Anatomy of deltoid flap based on posterior subcutaneous deltoid artery: a cadaveric investigation / Anatomía del colgajo deltoideo basado en la arteria subcutánea deltoidea posterior: una investigación en cadáver

The purpose of the study is to evaluate neurovascular anatomy of the deltoid flap based on the posterior subcutaneous deltoid artery (PSDA). Bilateral axillary artery dissections of the thirty-four shoulders of 17 formalin-fixed cadavers were performed (15 male, 2 female; age range 40 to 82 years) under the 4x loupe magnification. During the dissection of each region, the PSDA was evaluated with respect to the origin, the branches, course and anatomical relations with neighbouring structures. The PSDA was present in all cases. The PSDA was single in 26 (76.5%) cases, double in 2 (5.9%) cases and had early bifurcation in 6 (17.6%) cases. The mean length of the lateral cutaneous brachial nerve was 6.0 mm range from 49.0 mm to 83.9 mm. The mean distance between the piercing point of the PSDA and the acromion was 74.2 mm range from 51.0 mm to 96.3 mm. The pedicle bifurcated before reaching the superficial fascia in 6 cases (17.6%). An anatomic study of the posterior subcutaneous deltoid artery achieves reliable quantitative anatomic data and would be very helpful for utilizing deltoid flap. The quantitative and detailed anatomic information provided from the study may be of guidance to surgeons for safe operating period.

El objetivo del presente estudio fue evaluar la anatomía neurovascular del colgajo deltoideo basado en la arteria subcutánea deltoidea posterior (ASDP). Se realizaron disecciones axilares bilaterales de 34 hombros de 17 cadáveres (15 hombres y 2 mujeres con un rango etareo entre 40-82 años) fijados en formalina con ampliación mediante una lupa 4X. Durante la disección de cada región, la ASDP fue evaluada en relación con su origen, ramas, curso y relaciones anatómicas con estructuras vecinas. La ASDP estuvo presente en todos los casos. Observamos una ASDP en 26 casos (76,5%), dos en 2 casos (5,9%) y la bifurcación temprana en 6 casos (17,6%). La longitud media del nervio cutáneo braquial lateral fue de 6,0 mm (intervalo de 49,0-83,9 mm). La distancia media entre el punto de entrada y el acromion de la ASDP fue 74,2 mm (rango de 51,0-96,3 mm). La bifurcación del pedículo se presentó antes de llegar a la fascia superficial en 6 de los casos (17,6 %). El estudio anatómico de la parte posterior de la arteria deltoidea subcutánea entrega datos anatómicos, cuantitativos, fiables para la utilización del colgajo deltoideo. La información detallada y cuantitativa proporcionada en este estudio puede servir de orientación a los cirujanos para un abordaje y período quirúrgico seguro.

Hydroxyurea associated leg ulcer succesfully treated with hyperbaric oxygen in a diabetic patient.

Oxygen tension in healing tissues is heterogeneous. Increased oxygen mostly stimulates repair mechanisms and enhances tissue healing. Hyperbaric oxygen therapy increases blood and tissue oxygen content and may help maintain cellular integrity and function. Hydroxyurea (HU) is a cytotoxic agent, which leads to inactivation of ribonucleotide reductase, inhibition of cellular DNA synthesis, and cell death in the S phase. HU induced leg ulcers occur after use of this agent for a long time and at higher cumulative doses. Here we describe a diabetic patient with foot ulcer associated with HU treatment for polycythemia vera, who was treated successfully with hyperbaric oxygen and general wound care after discontinuation of HU. Faster improvement of leg ulcer in our patient compared to literature regarding HU withdrawal as single therapy suggests that hyperbaric oxygen may be helpful in the management of HU associated leg ulcers, especially in diabetic subjects.

Prefabrication of combined composite (chimeric) flaps in rats.

The purpose of this study was to prefabricate a new combined composite (chimeric) flap that consists of four different tissues. The tissues were prefabricated around two independent pedicles that ultimately join as a single main pedicle. In the inguinal area of 36 rats, the saphenous and the superficial inferior epigastric (SIE) pedicles were dissected and prepared as vascular carriers. A fascial graft and a local muscle flap were wrapped around the saphenous pedicle. The SIE pedicle was then implanted under the abdominal skin to supply a future skin flap. An ear cartilage graft was also inserted under the abdominal skin and adjacent to the implanted SIE pedicle. After allowing 2-, 4-, 6-, and 12-week prefabrication periods in different groups of nine animals, the prefabricated tissues were raised around two pedicles nourished by the femoral pedicle and then transferred. Flap survival was assessed by observation, microangiography and histology. The skin flaps showed survival rates of 52 +/- 17% (mean +/- standard error of the mean), 64 +/- 16%, 86 +/- 11%, and 100 +/- 0% of the total areas in the 2-, 4-, 6-, and 12-week prefabricated flaps respectively. None of the control grafts that were prepared on the contralateral side survived totally. A significant difference was found between the 12- and 2-week (p < 0.008), 12- and 4-week (p < 0.02), and 6- and 2-week (p < 0.05) prefabrication groups. Histologically, fascial and cartilage grafts, and portions of muscle were viable in the 2- and 4-week groups. Also, noticeable necrosis was found in the skin flaps in these groups. The muscle showed mild (at 2, 4, and 6 weeks) and moderate (at 12 weeks) atrophy. After prefabrication for 6 weeks, all tissues demonstrated good survival. This study shows that a combined composite flap can be prefabricated successfully in rats after a 6-week period of prefabrication.

Delayed prefabricated arterial composite venous flaps: an experimental study in rabbits.

Prefabrication of composite arteriovenous flaps with implantation of an autologous graft (cartilage) or an alloplastic material (porous polyethylene) was studied in 40 rabbits. Abdominal flaps based on bilateral epigastric pedicles were elevated. An ear cartilage graft or a porous polyethylene implant was inserted under the flap. Two weeks after the operation, 10 flaps with cartilage graft and 10 flaps with porous polyethylene were raised, converted to arteriovenous flaps, and resutured in place in the experimental groups. In the other 20 rabbits of the control groups, the flaps (10 with cartilage graft and 10 with porous polyethylene) were raised and resutured in place as conventional axial flaps. At the end of the second and fourth week postoperatively, samples were obtained from the flap tissues (including a part of the graft or implantation material) and were prepared for histologic examination in all rabbits. The viable areas of all flaps were assessed at the end of fourth week after the second operation. The mean survival rates were 99.4%, 99.7%, 99.5%, and 99.8% in the arteriovenous and control flaps prefabricated with cartilage graft and the arteriovenous and control flaps prefabricated with porous polyethylene respectively. The features of wound healing in the experimental and control groups were similar. The study showed that arteriovenous perfusion can nourish a prefabricated flap containing an implanted material (autologous or alloplastic) and these 2-week delayed composite flaps have a similar survival rate to delayed prefabricated conventional axial flaps.

A case of self-inflicted intraorbital injury: wooden foreign body introduced into the ethmoidal sinus.

A patient with an intraorbital wooden foreign body is presented. A 43-year-old schizophrenic male patient purposely introduced a twig through his left medial canthus and into the orbital cavity 6 months before presentation. Magnetic resonance imaging showed a well-delineated intraorbital object that partially penetrated the ethmoidal sinus through the medial orbital wall. Under general anesthesia, a 55-mm-long and 6-mm-diameter twig was removed through an incision along the sulcus palpebromalaris. Thick capsule formation around the foreign body, fibrosis of the adjacent tissues, and severe infection were observed. Diagnosis and management of intraorbital foreign bodies are discussed.

Surgical treatment for ischial pressure sores with gracilis myocutaneous flap.

Surgical reconstruction of ischial pressure sores is technically complex and presents a significant problem. Although there is consensus about the use of muscle or myocutaneous flaps in the closure of these sores, there is still dispute about which muscle or myocutaneous flap to use. This evaluation describes the use of the gracilis myocutaneous flap for the treatment of wide and chronic ischial pressure sores. Details of 14 cases are presented and compared with those described in the literature.

Ischemia/reperfusion injury in flow-through venous flaps.

The effects of ischemia/reperfusion (I/R) injury in flow-through venous flaps were evaluated in rabbits. The rates of flap survival and the levels of lipid peroxidation, protein oxidation, and sulfhydryl groups were compared between flow-through venous flaps, conventional flaps after an I/R period (experimental groups), and flow-through venous flaps without being subjected to I/R injury (control groups) in 20 animals. On the seventh day after the onset of reperfusion, 3 of 10 flow-through venous flaps (30%) and 6 of 10 arteriovenous flaps (60%) survived in the experimental groups. Flow-through venous flaps showed a decreased survival rate compared with control and conventional flaps (p < 0.05). Tissue lipid peroxide levels were found to be higher in venous flaps during reperfusion after secondary ischemia (p < 0.05). Tissue protein oxidation and total sulfhydryl groups levels did not show any difference among groups. This study suggests that more free radical damage occurs in flow-through venous flaps during I/R injury.

A combined reverse temporalis muscle flap and pericranial flap for reconstruction of an anterior cranial base defect: a case report.

After the excision of a recurrent squamous cell carcinoma in a 52-year-old man, a reverse temporalis muscle flap combined with a pericranial flap was used to reconstruct the anterior cranial base and the frontal defect. The combined flap is based on the superficial temporal fascia supplied by the superficial temporal vessels. We recommend the usage of the combined reverse temporalis muscle flap and the pericranial flap for reconstruction of the anterior cranial base, the frontal region, and other facial defects.

The effect of cobalt chloride on skin flap survival.

The effects of cobalt chloride on ischaemia-reperfusion injury were evaluated in skin flaps. Groin neurovascular island flaps, 3 x 6 cm, were elevated in rats and subjected to primary and secondary ischaemia. Primary ischaemia was produced by 1 hour occlusion of the femoral artery and vein and, 22 hours later, secondary ischaemia was produced by 3 hours venous occlusion. The treatment group received intraperitoneal cobalt chloride (5 or 10 mg/kg) at the time of secondary ischaemia. Flap survival was 80% in the control, 10 to 20% in the cobalt chloride treated, and 20% in the cobalt plus mannitol group. Mannitol (100 mg/kg) failed to prevent the harmful effects of cobalt. Skin flaps exposed to cobalt chloride exhibited increased thiobarbituric acid reactant (TBAR) levels of 20 to 30 times normal. Of the antioxidant enzymes, glutathione peroxidase activity increased by 40% (P < 0.01), whereas glutathione reductase activity decreased by 40% (P < 0.01) in the cobalt exposed groups. Glucose 6-phosphate dehydrogenase activity was not affected.

Primary lymphedema precox of the penis and its surgical treatment: a case report.

Primary penile lymphedema occurs infrequently and is seen in conjunction with a similar process in the scrotum. The accepted form of treatment is surgery since conservative medical treatment is of little value. Different surgical techniques have been described, but no single procedure has emerged as the ideal treatment. Radical excision of all lymphedematous tissues and reconstruction using local penile flaps yield excellent functional and cosmetic results. We treated a 13-year-old boy with primary penile lymphedema precox using radical excision and reconstruction with local penile flaps. At follow-up two years later, functional and cosmetic results were satisfactory.