Reverse sural flap for ankle and heel soft tissues reconstruction.

Introduction: The potential of the medial calf integument, as donor site for a free flap based on musculocutaneous branches of the medial sural artery, was first identified by Taylor and Daniel, following cadaver investigation. In 1981, Pontén described the fasciocutaneous sural flap as a reconstructive option for soft tissue loss of the lower extremity, particularly around the knee. Two years later, Donski and Fogdestram presented the distally based fasciocutaneous flap from the sural region followed by Montegut and Allen who considered the sural artery perforator flap as a viable alternative for the gastrocnemius myocutaneous flap. The sural flap proved a considerable versatility at the level of the lower leg (from the knee to the ankle and heel) as well as for other anatomical regions. The most common usage of the flap is for the distal-third defects of the leg. Materials and method: A group of 10 patients with soft tissue losses at the ankle or heal due to a various etiopathogeny represented by cancer excision, trauma, unstable scars, chronic osteomyelitis, in which a microsurgical free transfer had no indication or was not wanted, was presented. Our group reported a 30% complication rate in a high-risk patient population, including patients with diabetes mellitus, peripheral vascular disease, and venous insufficiency. Results: All the defects were covered successfully, without major complications. Usually, only a minor margin of the tip of the flap was lost, which was easily solved with a guided secondary healing. Most flaps showed a slight venous congestion, which cleared in a few days. The functional result was very good in all the patients, while the aesthetic appearance was acceptable even in female patients. Discussion: An ideal indication of a reverse sural flap may be a defect over an intact but partially exposed Achilles tendon. Conclusions: The sural reverse flap is useful in the ankle and foot soft tissues reconstruction whenever we have reasons not to use a microsurgical free transfer. Venous congestion with consecutive partial or complete flap loss is a common complication, so this would not be recommended in patients with obvious acute or chronic venous stasis. The reverse sural island flap should no longer be regarded as a flap of secondary choice to free tissue transfer, but as an equally valuable alternative for small and midsized defects around the ankle and heel.

Osteosynthesis using plates and screws after removing a limited area of the periosteum in order to reduce misclassified during radiological assessment metacarpal shaft fractures.

Hand fractures are one of the most common causes for presenting to the emergency room. Metacarpal fractures count about 18 to 44% of all hand fractures, and are most often standalone closed injuries, without misplacement, not needing operative treatment. We present a case in which osteosynthesis with plates and screws was used to reduce two metacarpal fractures in order to allow an early motion recovery, despite the fact that a small portion of the periosteum needed to be removed. The type of fractures were misclassified according to the radiological findings, therefore the correct diagnosis was established during surgery. The results according to the radiological aspects and to the DASH score were excellent with 95% function recovery at twelve months. In this case, the use of osteosynthesis with plates and screws led to a good fracture healing without any major complications. However, there are a series of complications related to this method that should be taken into consideration. Being misled by the radiological aspects of the fractures, the most certain way to classify a metacarpal shaft fracture is through exploratory surgery, even if in most of the cases the three radiological views are enough to establish the diagnosis. Abbreviations: DASH score = Disability of Arm, Shoulder and Hand score, TAM = Total Active Motion, MCP = metacarpal phalangeal joint, PIP = proximal inter phalangeal joint.

Surgical attitude in premalignant lesions and malignant tumors of the lower lip.

INTRODUCTION: Malignant tumors of the lower lip may have a variety of histopathology forms. The diagnosis and treatment of premalignant lesions are extremely important to avoid their malignant evolution. The lower lip tumor diagnosis is based on a series of correlations: anamnestic, clinical, laboratory and histopathological (the latter giving the certain diagnose). MATERIAL AND METHODS: This study was carried out by selecting the cases with lower lip tumors operated between January 2012 and July 2014, in the Plastic Surgery and Reconstructive Microsurgery Clinic of Bucharest Clinical Emergency Hospital. The variables considered in the study were the following: age, gender, exposure to risk factors, diagnosis, and histopathology. RESULTS: The histopathological examination revealed 63% squamous cell carcinoma, 30% basal cell carcinomas, 5% keratoacanthoma and 2% actinic keratosis. Men were the predominantly affected genre, with a percentage of 70%. In the group of patients studied, 66% were smokers. DISCUSSIONS: The rate of the malignant transformation of premalignant lesion was 32.6% for keratoacanthoma, 16.9% for actinic cheilitis, 10% for actinic keratoses. CONCLUSIONS: There were no clinical or laboratory features to plead for the pre-malignant or malignant character of the of a lower lip tumor, consequently histopathological examination was used for the diagnosis of the lesion. Due to the high percentage of malignant transformation of precancerous lesions, particularly in the form of squamous cell carcinoma, the surgical attitude intending to eradicate a lower lip tumor from an oncological point of view was the excision with oncologic safety margins followed by a lip reconstruction.

Electrical injuries. Biological values measurements as a prediction factor of local evolution in electrocutions lesions.

RATIONALE: Taking into account the incidence and the severity of electrocutions, we consider it extremely necessary to find effective, appropriate and particularized therapeutic solutions aimed at improving the survival, decreasing the mortality, ensuring a superior functional and aesthetic effect and facilitating the social reintegration. Given the severity of the general condition of the electrically injured patient and the fact that any worsening of the lesions has a systemic echo, the selection of the timing for re-excision is very important. The postponement of the surgical timing can break the precarious metabolic equilibrium and can hasten the installation of the multisystem organ failure (MSOF). OBJECTIVE: The study is intended to establish a possible connection between the clinical evolution of the electrically injured patient and the dynamics of three important biological parameters, able to provide data concerning the therapeutic attitude to be followed. The patients with a diagnostic of high-voltage electrocution, who will be admitted to the Clinic, will be followed for a period of 2 years. The parameters to be followed daily will be: - Creatin-kinase, as a marker of muscular damage. - Hemoglobin, as a marker of tissue oxygenation. - Leukocytes, as an indicator of a possible septic evolution. The therapeutic alternatives, including the administration of antiplatelet drugs will be studied. METHODS AND RESULTS: In the period October 2010-June 2013 a total of 12 cases of high-voltage electrocution were admitted in our clinic. Among these, some could be placed in the study of 7 cases, as the remaining patients died within the first 24 hours of hospitalization due to the endured lesions. All the patients were admitted to the ICU ward that supported the treatment and monitoring until their stabilization, at which time they were transferred to the ward. All the patients received anti-thromboxane treatment from their admission (injectable NSAIDs associated with antisecretory drugs). By mutual agreement with ICU service, Dipyridamole was not introduced because of the "steal effect" in the viable areas to the detriment of the already ischemic areas, the drug effect being obvious in vitro, but hard to be proven in the clinical case. The relationship between the CK level and the clinical appearance of the ischemic areas is relative. We cannot conclude that an increased level of CK is equivalent to an enlarged ischemic area and even less it does not provide us direct information concerning the best time for re-excision. The presence of a viable blood supply around the necrotic tissue will lead to an important resorption of degradation products in that area, a quasinormal level of CK having no value. The sealing of the necrosis areas and the lack of immediate resorption does not have a positive prognostic value. Taking into account that the electrocutions are mostly multiple injuries, the CK level can increase even after some muscular damages, fractures, independent of the actual electrocution lesion. In one case, the patient suffered from electrocution at both thoracic limbs. With the carbonization of the hands and grifa installed up to the level of the elbow fold, he stayed for 6 hours at the accident site until he had been recovered. At the moment of presentation to the hospital, his consciousness condition was satisfactory but the CK level was of over 20000 IU, becoming rapidly non-detectable, in combination with black urine. The patient's condition deteriorated quickly, and, although the bilateral shoulder disarticulation has been carried out, he died in the next 12 hours. DISCUSSION: As a conclusion, the CK level did not prove itself a prognostic for the surgical timing or the actual surgical attitude and could be influenced by a whole series of factors, dependent or not on the electrocution lesion. A radical attitude is to be preferred in cases with established ischemia; the prognostic being the more reserved the larger the damage and the longer the period of time from the event. The established treatment is of renal support and treatment of acute renal injury (AKI) subsequently installed. An increased level of leukocytes is always present as in any severe trauma, even if there are no immediate signs of infection of the electrocution lesions. Taking into account that the electrocution lesion as well as the one caused by burning destroys the natural defense barrier represented by the skin, the infection risk is major and that is why the therapeutic protocol stipulates the immediate establishment of a treatment with broad-spectrum antibiotics or with an association of antibiotics. The increase of the leukocytes level under antibiotics treatment involves either the contamination with a germ that is not sensitive to the respective antibiotic or the persistence of necrosis areas which secondarily infect, and where antibiotic penetration is very low. Therefore, the excision of the compromised tissues is an absolute necessity. In terms of prognostic, the increase of the leukocytes number signified an insufficient excision and indicated the resuming and deepening of the excisions. Taking into account that the patient has been admitted through the ICU service, the risk of contracting severe infections with selected germs is real. Another risk is that of infection with Clostridium difficile following the prolonged utilization of broad-spectrum antibiotics, especially in patients with associated diseases and reduced immunity per primam. The existence of completely separate circuits should solve the problem of contamination with bacteria of selected species; unfortunately, in our cases, we have faced this problem and the utilization of last choice antibiotics (Imipenem, Vancomycin, Targocid, etc.) as well as the association of immunoglobulins was necessary. All the patients admitted in the study received anti-thromboxane drugs in order to limit the ischemic process at tissue level. Despite the efforts we have made, the lack of blood and its derivatives or simply the negligence in patient monitoring, allowed the decrease, even transient of the Hb level, sometimes only for a few hours, but enough to allow the deepening of the ischemic lesions. Excisions were carried out in all the patients in emergency or even amputations of the extremities, with the wish to limit the extension of the ischemic lesions and the resorption of cell degradation products. The amputations performed in emergency did not always represent a saving solution; however, they remained the most effective measures when they were carried out immediately after the accident and obviously in viable tissue. The increase of CK is not an indicative factor itself in making re-excisions but orients the therapeutic approach, the utilization of the dialysis when the values do not decrease by treatment for renal support and the forcing of diuresis is required. The normalization of CK indicates the time when we can start the covering of the defects resulted as a consequence of the excisions. The level of the leukocytes represents both a prognostic factor and an indicative factor for the re-excision of the ischemic areas. An increased level under antibiotic therapy signifies either an incomplete excision or the contamination with flora resisting to the antibiotic that has been used. In the light of findings in the caring of the patients with electrocutions, I propose several caring/assessment protocols for the severe electrically injured patient.

Lower limb perforator propeller flaps - clinical applications.

BACKGROUND: A great variety of flaps have been used in lower limb reconstructive surgery: random pattern flaps, axial flaps and free microsurgical transfers with many variants. After further research on the cutaneous blood supply and improvement of microsurgical techniques, perforator propeller flaps began to be studied and used. MATERIAL AND METHOD: A propeller flap is defined as an insular flap mobilized through an axial rotation on a perforator pedicle in order to cover a defect that has to be reconstructed.According to the specialized literature data and to the studies we made on cadavers, this paper establishes a classification based on several criteria: 1) the position of the supplying perforator; 2) the reconstructive necessities and the skin island;3) the flap blood supply; 4) the aesthetic and functional demands of the reconstructed areas. Based on this study we established the specific reconstructive indications for these propeller flaps. CONCLUSIONS: The reconstructive lower limb strategy allows the use of the perforator propeller flaps as first therapeutic option for small and medium defects in certain areas considered as "critical". Knowledge of the pedicle length and the surface of the flaps facilitates the optimum flap choice in the reconstruction of a certain area.