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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.  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
5.  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
6.  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
7.  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
8.  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
9.  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
10.  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
11.  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
12.  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
13.  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
14.  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
15.  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
16.  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
17.  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
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.  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
20.  Extended abdominoperineal resection in women: the barbadian experience 
Background and objectives
We report our results of a selective approach to primary direct appositional vaginal repair versus transverse rectus abdominis flap repair (TRAM) in patients with extensive rectal/anal cancer or in cases with primary cancer of cervix, vagina or vulva involving the anal canal and anal sphincters.
Methods
Eighteen female patients (mean age: 62.9 years; range: 44–81 years) with a median follow-up of 14 months (range: 2–36 months) undergoing extended abdominoperineal reconstruction with total mesorectal excision between May 2002 and September 2005, were studied.
Results
Twelve patients underwent an extended abdominoperineal resection with hysterectomy and vaginectomy, with 6 patients undergoing primary TRAM flap reconstruction following pelvic exenteration. Exenterative procedures were performed in 2 cases of primary vaginal cancer, following Wertheim hysterectomy for carcinoma of the cervix with recurrence after radiation and in 2 further cases of anal cancer with extensive pelvic recurrence after primary chemoradiation. Fifteen cases are alive on follow-up with no evidence of disease; 2 patients who had recurrent carcinoma of the cervix and who underwent TRAM flap reconstruction, have recurrent disease after 5 and 6 months of follow-up, respectively.
Discussion
Our experience shows that careful primary closure of an extended abdominoperineal resection wound is effective and safe. Our one case of wound breakdown after primary repair underwent external beam and intracavitary irradiation primarily with wound breakdown of a primary repair followed by a delayed pedicled graciloplasty. TRAM flap reconstruction has been reserved in our unit for patients undergoing total pelvic extenteration. In general, we would recommend the use of TRAM flap reconstruction in younger sexually active patients where there has been external irradiation combined with brachytherapy.
doi:10.1186/1477-7800-4-1
PMCID: PMC1779795  PMID: 17214895
21.  Oncological safety of immediate rectus abdominis myocutaneous breast reconstruction in patients with locally advanced disease (stage IIb and III) 
South Asian Journal of Cancer  2013;2(4):239-242.
Background:
The management of locally advanced (Stage IIb and III) breast cancer is challenging. It often includes multimodal treatment with systemic therapy and/or radiation therapy and surgery. Immediate breast reconstruction has not traditionally been performed in these patients. We review the results of immediate rectus abdominis musculo-cutaneous (TRAM/VRAM) flap in 60 patients treated for Stage IIb and III breast cancer.
Materials and Methods:
Data were collected prospectively on 60 patients diagnosed with Stage IIb (32 patients) and Stage III (28 patients) breast cancer between May 2008 and May 2012. All patients had mastectomy and immediate rectus abdominis myocutaneous reconstruction (TRAM in 40 patients and VRAM in 20 patients). All patients received primary systemic therapy, and all patients received postoperative radiotherapy to the operative site.
Results:
Mean age was 40.13 (range 28-53) years, mean hospital stay was 8.86 days and mean follow-up for the group was 28 months. Neither of them developed local disease recurrence in the operative site till the last follow-up. Eight (13.3%) patients had some delay in chemo-radiation therapy due to flap-related complications. Flap-related complications were present in eight patients (partial flap failure in four and superficial skin necrosis in four). There was no adverse effect of chemo-radiation therapy on reconstructed breast.
Conclusion:
Immediate TRAM/VRAM breast reconstruction for locally advanced breast cancer is not associated with a significant delay in adjuvant therapy or an increased risk of local relapse. Radiation therapy can be delivered to the reconstructed breast when indicated without difficulty. Breast reconstruction facilitates surgical resection of locally advanced breast cancer with primary closure and should be considered if the patient desires immediate breast reconstruction.
doi:10.4103/2278-330X.119921
PMCID: PMC3889050  PMID: 24455647
Immediate breast reconstruction; rectus abdominis myocutaneous reconstruction; mastectomy
22.  Minimally Invasive Component Separation Results in Fewer Wound-Healing Complications than Open Component Separation for Large Ventral Hernia Repairs 
BACKGROUND
Minimally invasive component separation (CS) with inlay bioprosthetic mesh (MICSIB) is a recently developed technique for abdominal wall reconstruction that preserves the rectus abdominis perforators and minimizes subcutaneous dead space using limited-access tunneled incisions. We hypothesized that MICSIB would result in better surgical outcomes than would conventional open CS.
STUDY DESIGN
All consecutive patients who underwent CS (open or minimally invasive) with inlay bioprosthetic mesh for ventral hernia repair from 2005 to 2010 were included in a retrospective analysis of prospectively collected data. Surgical outcomes including wound-healing complications, hernia recurrences, and abdominal bulge/laxity rates were compared between patient groups based on the type of CS repair: MICSIB or open.
RESULTS
Fifty-seven patients who underwent MICSIB and 50 who underwent open CS were included. The mean follow-ups were 15.2±7.7 months and 20.7±14.3 months, respectively. The mean fascial defect size was significantly larger in the MICSIB group (405.4±193.6 cm2 vs. 273.8±186.8 cm2; p =0.002). The incidences of skin dehiscence (11% vs. 28%; p=0.011), all wound-healing complications (14% vs. 32%; p=0.026), abdominal wall laxity/bulge (4% vs. 14%; p=0.056), and hernia recurrence (4% vs. 8%; p=0.3) were lower in the MICSIB group than in the open CS group.
CONCLUSIONS
MICSIB resulted in fewer wound-healing complications than did open CS used for complex abdominal wall reconstructions. These findings are likely attributable to the preservation of paramedian skin vascularity and reduction in subcutaneous dead space with MICSIB. MICSIB should be considered for complex abdominal wall reconstructions, particularly in patients at increased risk of wound-healing complications.
doi:10.1016/j.jamcollsurg.2012.02.017
PMCID: PMC3889113  PMID: 22521439
23.  Experience with 24 Cases of Reconstructive Anterior Skull Base Surgery 
Skull base surgery  2000;10(2):65-70.
This article details our experience with 24 cases of anterior skull base reconstruction after tumor resection. They were classified into four types according to the resected region. In 11 cases of type I resection, the orbital part of frontal bone and/or cribriform plate of ethmoid bone were resected. In two cases of type II resection, the orbital contents and partial orbital bone were resected with the addition of type I. In five cases of type III resection, the maxillary bone was resected with the addition of type II. In six cases of type IV resection, the zygomatic bone and/or facial skin were resected with the addition of type III. The tumor originating from intracranial region was 25% of this series and all of them belonged to type I. The tumor originating from extracranial region tumor was 75% and its resected region was more extensive. In type I and II resections, the cranial flap, radial forearm free flap, or a combination of the two was used for reconstruction. The rectus abdominis myocutaneous/muscle free flap was used for reconstruction of massive defects in type III and IV defects. Total incidence of postoperative complications was 16.7%. Donor site deformity of the cranial flap at the frontal and temporal region in types I and II resections and facial contour deformity in zygomatic region and defect of upper and/or lower palpebra in type IV resection were major problems with postoperative facial appearance. Although use of the rectus abdominis myocutaneous free flap combined with costal cartilages improved the midfacial contour, palpebral reconstruction remained an unsolved problem in reconstructive skull base surgery. The reconstructive goals in skull base surgery are not only to obtain safe and reliable skull base reconstruction but also to restore the facial appearance postoperatively.
Images
PMCID: PMC1656764  PMID: 17171103
24.  Reconstruction of complex oral defects using bi-paddle pectoralis major flap - technical modifications and outcome in 54 cancer patients 
Objective
Reconstruction of locally advanced oral cancer presents a great challenge to the head and neck surgeon. The main goal of reconstruction is to provide intraoral lining and soft tissue cover. We discuss the use of Bipaddle pectoralis major myoculaneous flap (PMMF) and its modifications for reconstruction of complex oral defects following radical resection.
Study Design
Retrospective analysis of prospective oral cancer data base.
Setting
Tertiary Care Regional Cancer Center.
Patients
Three hundred and ten patients were operated for oral carcinoma in this unit between 1993 and 2001. The oral cancer patients who required soft tissue reconstruction for lining and cover were analyzed. Patients in whom bipaddle PMMF were utilised were studied in terms of surgical technique, morbidity, function and cosmetic outcome.
Results
Ninety-one (29.4 %) oral cancer patients required reconstruction for lining as well as cover. Of these, 54 (17.4 %) patients underwent a bipaddle PMMF flap reconstruction. Two horizontal skin islands were used in patients with lateral defects and two vertical islands in patients with central defects. There was no complication in 41 (76%) patients. Complete flap loss was seen in only one patient and differential flap loss in 2 patients (4 %) while seven (13 %) patients had only minor complication. All the patients received post-operative Radiotherapy. Good to average functional and cosmetic outcome was observed in 90% patients.
Conclusions
Bipaddle PMMF offers an effective and leliahle reconstructive option for complex oral defects. By using certain technical modifications, majority of complex oral defects can be managed successfully using a Bipaddle PMMF. In a developing country like India with a large oral cancer disease burden Bipaddle PMMF should he used routinely for complex oral defects in view of its simplicity, versatility and reliability.
doi:10.1007/BF02968744
PMCID: PMC3450944  PMID: 23119926
bipaddle pectoralis major myocutaneous flap; toral cancer
25.  Levator anguli oris muscle based flaps for nasal reconstruction following resection of nasal skin tumours 
Background
surgical excision remains the best tool for management of skin tumors affecting nasal skin, however many surgical techniques have been used for reconstruction of the nasal defects caused by excisional surgery. The aim of this work is the evaluation of the feasibility and outcome of levator anguli oris muscle based flaps.
Methods
Ninety patients of malignant nasal skin tumours were included in this study. Age was ranged from four to 78 years. For small unilateral defects affecting only one side ala nasi, levator anguli oris myocautaneous (LAOMC) flap was used in 45 patients. For unilateral compound loss of skin and mucus membrane, levator anguli oris myocautaneous mucosal (LAOMCM) flap was used in 23 patients. Very large defects; bilateral either LAOMC or LAOMCM flaps combined with forehead glabellar flaps were used to reconstruct the defect in 22 patients.
Results
Wound dehiscence was the commonest complication. Minor complications, in the form of haematoma and minor flap loss were managed conservatively. Partial flap loss was encountered in 6 patients with relatively larger tumours or diabetic co-morbidity, three of whom were required operative re-intervention in the form of debridement and flap refashioning, while total flap loss was not occurred at all.
Conclusions
Immediate nasal reconstruction for nasal skin and mucosal tumours with levator anguli oris muscle based flaps (LAOMC, LAOMCM) is feasible and spares the patient the psychic trauma due to organ loss.
doi:10.1186/1477-7819-9-23
PMCID: PMC3046908  PMID: 21333010

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