births, and thus the rate of perineal trauma.
The "hands-poised" delivery method is associated with lower rates of episiotomy, but increased rates of short-term pain and manual removal of the placenta. Likewise, an upright position during delivery is associated with lower rates of episiotomy, but no significant difference in overall rates of perineal trauma.
Non-suturing of first- and second-degree tears (perineal skin and muscles) may be associated with reduced wound healing up to 3 months after birth. However, leaving the perineal skin alone unsutured (vagina and perineal muscles sutured) reduces dyspareunia and may reduce pain at up to 3 months.
Absorbable synthetic sutures for repair of first- and second-degree tears and episiotomies are less likely to result in long-term pain than catgut sutures. Rapidly absorbed synthetic sutures reduce the need for suture removal. Continuous sutures reduce short-term pain.
Early primary overlap repair for third- and fourth-degree anal sphincter tears seems to be associated with lower risks for faecal urgency and anal incontinence symptoms than end-to-end approximation.
We don't know whether immersion in water during the first or second stage of labour has any effect on rates of perineal trauma or whether passive descent is better than active pushing.
It is unclear whether the sustained breath holding (Valsalva) method is more effective at reducing rates of perineal trauma compared with exhalatory or spontaneous pushing.
PMCID: PMC3275301  PMID: 21481287
9.  Perineal care 
Clinical Evidence  2008;2008:1401.
Introduction
Over 85% of women having a vaginal birth suffer some perineal trauma. Spontaneous tears requiring suturing are estimated to occur in at least a third of women in the UK and USA, with anal sphincter tears in 0.5% to 7% of women. Perineal trauma can lead to long-term physical and psychological problems.
Methods and outcomes
We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of intrapartum surgical and non-surgical interventions on rates of perineal trauma? What are the effects of different methods and materials for primary repair of first- and second-degree tears and episiotomies? What are the effects of different methods and materials for primary repair of obstetric anal sphincter injuries (third- and fourth-degree tears)? We searched: Medline, Embase, The Cochrane Library, and other important databases up to April 2007 (BMJ Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).
Results
We found 38 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.
Conclusions
In this systematic review we present information relating to the effectiveness and safety of the following interventions: active pushing, spontaneous pushing, and sustained breath-holding (Valsalva) method of pushing; continuous support during labour; conventional suturing; different methods and materials for primary repair of obstetric anal sphincter injuries; episiotomies (midline and mediolateral incisions); epidural analgesia; forceps; methods of delivery ("hands-on" method, "hands poised"); water births; non-suturing of muscle and skin (or perineal skin alone); passive descent in the second stage of labour; positions (supine or lithotomy positions, upright position during delivery); restrictive or routine use of episiotomy; sutures (absorbable synthetic sutures, catgut sutures, continuous sutures, interrupted sutures); and vacuum extraction.
Key Points
Over 85% of women having a vaginal birth suffer some perineal trauma. Spontaneous tears requiring suturing are estimated to occur in at least one third of women in the UK and USA, with anal sphincter tears in 0.5% to 7% of women.Risk factors include first vaginal delivery, large or malpositioned baby, older or white mother, abnormal collagen synthesis, poor nutritional state, and forceps delivery.
Perineal trauma can lead to long-term physical and psychological problems. Up to 10% of women continue to have long-term perineal pain; up to 25% will have dyspareunia or urinary problems, and up to 10% will report faecal incontinence.
Restricting routine use of episiotomy reduces the risk of posterior perineal trauma. Using episiotomies only when there are clear maternal or fetal indications increases the likelihood of maintaining an intact perineum, and does not increase the risk of third-degree tears.
We don't know whether pain or wound dehiscence are less likely to occur with midline episiotomy compared with mediolateral incision. Midline incisions may be more likely to result in severe tears, although we can't be sure about this.
Instrumental delivery increases the risk of perineal trauma. The risk of instrumental delivery is increased after epidural analgesia. Vacuum extraction reduces the rate of severe perineal trauma compared with forceps delivery, but increases the risk of cephalhaematoma and retinal haemorrhage in the newborn.
Continuous support during labour reduces the rate of assisted vaginal births, and thus the rate of perineal trauma.
The ‘hands-poised' delivery method is associated with lower rates of episiotomy, but increased rates of short-term pain and manual removal of the placenta. Likewise, an upright position during delivery is associated with lower rates of episiotomy, but no significant difference in overall rates of perineal trauma.
Non-suturing of first- and second-degree tears (perineal skin and muscles) may be associated with reduced wound healing up to 3 months after birth. However, leaving the perineal skin alone unsutured (vagina and perineal muscles sutured) reduces dyspareunia and may reduce pain at up to 3 months.
Absorbable synthetic sutures for repair of first- and second-degree tears and episiotomies are less likely to result in long-term pain compared with catgut sutures. Rapidly absorbed synthetic sutures reduces the need for suture removal. Continuous sutures reduce short-term pain.
Early primary overlap repair forthird- and fourth-degree anal sphincter tears seems to be associated with lower risks for faecal urgency and anal incontinence symptoms .
We dont know whether immersion in water during the first or second stage of labour has any effect on rates of perineal trauma.
PMCID: PMC2907946  PMID: 19445799
10.  The Deep Inferior Epigastric Perforator and Pedicled Transverse Rectus Abdominis Myocutaneous Flap in Breast Reconstruction: A Comparative Study 
Archives of Plastic Surgery  2013;40(3):187-191.
Background
Our objective was to compare the complication rates of two common breast reconstruction techniques performed at our hospital and the cost-effectiveness for each test group.
Methods
All patients who underwent deep inferior epigastric perforator (DIEP) flap and transverse rectus abdominis myocutaneous (TRAM) flap by the same surgeon were selected and matched according to age and mastectomy with or without axillary clearance. Patients from each resultant group were selected, with the patients matched chronologically. The remainder were matched for by co-morbidities. Sixteen patients who underwent immediate breast reconstruction with pedicled TRAM flaps and 16 patients with DIEP flaps from 1999 to 2006 were accrued. The average total hospitalisation cost, length of hospitalisation, and complications in the 2 year duration after surgery for each group were compared.
Results
Complications arising from both the pedicled TRAM flaps and DIEP flaps included fat necrosis (TRAM, 3/16; DIEP, 4/16) and other minor complications (TRAM, 3/16; DIEP, 1/16). The mean hospital stay was 7.13 days (range, 4 to 12 days) for the pedicled TRAM group and 7.56 (range, 5 to 10 days) for the DIEP group. Neither the difference in complication rates nor in hospital stay duration were statistically significant. The total hospitalisation cost for the DIEP group was significantly higher than that of the pedicled TRAM group (P<0.001).
Conclusions
Based on our study, the pedicled TRAM flap remains a cost-effective technique in breast reconstruction when compared to the newer, more expensive and tedious DIEP flap.
doi:10.5999/aps.2013.40.3.187
PMCID: PMC3665859  PMID: 23730591
Perforator flap; Surgical flap; Mammoplasty; Complications
11.  Correlating the deep inferior epigastric artery branching pattern with type of abdominal free flap performed in a series of 145 breast reconstruction patients 
INTRODUCTION
The deep inferior epigastric perforator (DIEP) flap is currently viewed as the gold standard in autologous breast reconstruction. We studied three-dimensional computed tomography angiography (CTA) in 145 patients undergoing free abdominal flap breast reconstruction to try to correlate deep inferior epigastric artery (DIEA) branching pattern with the type of flap performed and patient outcome. Today, reconstructive breast surgeons have become more experienced in raising DIEP flaps and operative times are becoming more acceptable. However, there remains significant interest in finding ways to aid this challenging dissection.
METHODS
We retrospectively evaluated consecutive patients between January 2007 and August 2008. CTAs were analysed using the Moon and Taylor (1988) classification of the DIEA branching pattern. Data gathered included pre-operative morbidity, type of abdominal wall free flap performed, length of operation, length of stay and complications.
RESULTS
Some 150 breast reconstructions were performed in 145 patients. There were 67 DIEP flaps, 69 MS-2 transverse rectus abdominis myocutaneous (TRAM) flaps and 14 MS-1 TRAM flaps (where MS-1 spares the lateral muscle and MS-2 spares both lateral and medial segments). Proportionally more DIEP flaps were performed in patients with a type 2 branching pattern. There was one flap loss (0.67%).
CONCLUSIONS
In this large CTA series, we found a type 1 (single artery) DIEA pattern most frequently, in contrast to the predominance of the type 2 bifurcating pattern observed previously. The higher proportion of DIEP flaps performed in the type 2 pattern patients is consistent with the documented shorter intramuscular course in this group. We have found CTA useful for faster selection of the best hemiabdomen for dissection and flap loss rates in our unit have reduced from 1.5% to 0.67%.
doi:10.1308/003588412X13171221592050
PMCID: PMC3954245  PMID: 23031768
Breast reconstruction; Free tissue flaps; Surgical flaps; Angiography
12.  Comparison of the Complications in Vertical Rectus Abdominis Musculocutaneous Flap with Non-Reconstructed Cases after Pelvic Exenteration 
Archives of Plastic Surgery  2014;41(6):722-727.
Background
Perineal reconstruction following pelvic exenteration is a challenging area in plastic surgery. Its advantages include preventing complications by obliterating the pelvic dead space and minimizing the scar by using the previous abdominal incision and a vertical rectus abdominis musculocutaneous (VRAM) flap. However, only a few studies have compared the complications and the outcomes following pelvic exenteration between cases with and without a VRAM flap. In this study, we aimed to compare the complications and the outcomes following pelvic exenteration with or without VRAM flap coverage.
Methods
We retrospectively reviewed the cases of nine patients for whom transpelvic VRAM flaps were created following pelvic exenteration due to pelvic malignancy. The complications and outcomes in these patients were compared with those of another nine patients who did not undergo such reconstruction.
Results
Flap reconstruction was successful in eight cases, with minor complications such as wound infection and dehiscence. In all cases in the reconstructed group (n=9), structural integrity was maintained and major complications including bowel obstruction and infection were prevented by obliterating the pelvic dead space. In contrast, in the control group (n=9), peritonitis and bowel obstruction occurred in 1 case (11%).
Conclusions
Despite the possibility of flap failure and minor complications, a VRAM flap can result in adequate perineal reconstruction to prevent major complications of pelvic exenteration.
doi:10.5999/aps.2014.41.6.722
PMCID: PMC4228216  PMID: 25396186
Pelvic exenteration; Rectus abdominis; Musculocutaneous flap
13.  Modified Vertical Rectus Abdominis Myocutaneous Flap Vaginal Reconstruction: An analysis of surgical outcomes 
Gynecologic oncology  2011;125(1):252-255.
Objective
To examine the early and late flap related morbidity and associated risk factors in patients with modified vertical rectus abdominis myocutaneous (VRAM) flap neovaginal reconstruction at the time of pelvic exenteration for gynecologic malignancy.
Methods
From January 1993 to January 2011, all patients were identified who underwent anterior, posterior, or total pelvic exenteration with VRAM flap neovaginal reconstruction. Patient records were systematically reviewed and demographic, clinicopathologic, operative details, flap related complications, and risk factors for wound healing were recorded and statistical analysis performed.
Results
46 patients were identified who underwent exenteration with VRAM flap vaginal reconstruction. A risk factor for poor healing including obesity, diabetes, smoking, prior radiation, previous abdominal surgery, or poor nutritional status was present in 38 (82.6%) patients, and 24 (52.2%) had two or more risk factors. Flap complications occurred in 9 (19.6%) patients, one with complete flap necrosis that required re-operation, two with superficial flap necrosis, and three with superficial flap separation. Three patients (6.5%) suffered from vaginal stenosis, one of which was complete. Anterior abdominal wound separation occurred in 22 (47.8%) patients and pelvic abscess occurred in 14 (30.4%) patients. No individual risk factor was significantly associated with VRAM flap related morbidity; however obesity, prior radiation, and prior abdominal incision were present in nearly all the patients with flap complications.
Conclusions
This series confirms that modified VRAM flaps can be used successfully at the time of exenteration, even in an increasingly high risk patient population with an acceptable risk for flap complications.
doi:10.1016/j.ygyno.2011.12.427
PMCID: PMC4264595  PMID: 22166844
14.  Initial experience with breast reconstruction using the transverse rectus abdominis myocutaneous flap: a study of 45 patients. 
The Ulster Medical Journal  1999;68(1):22-26.
Breast conserving surgery for breast cancer has led to an increased interest in reconstruction following mastectomy. The transverse rectus abdominis myocutaneous flap has been proven to give good results in terms of restoration of body symmetry with near normal contour and consistency. Furthermore, immediate reconstruction has the advantage of a single procedure with less psychological morbidity, and reduction in hospital stay and overall complication rate. The aim of this study was to review our experience with the transverse rectus abdominis myocutaneous flap procedure an initial series of 45 patients. The overall complication rate of 27% is similar to that reported in the literature, with no total flap loss and nine patients with partial flap loss. There was no delay in commencement of adjuvant chemotherapy or radiotherapy and we believe our ability to detect local recurrence has not been compromised. We consider that immediate breast reconstruction is now an integral part of the surgical treatment of breast cancer.
PMCID: PMC2449136  PMID: 10489808
15.  Risk Factors for Complications after Reconstructive Surgery for Sternal Wound Infection 
Archives of Plastic Surgery  2014;41(3):253-257.
Background
Although the utility of flaps for the treatment of sternal wound infections following median sternotomy has been reported for 30 years, there have been few reports on the risk factors for complications after reconstruction. The objective of this investigation was to identify factors related to complications after the reconstruction of sternal wound infections.
Methods
A retrospective analysis of 74 patients with reconstructive surgery after sternal wound infection over a 5-year period was performed. Clinical data including age, sex, body mass index (BMI), comorbidities, bacterial culture, previous cardiac surgery, wound depth, mortality rate, type of reconstructive procedure, and complication rate were collected.
Results
The patients' BMI ranged from 15.2 to 33.6 kg/m2 (mean, 23.1±3.74 kg/m2). Wound closure complications after reconstructive surgery were observed in 36.5% of the cases. The mortality rate was 2.7%. Diabetes mellitus significantly affected the rate of wound closure complications (P=0.041). A significant difference in the number of complications was seen between Staphylococcus aureus (S. aureus) and coagulase-negative Staphylococci (P=0.011). There was a correlation between harvesting of the internal thoracic artery and postoperative complications (P=0.048). The complication rates of the pectoralis major flap, rectus abdominis flap, omentum flap, a combination of pectoralis major flap and rectus abdominis flap, and direct closure were 23.3%, 33.3%, 100%, 37.5%, and 35.7%, respectively.
Conclusions
Diabetes mellitus, S. aureus, harvesting of the internal thoracic artery, and omentum flap were significant factors for complications after reconstruction. The omentum flap volume may be related to the complications associated with the omentum flap transfer in the present study.
doi:10.5999/aps.2014.41.3.253
PMCID: PMC4037771  PMID: 24883276
Mediastinitis; Postoperative complications; Surgical flaps; Risk factors; Omentum
16.  Increased Flap Weight and Decreased Perforator Number Predict Fat Necrosis in DIEP Breast Reconstruction 
Background:
Compromised perfusion in autologous breast reconstruction results in fat necrosis and flap loss. Increased flap weight with fewer perforator vessels may exacerbate imbalances in flap perfusion. We studied deep inferior epigastric perforator (DIEP) and muscle-sparing transverse rectus abdominis myocutaneous (MS-TRAM) flaps to assess this concept.
Methods:
Data from patients who underwent reconstruction with DIEP and/or MS-TRAM flaps between January 1, 2010 and December 31, 2011 (n = 123) were retrospectively reviewed. Patient demographics, comorbidities, intraoperative parameters, and postoperative outcomes were collected, including flap fat necrosis and donor/recipient site complications. Logistic regression analysis was used to examine effects of flap weight and perforator number on breast flap fat necrosis.
Results:
One hundred twenty-three patients who underwent 179 total flap reconstructions (166 DIEP, 13 MS-TRAM) were included. Mean flap weight was 658 ± 289 g; 132 (73.7%) were single perforator flaps. Thirteen flaps (7.5%) developed fat necrosis. African American patients had increased odds of fat necrosis (odds ratio, 11.58; P < 0.001). Odds of developing fat necrosis significantly increased with flap weight (odds ratio, 1.5 per 100 g increase; P < 0.001). In single perforator flaps weighing more than 1000 g, six (42.9%) developed fat necrosis, compared to 14.3% of large multiple perforator flaps.
Conclusions:
Flaps with increasing weight have increased risk of fat necrosis. These data suggest that inclusion of more than 1 perforator may decrease odds of fat necrosis in large flaps. Perforator flap breast reconstruction can be performed safely; however, considerations concerning race, body mass index, staging with tissue expanders, perforator number, and flap weight may optimize outcomes.
doi:10.1097/GOX.0b013e318294e41d
PMCID: PMC4184055  PMID: 25289212
17.  An Algorithmic Approach to Total Breast Reconstruction with Free Tissue Transfer 
Archives of Plastic Surgery  2013;40(3):173-180.
As microvascular techniques continue to improve, perforator flap free tissue transfer is now the gold standard for autologous breast reconstruction. Various options are available for breast reconstruction with autologous tissue. These include the free transverse rectus abdominis myocutaneous (TRAM) flap, deep inferior epigastric perforator flap, superficial inferior epigastric artery flap, superior gluteal artery perforator flap, and transverse/vertical upper gracilis flap. In addition, pedicled flaps can be very successful in the right hands and the right patient, such as the pedicled TRAM flap, latissimus dorsi flap, and thoracodorsal artery perforator. Each flap comes with its own advantages and disadvantages related to tissue properties and donor-site morbidity. Currently, the problem is how to determine the most appropriate flap for a particular patient among those potential candidates. Based on a thorough review of the literature and accumulated experiences in the author's institution, this article provides a logical approach to autologous breast reconstruction. The algorithms presented here can be helpful to customize breast reconstruction to individual patient needs.
doi:10.5999/aps.2013.40.3.173
PMCID: PMC3665857  PMID: 23730589
Breast cancer; Breast reconstruction; Free tissue flaps
18.  The transpelvic rectus abdominis flap: its use in the reconstruction of extensive perineal defects. 
We present our experience of rectus abdominis flaps tunnelled transpelvically in 12 patients (mean age 48.4 years, range 19-72 years) with a diverse range of surgical pathologies, the largest reported series to date. Satisfactory obturation of the pelvic cavity and control of radionecrotic tissue sepsis was achieved. Average duration of hospital stay was 17.6 days with a mean follow-up of 18.7 months. The rectus abdominis flap provides a significant volume of well-vascularised tissue, ideally suited for reconstruction of extensive perineal defects after tumour ablative surgery. When tunnelled transpelvically, the flap is unique in its ability to obturate the pelvic inlet, eliminating the distressing complication of perineal bowel herniation and allowing for perineal radiotherapy.
PMCID: PMC2502103  PMID: 7598425
19.  Chemotherapy-induced enterocutaneous fistula after perineal hernia repair using a biological mesh: a case report 
This is the first reported case of an enterocutaneous fistula as a late complication to reconstruction of the pelvic floor with a Permacol™ mesh after a perineal hernia. A 70-year-old man had a reconstruction of the pelvic floor with a biological mesh because of a perineal hernia after laparoscopic abdominoperineal resection. Nine months after the perineal hernia operation, the patient had multiple metastases in both lungs and liver. The patient underwent chemotherapy, including bevacizumab, irinotecan, calcium folinate, and fluorouracil. Six weeks into chemotherapy, the patient developed signs of sepsis and complained of pain from the right buttock. Ultrasound examination revealed an abscess, which was drained, guided by ultrasound. A computed tomography scan showed a subcutaneous abscess cavity located in the right buttock with communication to the small bowel. Operative findings confirmed a perineal fistula from the distal ileum to perineum. A resection of the small bowel with primary anastomosis was performed. The postoperative course was complicated by fluid and electrolyte disturbances, but the patient was stabilized and finally discharged to a hospice for terminal care after 28 days of hospital stay. It seems that hernia repairs with biological meshes have lower erosion and infection rates compared with synthetic meshes, and so far, evidence suggests that biological grafts are safe and effective in the treatment of pelvic floor reconstruction. There have been no reports of enteric fistulas after pelvic reconstruction with biological meshes. However, the development of intestinal fistulas after chemotherapy with bevacizumab has been described in the literature. Our case report supports this association between bevacizumab and fistula formation among rectal cancer patients, as symptoms of a fistula started only 6 weeks into bevacizumab treatment but approximately 12 months after the perineal hernia operation, even after pelvic reconstruction using a biological mesh and without local recurrence.
doi:10.2147/IMCRJ.S54192
PMCID: PMC3904807  PMID: 24489478
rectal cancer; abdominoperineal resection; enterocutaneous fistula; perineal hernia; biological mesh
20.  Hypopharynx reconstruction with pectoralis major myofascial flap: our experience in 45 cases 
SUMMARY
A pectoralis major myofascial flap (PMMF) is a simple variant of the pectoralis major myocutaneous flap (PMMC), and allows avoiding some of the disadvantages of Ariyan's technique while reducing well-known, overall complications. This is a retrospective analysis of 45 hypopharyngeal reconstructions (40 immediate reconstructions after subtotal pharyngolaryngectomy and 5 performed during revision surgery) using PMMF flap, performed from February 1995 to February 2008 in the Department of Otolaryngology at the "San Camillo- Forlanini" Hospitals in Rome, in collaboration with the Department of Plastic Surgery. In our series, we observed postoperative flap-related complications in 6.7% of cases. The incidence of major flap complications requiring surgical revision was 2.2%. Two minor complications were seen: hypopharyngeal stenosis and a salivary fistula, both of which were managed without surgery. Total or partial necrosis did not occur in any case. There were four postoperative deaths, but which were not related to flap complications in any case. In the remaining cases, oesophageal X-ray imaging showed the absence of fistulas and adequate calibre of the reconstructed tract; oral intake started within postoperative day 10-12, without swallowing problems of liquid or solid food. Postoperative radiotherapy performed in 30 patients was well tolerated. The PMMF flap is safe one-step procedure with low morbidity that is particularly useful for partial hypopharyngeal reconstructions, overcoming the disadvantages of the PMMC flap and offering comparable results to fasciocutaneous free flaps.
PMCID: PMC3383077  PMID: 22767969
Hypopharynx reconstruction; Pectoralis major myofascial flap; Complications
21.  The outcomes of midline versus medio-lateral episiotomy 
Reproductive Health  2007;4:10.
Background
Episiotomy is the surgical enlargement of the vaginal orifice by an incision of the perineum during the second stage of labor or just before delivery of the baby. During the 1970s, it was common to perform an episiotomy for almost all women having their first delivery, ostensibly for prevention of severe perineum tears and easier subsequent repair. However, there are no data available to indicate if an episiotomy should be midline or medio-lateral. We compared midline versus medio-lateral episiotomy for complication such as extended perineal tears, pain scores, wound infection rates and other complications.
Methods
We conducted a prospective cohort including 1,302 women, who gave birth vaginally between April 2005 and February 2006 at Srinagarind Hospital – a tertiary care center in Northeast Thailand. All women included had low risk pregnancies and delivered at term. The outcome measures included deep perineal tears (including perineal tears with anal sphincter and/or rectum tears), other complications, and women's satisfaction at 48 hours and 6-weeks postpartum.
Results
In women with midline episiotomy, deep perineal tears occurred in 14.8%, which is statistically significantly higher compared to 7% in women who underwent a medio-lateral episiotomy (p-value < 0.05). There was no difference between the groups for other outcomes (such as blood loss, vaginal hematoma, infection, pain, dyspareunia, and women's satisfaction with the method). The risk factors for deep perineal tears were: midline episiotomy, primiparity, maternal height < 145 cm, fetal birth weight > 3,500 g and forceps extraction.
Conclusion
Midline compared to medio-lateral episiotomy resulted in more deep perineal tears. It is more likely deep perineal tears would occur in cases with additional risk factors.
doi:10.1186/1742-4755-4-10
PMCID: PMC2174441  PMID: 17967168
22.  Vacuum-Assisted Closure of Perineal War Wound Related to Rectum 
Eplasty  2009;9:e55.
Introduction: Vacuum-assisted wound closure therapy has widely been used in various clinical applications with successful results and has considerably increased in popularity over the past decade. The patient who sustained a complex war wound to his perineum has been presented. Methods: After the initial treatment he was discharged from the hospital in which he had been treated for 4 days in Iraq. On the examination, all wounds were deeply contaminated with foreign bodies and also involved significant volume of devitalized tissue. Perineal injury had not only caused a large skin defect but also left a deep wound leading to rectal perforation, so the wound and its borders were quite contaminated and infected by rectal contents. After improving his general condition with medical treatment, he underwent an immediate operation in which first a colostomy was performed and then the wound tract placed between perineum and rectum was sharply and extensively debrided to viable-appearing bleeding tissue to remove the whole necrotic tissues, foreign bodies, cloths, and debris. At the end of the intervention, a negative pressure dressing was applied and used during 12 days and then completed. Results: The wound tract obliterated entirely without permitting any leakage of rectal contents, and wound bed appeared clean, granulated, contracted, and viable enough for definitive closure with flap mobilization. Conclusions: When dealing with this experience presenting an unusual wound that was in a very difficult area of the body for the treatment, perineum, caused from a challenging reason, war injury, and also was complicated with rectal injury, the technique seems to have a significant beneficial effect on the healing of complicated wounds such as in perineal wound and war wound, even if these are at risk of severe infection and progressive tissue necrosis.
PMCID: PMC2779997  PMID: 20011583
23.  Update on Breast Reconstruction Using Free TRAM, DIEP, and SIEA Flaps 
Seminars in Plastic Surgery  2004;18(2):97-104.
Breast reconstruction using autologous tissue is commonly accomplished using the transverse rectus abdominis myocutaneous (TRAM) flap. The establishment of microvascular surgery led to the development of the free TRAM flap because of its increased vascularity and decreased rectus abdominis sacrifice. The muscle-sparing free TRAM, DIEP, and SIEA flap techniques followed in an effort to decrease abdominal donor site morbidity by decreasing injury to the rectus abdominis muscle and fascia. Data have accumulated over the past decade that show that muscle- and fascia-sparing techniques, such as the use of DIEP flaps, result in measurably better postoperative abdominal strength. However, muscle-sparing techniques do not appear to decrease the risk of abdominal bulging or hernia, and there are no significant differences in patient-reported abdominal weakness or functional impairments. The SIEA flap is presented as a reemerging method that can virtually eliminate abdominal donor site morbidity. Sensory nerve coaptation to improve reconstructed breast sensation is also reviewed.
doi:10.1055/s-2004-829044
PMCID: PMC2884730  PMID: 20574488
Breast reconstruction; flap; TRAM; DIEP; SIEA
24.  Chondrosarcoma from the sternum: Reconstruction with titanium mesh and a transverse rectus abdominis myocutaneous flap after subtotal sternal excision 
Summary
Background
Chondrosarcoma arising from the sternum is extremely rare and is often untreatable. Removal of the sternum for malignant tumor results in large defects in bone and soft tissue, causing deformity and paradoxical movement of the chest wall and making subsequent repair of the thorax very important. We report a very rare patient with a chondrosarcoma of the sternum who underwent case chest wall resection, followed by reconstruction using a titanium mesh covered with a transverse rectus abdominis myocutaneous (TRAM) flap.
Case Report
A 63-year-old man was referred to our hospital with progressively enlarged swelling of his anterior chest wall. Physical examination showed a 2.5×2.0 cm mass fixed to the sternum, which was diagnosed as a chondrosarcoma based on clinical findings, imaging characteristics and incision biopsy results. The patient underwent a subtotal sternal and chest wall resection to remove the tumor, followed by reconstruction with a titanium mesh and a TRAM flap. There were no complications associated with surgery.
Conclusions
We report an extremely rare case of a patient who underwent subtotal sternal resection, followed by reconstruction, for a large chondrosarcoma. The elasticity and rigidity provided by the titanium mesh and the complete coverage of the surgical wound by a TRAM flap suggest that these procedures may be useful in reconstructing large defects in the chest wall.
doi:10.12659/MSM.883471
PMCID: PMC3560565  PMID: 23018358
chondrosarcoma; sternum; transverse rectus abdominis myocutaneous frap; titanium mesh; reconstruction; bone tumors
25.  Reconstruction of scalp defects with the radial forearm free flap 
Head & Neck Oncology  2012;4:21.
Background
Advanced and recurrent cutaneous squamous cell carcinoma of the scalp and forehead require aggressive surgical excision often resulting in complex defects requiring reconstruction. This study evaluates various microvascular free flap reconstructions in this patient population, including the rarely utilized radial forearm free flap.
Patients and methods
A retrospective review of patients undergoing free flap surgeries (n = 47) of the scalp between 1997 and 2011 were included. Patients were divided primarily into two cohorts: a new primary lesion (n = 21) or recurrence (n = 26). Factors examined include patient demographics, indication for surgery, defect, type of flap used, complications (major and minor), and outcomes.
Results
The patients were primarily male (n = 34), with a mean age of 67 years (25–91). A total of 58 microvascular free flap reconstructions were performed (radial forearm free flap: n = 28, latissimus dorsi: n = 20, rectus abdominis: n = 9, scapula: n = 1). Following reconstruction with a radial forearm free flap, duration of hospitalization was shorter (P = 0.04) and complications rates were similar (P = 0.46). Donor site selection correlated with defect area (P < 0.001), but not with the extent of skull defect (P = 0.70). Larger defect areas correlated with higher complications rates (P = 0.03) and longer hospitalization (P = 0.003). Patients were more likely to require multiple reconstructions if referred for a recurrent lesions (P = 0.01) or received prior radiation therapy (P = 0.02).
Conclusion
Advanced and recurrent malignancies of the scalp are aggressive and challenging to treat. The radial forearm free flap is an underutilized free flap in the reconstruction of complex scalp defects.
doi:10.1186/1758-3284-4-21
PMCID: PMC3414765  PMID: 22583845
Scalp defect; Free flap; Calvarium; Reconstruction; Cancer

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