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1.  First results with the immediate reconstructive strategy for internal hardware exposure in non-united fractures of the distal third of the leg: case series and literature review 
Background
Fractures of the distal third of the leg are increasingly common and are often handled by open reduction and internal fixation. Exposure and infection of internal hardware could occur, especially after high energy traumas, requiring hardware removal and delayed soft tissue reconstruction. Nevertheless immediate soft tissue reconstruction without internal hardware removal is still possible in selected patients.
In this study the effectiveness and the complications of immediate soft tissue reconstruction without internal hardware removal is analyzed.
Methods
13 patients, affected by internal hardware exposure in the distal leg, treated with immediate soft tissue reconstruction with pedicled flaps and hardware retention, are retrospectively analyzed, with special regard to flap survival and wound infection.
Results
Wound infection was observed in 10 cases before surgery and in 5 cases surgical debridement was necessary before reconstruction which was performed in a separate operative session.
After reconstruction, wound dehiscence and infection occurred in 5 cases, and in 3 cases removal of internal hardware was necessary in order to achieve the complete healing of dehiscence. In one case the previous flap failed but prompt reconstruction with a sural fasciocutaneous flap was performed without hardware removal and without complications. Pre-operative infection and late reconstructive surgery are predictive for higher rates of post-operative complications (respectively p 0.018 and p 0.028).
Conclusion
Our approach achieved full recovery in 53.8% of the treated cases after one-step surgery, therefore reducing hospitalization and allowing early mobilization. Controlled trials are needed to confirm the effectiveness of this strategy, although the present case series shows encouraging results.
doi:10.1186/1749-799X-7-30
PMCID: PMC3489621  PMID: 22929129
Exposure; Flap; Internal fixator; Reconstruction; Leg; Fracture; Internal hardware exposure; Infection; Immediate reconstruction; Pedicled flaps; Lower limb
2.  Rectus abdominis myocutaneous flaps for perineal reconstruction: modifications to the technique based on a large single-centre experience 
INTRODUCTION
Perineal wound breakdown with delayed wound healing represents a significant cause of morbidity following surgery and radiotherapy to the perineum. The rectus abdominis myocutaneous (RAM) flap has been used increasingly to reconstruct the perineum with good effect. We describe our six-year experience of reconstruction of the perineum with the RAM flap and share some surgical adjuncts we believe are useful.
METHODS
We conducted a retrospective case note review of all patients who underwent a reconstruction of the perineum using the RAM flap between August 2003 and October 2009. Indications for the flap, complication rates and outcomes were all observed.
RESULTS
We conducted 16 RAM flap procedures, 15 of which (94%) were primary repairs and 1 (6%) a secondary repair. Three (19%) developed donor site hernias, two (12.5%) developed minor perineal wound infections, eight (50%) developed minor perineal wound breakdown and in one (6%) flap failure was observed. No perineal hernias were observed. There were no surgical mortalities.
CONCLUSIONS
The RAM flap has a high success rate and an acceptable morbidity rate and is a useful tool in the reconstruction of complex perineal wounds. Modifications to the standard surgical technique may reduce complications and improve the versatility of this flap.
doi:10.1308/003588411X572268
PMCID: PMC3365455  PMID: 21943461
Abdominoperineal resection; Perineal wound; Rectus abdominis flap
3.  CLOSURE OF LARYNGECTOMY DEFECTS IN THE AGE OF CHEMORADIATION THERAPY 
Head & neck  2011;34(4):580-588.
The use of chemoradiation therapy in laryngeal cancer has resulted in significant reconstructive challenges. Although reconstruction of salvage laryngectomy defects remains controversial, current literature supports aggressive management of these defects with vascularized tissue, even when there is sufficient pharyngeal tissue present for primary closure. Significant advancement in reconstructive techniques has permitted improved outcomes in patients with advanced disease who require total laryngopharyngectomy or total laryngoglossectomy. Use of enteric and fasciocutaneous flaps result in good patient outcomes. Finally, wound complication rates after salvage surgery approach 60% depending on comorbid conditions such as cardiac insufficiency, hypothyroidism, or extent of previous treatment. Neck dehiscence, great vessel exposure, fistula formation, or cervical skin necrosis results in complex wounds that can often be treated initially with negative pressure dressings followed by definitive reconstruction. The timing of repair and approach to the vessel-depleted neck also present challenges in this patient population. Currently, there is significant institutional bias in the management of the patient with postchemoradiation salvage laryngectomy. Future prospective multi-institutional studies are certainly needed to more clearly define optimal treatment of these difficult patients.
doi:10.1002/hed.21712
PMCID: PMC3951360  PMID: 21416549
salvage surgery; laryngectomy; wound complications; head and neck cancer; free flap
4.  Secondary omental and pectoralis major double flap reconstruction following aggressive sternectomy for deep sternal wound infections after cardiac surgery 
Background
Deep sternal wound infection after cardiac surgery carries high morbidity and mortality. Our strategy for deep sternal wound infection is aggressive strenal debridement followed by vacuum-assisted closure (VAC) therapy and omental-muscle flap reconstrucion. We describe this strategy and examine the outcome and long-term quality of life (QOL) it achieves.
Methods
We retrospectively examined 16 patients treated for deep sternal wound infection between 2001 and 2007. The most recent nine patients were treated with total sternal resection followed by VAC therapy and secondary closure with omental-muscle flap reconstruction (recent group); whereas the former seven patients were treated with sternal preservation if possible, without VAC therapy, and four of these patients underwent primary closure (former group). We assessed long-term quality of life after DSWI by using the Short Form 36-Item Health Survey, Version 2 (SF36v2).
Results
One patient died and four required further surgery for recurrence of deep sternal wound infection in the former group. The duration of treatment for deep sternal wound infection in the recent group was significantly shorter than that in previous group (63.4 ± 54.1 days vs. 120.0 ± 31.8 days, respectively; p = 0.039). Despite aggressive sternal resection, the QOL of patients treated for DSWI was only minimally compromised compared with age-, sex-, surgical procedures-matched patients without deep sternal wound infection.
Conclusions
Aggressive sternal debridement followed by VAC therapy and secondary closure with an omental-muscle flap is effective for deep sternal wound infection. In this series, it resulted in a lower incidence of recurrent infection, shorter hospitalization, and it did not compromise long-term QOL greatly.
doi:10.1186/1749-8090-6-56
PMCID: PMC3094378  PMID: 21501461
5.  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
6.  Reconstruction of Abdominal Wall of a Chronically Infected Postoperative Wound with a Rectus Abdominis Myofascial Splitting Flap 
Archives of Plastic Surgery  2013;40(1):28-35.
Background
If a chronically infected abdominal wound develops, complications such as peritonitis and an abdominal wall defect could occur. This could prolong the patient's hospital stay and increase the possibility of re-operation or another infection as well. For this reason, a solution for infection control is necessary. In this study, surgery using a rectus abdominis muscle myofascial splitting flap was performed on an abdominal wall defect.
Methods
From 2009 to 2012, 5 patients who underwent surgery due to ovarian rupture, cesarean section, or uterine myoma were chosen. In each case, during the first week after operation, the wound showed signs of infection. Surgery was chosen because the wounds did not resolve with dressing. Debridement was performed along the previous operation wound and dissection of the skin was performed to separate the skin and subcutaneous tissue from the attenuated rectus muscle and Scarpa's fascial layers. Once the anterior rectus sheath and muscle were adequately mobilized, the fascia and muscle flap were advanced medially so that the skin defect could be covered for reconstruction.
Results
Upon 3-week follow-up after a rectus abdominis myofascial splitting flap operation, no major complication occurred. In addition, all of the patients showed satisfaction in terms of function and esthetics at 3 to 6 months post-surgery.
Conclusions
Using a rectus abdominis myofascial splitting flap has many esthetic and functional benefits over previous methods of abdominal defect treatment, and notably, it enabled infection control by reconstruction using muscle.
doi:10.5999/aps.2013.40.1.28
PMCID: PMC3556530  PMID: 23362477
Abdominal wound closure techniques; Wound infection; Rectus abdominis
7.  Microdialysis of paraspinal muscle in healthy volunteers and patients underwent posterior lumbar fusion surgery 
European Spine Journal  2009;18(11):1604-1609.
Paraspinal muscle damage is inevitable during conventional posterior lumbar fusion surgery. Minimal invasive surgery is postulated to result in less muscle damage and better outcome. The aim of this study was to monitor metabolic changes of the paraspinal muscle and to evaluate paraspinal muscle damage during surgery using microdialysis (MD). The basic interstitial metabolisms of the paraspinal muscle and the deltoid muscle were monitored using the MD technique in eight patients, who underwent posterior lumbar fusion surgery (six male and two female, median age 57.7 years, range 37–74) and eight healthy individuals for different positions (five male and three female, age 24.1 ± 0.8 years). Concentrations of glucose, glycerol, and lactate pyruvate ratio (L/P) in both tissues were compared. In the healthy group, the glucose and glycerol concentrations and L/P were unchanged in the paraspinal muscle when the body position changed from prone to supine. The glucose concentration and L/P were stable in the paraspinal muscle during the surgery. Glycerol concentrations increased significantly to 243.0 ± 144.1 μM in the paraspinal muscle and 118.9 ± 79.8 μM in the deltoid muscle in the surgery group. Mean glycerol concentration difference (GCD) between the paraspinal muscle and the deltoid tissue was 124.1 μM (P = 0.003, with 95% confidence interval 83.4–164.9 μM). The key metabolism of paraspinal muscle can be monitored by MD during the conventional posterior lumbar fusion surgery. The glycerol concentration in the paraspinal muscle is markedly increased compared with the deltoid muscle during the surgery. It is proposed that GCD can be used to evaluate surgery related paraspinal muscle damage. Changing body position did not affect the paraspinal muscle metabolism in the healthy subjects.
doi:10.1007/s00586-009-1021-x
PMCID: PMC2899392  PMID: 19418074
Glucose; Lactate pyruvate ratio; Glycerol; Paraspinal muscle; Microdialysis
8.  Investigation of Severe Craniomaxillofacial Battle Injuries Sustained by U.S. Service Members: A Case Series 
This case series describes craniomaxillofacial battle injuries, currently available surgical techniques, and the compromised outcomes of four service members who sustained severe craniomaxillofacial battle injuries in Iraq or Afghanistan. Demographic information, diagnostic evaluation, surgical procedures, and outcomes were collected and detailed with a follow-up of over 2 years. Reconstructive efforts with advanced, multidisciplinary, and multiple revision procedures were indicated; the full scope of conventional surgical options and resources were utilized. Patients experienced surgical complications, including postoperative wound dehiscence, infection, flap failure, inadequate mandibular healing, and failure of fixation. These complications required multiple revisions and salvage interventions. In addition, facial burns complicated reconstructive efforts by delaying treatment, decreasing surgical options, and increasing procedural numbers. All patients, despite multiple surgeries, continue to have functional and aesthetic deficits as a result of their injuries. Currently, no conventional treatments are available to satisfactorily reconstruct the face severely ravaged by explosive devices to an acceptable level, much less to natural form and function.
doi:10.1055/s-0032-1329542
PMCID: PMC3577603  PMID: 24294409
craniomaxillofacial battle injuries; explosive injuries; reconstruction; surgical complications; surgical outcomes
9.  Adductor Myocutaneous Flap Coverage for Hip and Pelvic Disarticulations of Sarcomas with Buttock Contamination 
Background
Hip disarticulation and hemipelvectomy are alternatives to limb-salvage procedures for patients with extensive tumors of the upper thigh and buttocks. In cases when neither the conventional posterior gluteus maximus flap nor the anterior quadriceps flap can be used because of the location of the tumor, a medial adductor myocutaneous flap may be an alternative.
Description of Technique
The flap is outlined over the anteromedial thigh. The distal extent is at the level of the adductor hiatus. The common femoral vessels and nerve are traced, preserved, and protected. The adductor muscles then are divided above their insertions on the femur and preserved with the flap. En bloc removal of the tumor is performed by either hip disarticulation or hemipelvectomy. The long adductor myocutaneous flap is brought up laterally and proximally to close the wound.
Patients and Methods
We reviewed four patients who underwent a medial adductor myocutaneous flap after either hip disarticulation or hemipelvectomy. The medical records and radiographs were analyzed. These patients were followed up for at least a year or until death.
Results
Wide surgical margins were achieved in all four patients and the flap remained viable, with no skin necrosis or flap breakdown. The patients were able to sit on the flap, and one patient was able to wear a prosthesis.
Conclusions
In patients undergoing hip disarticulation or hemipelvectomy where tumor infiltration or inadvertent contamination by previous surgery will not allow the traditional posterior gluteus maximus or anterior quadriceps flap, this unconventional medial adductor myocutaneous flap is a feasible, technically simple option.
Level of Evidence
Level IV therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
doi:10.1007/s11999-010-1467-5
PMCID: PMC3008907  PMID: 20632137
10.  Reconstruction of Various Perinasal Defects Using Facial Artery Perforator-Based Nasolabial Island Flaps 
Archives of Plastic Surgery  2013;40(6):754-760.
Background
Classical flaps for perinasal defect reconstruction, such as forehead or nasolabial flaps, have some disadvantages involving limitations of the arc of rotation and two stages of surgery. However, a perforator-based flap is more versatile and allows freedom in flap design. We introduced our experience with reconstruction using a facial artery perforator-based propeller flap on the perinasal area. We describe the surgical differences between different defect subtypes.
Methods
Between December 2005 and August 2013, 10 patients underwent perinasal reconstruction in which a facial artery perforator-based flap was used. We divided the perinasal defects into types A and B, according to location. The operative results, including flap size, arc of rotation, complications, and characteristics of the perforator were evaluated by retrospective chart review and photographic evaluation.
Results
Eight patients were male and 2 patients were female. Their mean age was 61 years (range, 35-75 years). The size of the flap ranged from 1 cm×1.5 cm to 3 cm×6 cm. Eight patients healed uneventfully, but 2 patients presented with mild flap congestion. However, these 2 patients healed by conservative management without any additional surgery. All of the flaps survived completely with aesthetically pleasing results.
Conclusions
The facial artery perforator-based flap allowed for versatile customized flaps, and the donor site scar was concealed using the natural nasolabial fold.
doi:10.5999/aps.2013.40.6.754
PMCID: PMC3840184  PMID: 24286050
Perforator flap; Nose; Surgical flaps
11.  2-Octyl-cyanoacrylate for wound closure in cervical and lumbar spinal surgery 
Neurosurgical Review  2010;33(4):483-489.
It is claimed that wound closure with 2-octyl-cyanoacrylate has the advantages that band-aids are not needed in the postoperative period, that the wound can get in contact with water and that removal of stitches is not required. This would substantially enhance patient comfort, especially in times of reduced in-hospital stays. Postoperative wound infection is a well-known complication in spinal surgery. The reported infection rates range between 0% and 12.7%. The question arises if the advantages of wound closure with 2-octyl-cyanoacrylate in spinal surgery are not surpassed by an increase in infection rate. This study has been conducted to identify the infection rate of spinal surgery if wound closure was done with 2-octyl-cyanoacrylate. A total of 235 patients with one- or two-level surgery at the cervical or lumbar spine were included in this prospective study. Their pre- and postoperative course was evaluated. Analysis included age, sex, body mass index, duration and level of operation, blood examinations, 6-week follow-up and analysis of preoperative risk factors. The data were compared to infection rates of similar surgeries found in a literature research and to a historical group of 503 patients who underwent wound closure with standard skin sutures after spine surgery. With the use of 2-octyl-cyanoacrylate, only one patient suffered from postoperative wound infection which accounts for a total infection rate of 0.43%. In the literature addressing infection rate after spine surgery, an average rate of 3.2% is reported. Infection rate was 2.2% in the historical control group. No risk factor could be identified which limited the usage of 2-octyl-cyanoacrylate. 2-Octyl-cyanoacrylate provides sufficient wound closure in spinal surgery and is associated with a low risk of postoperative wound infection.
doi:10.1007/s10143-010-0258-5
PMCID: PMC2936674  PMID: 20440558
Wound infection; Dermabond; 2-Octyl-cyanoacrylate; Spinal surgery
12.  Is Post-Sternotomy Mediastinitis Still Devastating after the Advent of Negative-Pressure Wound Therapy? 
Texas Heart Institute Journal  2011;38(4):375-380.
In this study, we reviewed a 15-year experience with the treatment of a severe sequela of cardiac surgery: post-sternotomy mediastinitis. We compared the outcomes of conventional treatment with those of negative-pressure wound therapy, focusing on mortality rate, sternal reinfection, and length of hospital stay.
We reviewed data on 157 consecutive patients who were treated at our institution from 1995 through 2010 for post-sternotomy mediastinitis after cardiac surgery. Of these patients, 74 had undergone extensive wound débridement followed by negative-pressure wound therapy, and 83 had undergone conventional treatment, including primary wound reopening, débridement, closed-chest irrigation without rewiring, topical application of granulated sugar for recurrent cases, and final plastic reconstruction with pectoral muscle flap in most cases.
The 2 study groups were homogeneous in terms of preoperative data and operative variables (the primary cardiac surgery was predominantly coronary artery bypass grafting). Negative-pressure wound therapy was associated with lower early mortality rates (1.4% vs 3.6%; P = 0.35) and significantly lower reinfection rates (1.4% vs 16.9%; P = 0.001). Significantly shorter hospital stays were also observed with negative pressure in comparison with conventional treatment (mean durations, 27.3 ± 9 vs 30.5 ± 3 d; P = 0.02), consequent to the accelerated process of wound healing with negative-pressure therapy.
Lower mortality and reinfection rates and shorter hospital stays can result from using negative pressure rather than conventional treatment. Therefore, negative-pressure wound therapy is advisable as first-choice therapy for deep sternal wound infection after cardiac surgery.
PMCID: PMC3147206  PMID: 21841864
Atmospheric pressure; bacterial infections; cardiac surgical procedures/adverse effects; length of stay; mediastinitis/prevention & control/therapy; postoperative complications/prevention & control/therapy; surgical wound infection/etiology/mortality/prevention & control/surgery; survival rate; vacuum curettage/methods; wound healing/physiology/therapy
13.  A systematic approach to the failed plastic surgical reconstruction of the diabetic foot 
Diabetic Foot & Ankle  2011;2:10.3402/dfa.v2i0.6435.
Plastic reconstruction for diabetic foot wounds must be approached carefully and follow sound micro-surgical principles as it relates to the anatomy of the designated flap chosen for coverage. First, the surgeon always needs to evaluate the local and general conditions of the presenting pathology and patient, respectively when considering a flap for reconstruction. The flap that is chosen is based on the vascularity, location, and size of the defect. Salvage of the failed flap and revisional reconstructive procedures are very challenging. Often, adjunctive therapies such as hyperbaric oxygen, negative pressure wound therapy, vasodilators, and/or vascular surgery is required. In certain case scenarios, such as patients with poor general health and compromised local vascularity in which revisional flap coverage cannot be performed, the above mentioned adjunctive therapies could be used as a primary treatment to potentially salvage a failing flap.
doi:10.3402/dfa.v2i0.6435
PMCID: PMC3284291  PMID: 22396827
pedicle flaps; muscle flaps; diabetic foot; osteomyelitis; plastic surgery
14.  Flap Anchoring Following Primary Breast Cancer Surgery Facilitates Early Hospital Discharge and Reduces Costs 
Breast Care  2010;5(2):97-101.
Summary
Background
Routine drain placement after breast cancer surgery is standard practice. Anchoring the axillary and mastectomy flaps to the underlying chest wall with sutures has been advocated as a means of avoiding drainage following breast surgery. This study compares outcomes following flap fixation or routine drain placement and uniquely considers the economic implications of each technique.
Patients and Methods
Data on seroma formation and wound infection following mastectomy and axillary clearance were recorded prospectively. Patients underwent either routine drain placement or flap anchoring using subcutaneous tacking sutures without drainage. Equipment and surgical bed costs were provided by our finance department.
Results
Data was available for 135 patients. 76 underwent flap anchoring without drainage and 59 had routine drainage. There was no difference in seroma rates between the two groups: 49% vs. 59% (p = 0.22). However, the length of hospital stay was reduced in the flap fixation group: 1.88 vs. 2.67 days (p < 0.0001). Per patient, flap suturing equated to an estimated financial saving of £ 240.
Conclusions
Flap anchoring resulted in a significantly shorter hospital stay than routine drainage, with a comparable rate of seroma formation. This technique presents a viable alternative to drain placement and could lead to a considerable economic savings.
doi:10.1159/000301586
PMCID: PMC2931043  PMID: 20847821
Seroma; Flap fixation; Flap anchoring; Breast cancer
15.  Assessment of peri- and postoperative complications and Karnofsky-performance status in head and neck cancer patients after radiation or chemoradiation that underwent surgery with regional or free-flap reconstruction for salvage, palliation, or to improve function 
Background
Surgery after (chemo)radiation (RCTX/RTX) is felt to be plagued with a high incidence of wound healing complications reported to be as high as 70%. The additional use of vascularized flaps may help to decrease this high rate of complications. Therefore, we examined within a retrospective single-institutional study the peri--and postoperative complications in patients who underwent surgery for salvage, palliation or functional rehabilitation after (chemo)radiation with regional and free flaps. As a second study end point the Karnofsky performance status (KPS) was determined preoperatively and 3 months postoperatively to assess the impact of such extensive procedures on the overall performance status of this heavily pretreated patient population.
Findings
21 patients were treated between 2005 and 2010 in a single institution (17 male, 4 female) for salvage (10/21), palliation (4/21), or functional rehabilitation (7/21). Overall 23 flaps were performed of which 8 were free flaps. Major recipient site complications were observed in only 4 pts. (19%) (1 postoperative haemorrhage, 1 partial flap loss, 2 fistulas) and major donor site complications in 1 pt (wound dehiscence). Also 2 minor donor site complications were observed. The overall complication rate was 33%. There was no free flap loss. Assessment of pre- and postoperative KPS revealed improvement in 13 out of 21 patients (62%). A decline of KPS was noted in only one patient.
Conclusions
We conclude that within this (chemo)radiated patient population surgical interventions for salvage, palliation or improve function can be safely performed once vascularised grafts are used.
doi:10.1186/1748-717X-6-109
PMCID: PMC3179945  PMID: 21896171
head and neck cancer; radiation; free flap; regional flap; Karnofsky performance status
16.  The risk of hematoma following extensive electromyography of the lumbar paraspinal muscles 
Muscle & nerve  2012;46(1):26-30.
Introduction
The purpose of this study is to provide a controlled trial looking at the risk of paraspinal hematoma formation following extensive paraspinal muscle electromyography.
Methods
54 subjects ages 55-80 underwent MRI of the lumbar spine before or shortly after electromyography using the paraspinal mapping technique. A neuroradiologist, blinded to the temporal relationship between the EMG and MRI, reviewed the MRIs to look for hematomas in or around the paraspinal muscles.
Results
Two MRIs demonstrated definite paraspinal hematomas, while 10 were found to have possible hematomas. All hematomas were < 15 mm, and none were close to any neural structures. There was no relationship between MRI evidence of hematoma and either the timing of the EMG or the use of aspirin or other non-steroidal anti-inflammatory drugs.
Discussion
Paraspinal electromyography can be considered safe in the general population and those taking non-steroidal anti-inflammatory drugs.
doi:10.1002/mus.23288
PMCID: PMC3374880  PMID: 22644875
Electromyography; Paraspinal muscles; Hematoma; Paraspinal mapping; Complications
17.  Wound conditioning by vacuum assisted closure (V.A.C.) in postoperative infections after dorsal spine surgery 
European Spine Journal  2006;15(9):1388-1396.
The use of vacuum assisted closure (V.A.C.) therapy in postoperative infections after dorsal spinal surgery was studied retrospectively. Successful treatment was defined as a stable healed wound that showed no signs of acute or chronic infection. The treatment of the infected back wounds consisted of repeated debridement, irrigation and open wound treatment with temporary closure by V.A.C. The instrumentation was exchanged or removed if necessary. Fifteen patients with deep subfascial infections after posterior spinal surgery were treated. The implants were exchanged in seven cases, removed completely in five cases and left without changing in one case. In two cases spinal surgery consisted of laminectomy without instrumentation. In two cases only the wound defects were closed by muscle flap, the remaining ones were closed by delayed suturing. Antibiotic treatment was necessary in all cases. Follow up was possible in 14 patients. One patient showed a new infection after treatment. The study illustrates the usefulness of V.A.C. therapy as a new alternative management for wound conditioning of complex back wounds after deep subfascial infection.
doi:10.1007/s00586-006-0164-2
PMCID: PMC2438567  PMID: 16835734
Spine; Instrumentation; Infection; Vacuum assisted closure; Topic negative pressure
18.  Muscle Flaps and Their Role in Limb Salvage 
Muscle flaps have proved to be a valuable and versatile tool in the surgical treatment of the severely compromised lower extremity. Utilized as both local pedicle flaps and free tissue transfers, muscles have been successfully employed to cover complex wounds, manage osteomyelitis, salvage infected vascular grafts, treat recalcitrant venous stasis ulcers, preserve amputation levels, and restore motion following compartment syndrome. Free flap pedicles have also been used in a flow-through fashion to create a distal arterial bypass. This article explores the multipurpose role of muscle flaps in limb salvage surgery and their beneficial physiologic characteristics in hostile wound environments.
PMCID: PMC3693523  PMID: 23805342
muscle flaps; limb salvage
19.  The value of mastectomy flap fixation in reducing fluid drainage and seroma formation in breast cancer patients 
Background
Prolonged and excessive drainage of serous fluid and seroma formation constitute the most common complications after mastectomy for breast carcinoma. Seroma formation delays wound healing, increases susceptibility to infection, skin flap necrosis, persistent pain and prolongs convalescence. For this, several techniques have been investigated to improve primary healing and minimize seroma formation.
Materials and methods
Between June 2009 and July 2010 forty patients with breast carcinoma, scheduled for modified radical mastectomy, were randomly divided into 2 groups, the study group (20) and the control group (20). In the study group; the mastectomy flaps were fixed to the underlying muscles in raws, at various parts of the flap and at the wound edge using fine absorbable sutures. In the control group; the wound was closed in the conventional method at the edges. Closed suction drains were used in both groups. Patients, tumor characteristics and operative related factors were recorded. The amount and color of drained fluid were recorded daily. The drains were removed when the amount become less than 50 cc. The total amount and duration of drained fluid and the formation of seroma were recorded and the results were compared between the two groups.
Results
In the flap fixation group, the drain was removed in significantly shorter time compared to the control group (p < 0.001). Also, the total amount of fluid drained was significantly lower in the flap fixation group (p < 0.001). The flap fixation group showed a significantly lower frequency of seroma formation compared to the control group, both clinically (p = 0.028) and ultrasonographically (p = 0.047).
Conclusions
The mastectomy flap fixation technique is a valuable procedure that significantly decreases the incidence of seroma formation, and reduces the duration and amount of drained fluid. However, it should be tried on a much wider scale to prove its validity.
doi:10.1186/1477-7819-10-8
PMCID: PMC3279306  PMID: 22236813
mastectomy; flap; fixation; seroma
20.  Reconstruction of an emergency thoracotomy wound with free rectus abdominis flap: Anatomic and radiologic basis for the surgical technique 
An alcoholic 50-year-old male patient with a history of schizophrenia sustained stab wounds into both ventricles and left lung, and survived following an emergency department thoracotomy. The EDT wound, however became infected requiring serial debridements of soft tissue, rib cartilage and sternum. Regional flap options such as pectoralis major and latissimus dorsi muscle flaps could not be employed due to inadequate reach of these flaps. Additionally, bilateral transection of the internal mammary arteries during emergency thoracotomy eliminated the use of rectus abdominis muscles as pedicled flaps based on the superior epigastric vasculature. Therefore, the EDT wound was reconstructed by using the right rectus abdominis muscle as a free flap. The deep inferior epigastric vessels of the flap were anastomosed to the right internal mammary vessels proximal to their transection level in the third-forth intercostal space. The flap healed with no further wound complications.
doi:10.1186/1749-7922-5-12
PMCID: PMC2873277  PMID: 20459668
21.  Negative-Pressure Wound Therapy and Laparoscopic Omentoplasty for Deep Sternal Wound Infections after Median Sternotomy 
Texas Heart Institute Journal  2012;39(3):367-371.
Deep sternal wound infection remains one of the most serious complications in patients who undergo median sternotomy for coronary artery bypass surgery.
We describe our experience in treating 6 consecutive patients with our treatment protocol that combines aggressive débridement, broad-spectrum antibiotics, negative-pressure wound therapy, omentoplasty with laparoscopically harvested omentum, and the use of bilateral pectoral muscle advancement flaps.
The number of débridements needed in order to attain clinically clean wounds and negative cultures varied between 1 and 10, with a median of 5. The length of stay after omentoplasty and bilateral pectoral muscle advancement flap placement varied between 11 and 22 days. One of the 6 patients developed a small wound dehiscence that was treated conservatively. No bleeding related to vacuum-assisted closure therapy was identified. Three patients had pneumonia. Two of the 3 patients had an episode of acute renal failure. The 30-day mortality rate was zero, although 1 patient died in the hospital 43 days after the reconstructive surgery, of multiple-organ failure due to pneumonia that was induced by end-stage pulmonary fibrosis. No patient died between hospital discharge and the most recent follow-up date (4–12 mo). Late local follow-up results, both functional and aesthetic, were good.
We conclude that negative-pressure wound therapy—in combination with omentoplasty using laparoscopically harvested omentum and with the use of bilateral pectoral advancement flaps—is a valuable technique in the treatment of deep sternal wound infection because it produces good functional and aesthetic results.
PMCID: PMC3368473  PMID: 22719146
Coronary artery bypass grafting; debridement; deep sternal wound infection; laparoscopy; mediastinitis; negative-pressure wound therapy; omentoplasty; surgical flaps; surgical wound infection/mortality/surgery
22.  C2 lamina reconstruction using locking miniplate for the intradural tumor of the craniocervical junction (two case reports) 
European Spine Journal  2012;21(Suppl 4):509-512.
Objective
To describe a technique for C2 lamina reconstruction using locking miniplates for the extirpation of spinal tumors in the craniocervical junction.
Summary of background data
Many spinal surgery cases in which lamina reconstructions have been performed using non-locking miniplates have been reported. However, there is only one report of the use of locking miniplates for lamina reconstruction in spinal tumor cases.
Methods
We performed C2 lamina reconstructions using locking miniplates in a patient with a spinal tumor and another with a cystic lesion. The clinical and radiologic features of both cases are reported, and the surgical technique is described.
Results
A 62-year-old female and a 30-year-old male were diagnosed with meningioma and a neurenteric cyst, respectively, in the craniocervical junction. Extirpation of these lesions was performed in combination with C2 lamina reconstruction and reattachment of the paraspinous muscle to the C2 spinous process. A follow-up examination at 1 year postoperatively demonstrated no significant change in the sagittal alignment of the cervical spine and a good postoperative course in both cases. Bony fusion was detected in both cases, and no implant failure occurred in either case.
Conclusions
This procedure results in rigid fixation of the reimplanted C2 lamina and helps to restore the paraspinous muscles. For these reasons, it appears to be a useful surgical procedure for spinal tumors requiring C2 laminectomy and does not cause postoperative kyphosis of the cervical spine.
doi:10.1007/s00586-011-2138-2
PMCID: PMC3369031  PMID: 22228574
Lamina reconstruction; Locking miniplate; C2; Spinal tumor
23.  Spinous process-splitting open pedicle screw fusion provides favorable results in patients with low back discomfort and pain compared to conventional open pedicle screw fixation over 1 year after surgery 
European Spine Journal  2012;21(4):745-753.
Introduction
The conventional open pedicle screw fusion (PSF) requires an extensive detachment of the paraspinal muscle from the posterior aspect of the lumbar spine, which can cause muscle injury and subsequently lead to “approach-related morbidity”. The spinous process-splitting (SPS) approach for decompression, unilateral laminotomy for bilateral decompression, and the Wiltse approach for pedicle screw insertion are considered to be less invasive to the paraspinal musculature. We investigated whether SPS open PSF combined with the abovementioned techniques attenuates the paraspinal muscle damage and yields favorable clinical results, including alleviation in the low back discomfort, in comparison to the conventional open PSF.
Methods
We studied 53 patients who underwent single-level PSF for the treatment of degenerative spondylolisthesis (27 patients underwent SPS open PSF and the other 26 underwent the conventional open PSF). The clinical outcomes were assessed using the Japanese Orthopedic Association (JOA) score, the Roland–Morris disability questionnaire (RDQ), and the visual analog scale (VAS) for low back pain and low back discomfort (heavy feeling or stiffness). Postoperative multifidus (MF) atrophy was evaluated using MRI. Follow-up examinations were performed at 1 and 3 years after the surgery.
Results
Although there was no significant difference in the JOA and RDQ score between the two groups, the VAS score for low back pain and discomfort after the surgery were significantly lower in the SPS open PSF group than in the conventional open PSF group. The extent of MF atrophy after SPS open PSF was reduced more significantly than after the conventional open PSF during the follow-up. The MF atrophy ratio was found to correlate with low back discomfort at the 1-year follow-up examination.
Conclusion
In conclusion, SPS open PSF was less damaging to the paraspinal muscle than the conventional open PSF and had a significant clinical effect, reducing low back discomfort over 1 year after the surgery.
doi:10.1007/s00586-011-2146-2
PMCID: PMC3326135  PMID: 22237851
Posterior lumbar fusion; Multifidus muscle; Wiltse approach; Minimally invasive; Conventionally open
24.  Pedicled Fasciocutaneous Flap of Multi-island Design for Large Sacral Defects 
We designed a new pedicled fasciocutaneous flap for large sacral defects that combined a classic superior gluteal artery perforator flap and an acentric axis perforator pedicled propeller flap. We asked whether this technique would be simple and result in few complications. Six patients with large sacral defects had reconstruction using this technique in one stage. The size of the defect and postoperative complications in each patient were assessed. The minimum followup was 6 months (mean, 20.1 months; range, 6–38 months). All wounds healed with no recurrence during followup. Five patients achieved healing primarily, and another with minimal drainage achieved healing by secondary intention after a dressing change. No patients had deep infection, wound dehiscence, necrosis, or partial loss or shrinkage of the flap at final followup. The buttocks were symmetric. We consider this a good alternative for reconstructing large sacral defects because it is a relatively simple procedure and results in few complications.
Level of Evidence: Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.
doi:10.1007/s11999-008-0643-3
PMCID: PMC2706336  PMID: 19048353
25.  The Reconstruction of the Mutilated Hand 
Seminars in Plastic Surgery  2010;24(1):77-102.
ABSTRACT
The challenging reconstructive treatment of defects in the upper extremity requires a sound working knowledge of a variety of flaps. As the hand surgeon weighs the pros and cons of each possible flap to obtain definitive closure, he or she must also integrate the priorities of function, contour, and stability as well as the anticipation of further reconstructive surgery in choosing the flap of choice. This review describes the various flaps available for closure of soft tissue defects of the upper extremity. The principles of management of wounds of the upper extremity is described to guide hand surgeons in the early treatment of massive wounds that will eventually need free tissue coverage. Currently used flaps include fasciocutaneous, fascial, musculocutaneous, muscle, and osteocutaneous flaps. Flap selection is based on the characteristics of the defect including size, shape, and location, the availability of donor sites, and the goals of reconstruction. Improved techniques of microsurgery and an ever increasing repertoire of flaps provide the framework for hand surgeons to offer the most appropriate flap based on donor site, thickness, amount of tissue needed, and composition. A discussion of the selection of ideal flaps for any given defect should enable the reconstructive hand surgeon to provide the most appropriate coverage of wounds to the hand and upper extremity.
doi:10.1055/s-0030-1253245
PMCID: PMC2886998  PMID: 21286307
Mutilated hand; hand reconstruction; free flaps; soft tissue

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