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.

Preservation of denervated muscle form and function by clenbuterol in a rat model of peripheral nerve injury.

The effects of clenbuterol in preserving the form and function of muscle after unilateral sciatic nerve division and epineural repair were investigated in a rat model. The drug (a beta2-adrenoceptor agonist) was administered daily for six weeks by gastric gavage (10 microg/kg body weight), interrupted every 5 days by a 2 day omission of dosing to avoid drug desensitization. Clenbuterol reduced the loss of wet weight, total protein, muscle fibre cross sectional area and (in part) contractile forces in denervated hindlimb muscles, with most effects lasting until reinnervation. The effects were dependent on muscle type, with slow-twitch oxidative muscle (soleus) and mixed-fibre (gastrocnemius) showing greater sensitivity to the drug than fast-twitch muscle (extensor digitorum longus). Anabolic effects on the contralateral innervated muscles tended to be small. The results suggest a potential for the adjuvant use of selective beta -adrenoceptor agonists in the management of peripheral nerve injuries in humans.

The use of a bilaminate artificial skin substitute (Integra) in acute resurfacing of burns: an early experience.

Integra artificial skin provides immediate full-thickness reconstruction for cutaneous burns. The clinical outcome appears to be superior in terms of final function and cosmesis. Consequently the use of such a skin substitute is being heralded as the future treatment of choice, particularly for massive burns where autologous donor skin is limited. The three cases reported here describe the senior author's early experience with Integra and highlight some of the difficulties and successes encountered. A high rate of dermal graft loss and slow epidermal engraftment have tempered the original enthusiasm, but with growing experience the final outcome justifies the continued use of Integra in our unit.

Ossification in the rectus sheath following free rectus flap.

Heterotopic ossification (HO) is a rare complication of laparotomy wounds. In this report, we describe an unusual presentation of ossification within the closed sheath following the harvest of a free rectus flap for lower limb reconstruction. Of specific interest to this case is that access to the rectus was gained through a lower transverse approach. Furthermore, the extremities of this incision were utilised for harvest of cancellous bone from the iliac crests. Given that one explanation for HO is intraoperative seeding it is of note that no problem was encountered in the wound intimately associated with the bony disruption.

Peripheral gangrene associated with fulminating meningococcal septicaemia. Is early escharotomy indicated?

We present a case of a 3-month-old boy presenting with fulminating meningococcal septicaemia associated with extensive peripheral gangrene requiring amputation of three limbs. The surgical management options and the role of early fasciotomy are discussed.

The use of pH adjusted lignocaine in controlling operative pain in the day surgery unit: a prospective, randomised trial.

We report the results of a randomised, case matched, controlled, double blind study on 40 patients undergoing correction of their prominent ears, comparing efficacy of pH adjusted lignocaine to lignocaine alone in controlling operative pain. Each patient received commercial lignocaine in one ear and the same preparation reconstituted with 1 ml of 8.4% sodium bicarbonate in the other ear according to our randomisation protocol. 30 patients were studied to compare the difference between the buffered and commercial preparation infiltrated at room temperature. A further 10 patients were studied to assess the benefit the buffered preparation at room temperature had over commercial lignocaine warmed to body temperature. Linear analogue pain scores for discomfort at infiltration and during the operation itself were analysed. Buffered lignocaine imparts a significant reduction in pain on infiltration, compared to the commercial preparation at both room and body temperature. Both preparations were equally effective in obliterating pain during the operation itself.