Thalidomide-related vessel thrombosis in microsurgical free tissue transfer.

This article describes a 49-year-old man with lower gum cancer who received tumor ablation by an otolaryngologist and immediate reconstruction with microsurgical free tissue transfer. The thrombosis occurred at the arterial anastomotic site at least twice during operation by an experienced microsurgeon and progressed to skin paddle necrosis following surgery. The thalidomide-induced recipient vessel thrombosis is highly suspected after excluding other hypercoagulation problems and technique errors. While thalidomide is increasingly used as an adjuvant therapy agent in head and neck cancer treatment, its potential adverse effect resulting in recipient vessel thrombosis is worth consideration in microsurgery. Prophylatic antithrombosis agents are thus recommended to prevent this potential side effect.

Anterolateral thigh perforator flap: varying perforator anatomy.

The anterolateral thigh (ALT) perforator flap is based on the septocutaneous or musculocutaneous perforators from the lateral circumflex femoral vessels. Each perforator artery should be accompanied by 2 veins. Anomalies of the perforator anatomy in the subfascia and intramuscular layer are rarely reported. This study analyzed 6 anatomic perforator variations from subfascial to intramuscular level out of 1043 ALT perforator flaps performed from 2005 to 2007 in China Medical University Hospital in Taichung, Taiwan and from 2004 to 2007 in E-Da Hospital in Kaohsiung, Taiwan. The perforator flaps included (1) 1 perforator artery and 4 accompanying veins, (2) 1 perforator artery and 1 accompanying vein, (3) 1 tortuous perforator artery and 1 accompanying vein, (4) 1 perforator artery with no accompanying vein, (5) 2 veins with no accompanying perforator artery, and (6) 1 vein only. These variations in perforator anatomy were believed to be the causes of total or partial flap failure after excluding all the other possibilities such as vessel kinking or perforator injury during intramuscular dissection. Further, the nearby anteromedial thigh or tensor fasciae lata flaps were considered alternative flaps in cases of unusual perforator anatomy. The contralateral ALT flap was also necessary in some cases. However, anatomic variations in perforators from subfascial to intramuscular layer must be considered if the flap is to be used safely and reliably.

Epistaxis as the only initial symptom in pediatric naso-orbital-ethmoid fracture complicated with meningitis.

Epistaxis is a frequent finding in patients with facial trauma. Herein, we report an unusual presentation of pediatric naso-orbital-ethmoid (NOE) fracture with epistaxis as the only initial symptom. The course of the patient's condition was later complicated by meningitis, related in part to the delay in diagnosis. A 3-year-old girl with preexisting upper respiratory symptoms was involved in a traffic accident, sustaining blunt trauma to the right side of her face. During the initial examination, only right-sided epistaxis was noted. Five days later, she developed febrile convulsion and was admitted to the intensive care unit with other signs of meningitis such as mental status change and neck stiffness. Her craniofacial computed tomographic scan showed a right-sided NOE fracture with minimal displacement and without dura tear. The cerebrospinal fluid culture grew Streptococcus pneumoniae, which may be due to ascending infection as a result of cribriform plate fracture. Intravenous antibiotic therapy was initiated with good response, and she was discharged from the hospital after 2 weeks. The presence of epistaxis and periorbital bruise, together with other symptoms and signs, helps in the identification of NOE and cribriform plate fracture. A high index of suspicion with repetitive computed tomographic scans is necessary to achieve correct early diagnosis. Parental antibiotic therapy is indicated if ascending cerebrospinal fluid infection develops.

Long-term management of craniofacial osteosarcoma.

Primary osteosarcoma of the calvarium is rare. A 22-year-old female patient was admitted for a progressively enlarging, indurated mass under her scalp for 6 months. A computed tomographic scan revealed a 4 x 3 x 2-cm3 osteolytic lesion over the right parietal cortex with a sunburst appearance. The patient underwent en bloc tumor resection using bicortical parietal craniectomy with a 2-cm margin of normal bone, including the tightly adherent periosteum over the tumor. Immediate cranioplasty was performed with split-thickness autogenous calvarial bone grafts. Histopathologic examination showed the tumor to be a primary high-grade osteosarcoma of the skull. She received postoperative chemotherapy. She has recovered well and remains without any evidence of disease at her most recent, 8-year follow-up. The key to disease-free survival in treating primary osteosarcoma of the calvarium is complete surgical resection with immediate reconstruction followed by adjuvant chemotherapy.

Simple and reliable way in sternum wound coverage--tripedicle pectoralis major musculocutaneous flap.

OBJECTIVE: Sternotomy wound infection requires radically debridements and need secondary reconstruction of the resulting defect. Pectoralis major muscular or musculocutaneous flap is quite common in sternal wound closure. We modified the pectoralis major musculocutaneous flap design: bipedicle advancement cutaneous flap combined with thoracoacromial myocutaneous perforators, as a "tripedicle" fashion. We tried to utilize the cutaneous pedicle to provide a reliable skin coverage and decrease the wound dehiscence rate in lower one third sternal wound. METHODS: Four patients undergoing median sternotomy surgery between 2004 and 2007 suffered from sternal wound infection and received tri-pedicle pectoralis major musculocutaneous flaps transfer. RESULTS: No skin paddle necrosis or wound dehiscence occurred in the postoperative course. Cosmetically and chest stability were satisfactory without complains about the daily activity. CONCLUSIONS: Tripedicle pectoralis major musculocutaneous flap is a simple and reliable technique to cover sternal wound defect necessitating resurfacing surgery. The blood supply to the skin paddle can be enriched by the superior and inferior cutaneous pedicle and the wound dehiscence rate is decreased with this technique.

Penile replantation, complication management, and technique refinement.

We describe a case of complete guillotine-type penile amputation at the proximal penile shaft. The blood flow was established 10 h after trauma. Circulation in the replanted penis was quite good but there was progressive prepuce necrosis after the hematoma. Cosmetic and urinary outcome was good 6 weeks later. The repair of deep dorsal penile vessels helps in corpus tissue healing and glans circulation. The blood supply from the corpus tissue is sufficient for the survival of the replanted penis even when the repaired dorsal vessels were occluded. Surgical pitfalls in replantation procedures and complication management are discussed.

Using the descending branch of the lateral femoral circumflex vessel as a source of two independent flaps.

BACKGROUND: Simultaneous reconstruction of two separate defects by two free flaps is time consuming and often requires two donor sites. The anterior and lateral aspect of the thigh is an ideal donor site for free tissue harvest without incurring significant morbidity. In this article, the authors describe their recently developed technique that allows for harvesting two independent fasciocutaneous free flaps from the same descending branch of lateral circumflex femoral vessel as a new clinical application of the versatile anterolateral thigh flap. METHODS: A total of eight flaps were developed from left thighs of four patients. There were two male and two female patients, with a mean age of 42.0 years. The defects were either on the lower extremity (n = 2) or in the oral cavity (n = 2). Each anterolateral aspect of the thigh was used to develop two perforator flaps, based on one perforator each. The anterolateral thigh flap was elevated in the standard manner based on at least two cutaneous vessels of the descending branch of the lateral circumflex femoral artery. The skin flaps were tailored to the recipient site requirement and the main descending branches of the lateral femoral circumflex vessels were divided in between to be used as the pedicle of both flaps. The mean flap dimensions ranged from 2.5 x 4 cm to 8 x 12 cm (mean, 5 x 8 cm). The mean operation time was 11 hours 30 minutes. The mean length of the pedicle was 9 cm (ranged, 8 to 11 cm). The mean external diameter of the descending branch in the mid thigh and where it joined to the lateral circumflex femoral artery was 1.75 mm and 3 mm, respectively. Three donor sites were closed directly and one was grafted. RESULTS: All flaps survived completely. No complications were encountered. Donor-site morbidity was negligible. Hospitalization averaged 9.9 +/- 1.7 days. CONCLUSION: Two fasciocutaneous flaps based on independent skin vessels can be reliably harvested from the same descending branch of the lateral femoral circumflex artery for simultaneous reconstruction of two separate defects.