Primary reattachment of avulsed skin flaps with negative pressure wound therapy in degloving injuries of the lower extremity.

Large avulsed skin flaps of the lower extremity caused by degloving injuries eventually develop skin necrosis in most cases. The current treatment option involves excision of the degloved skin and reapplication as a full- or split-thickness skin graft. We considered that reattachment of avulsed skin flaps without excision would be theoretically beneficial, since some circulation may remain around the connected pedicle and thus facilitate graft take. Furthermore, securing the skin to the original anatomic position is much easier using retained landmarks. We treated a total of 12 patients (13 cases) with degloving injuries of the lower extremity. In all cases, the avulsed skin flap was defatted and sewn back to the original position, then negative-pressure wound therapy was applied over those grafts as a bolster for approximately 7 days. Most of the avulsed skin flap took excellently, particularly close to the connected pedicle. Nine cases did not need any additional surgical procedures. Four cases required secondary skin graft for a small area of open wound due to partial necrosis of the defatted skin, as well as the raw surface left by the primary skin defect in the initial operation. Primary reattachment of the avulsed skin flaps without excision is convenient and efficient to cover the open wound over the exposed fascia and periosteum in degloving injuries. This would potentially offer a better alternative to definitive wound closure.

Gadolinium enhanced three-dimensional magnetic resonance portography with subtraction.

The aim was to evaluate a subtraction technique for breath-hold gadolinium enhanced three-dimensional magnetic resonance portography (3D-MRP). 26 patients with gastric and/or duodenal varices related to portal hypertension were investigated by 3D-MRP with two phase acquisitions. A partial volume maximum intensity projection (MIP) image after subtracting selective arterial phase images from subsequent portal venous phase images (subtraction 3D-MRP) was compared with the partial volume MIP without subtraction (non-subtraction 3D-MRP) to assess visualization of the portal vein and its collaterals. Subtraction 3D-MRP depicted excellent visualization of the portal vein, although this was not significantly better than non-subtraction 3D-MRP. However, subtraction 3D-MRP gave superior visualization of portal collaterals, with effective suppression of arterial and renal signal intensities, compared with non-subtraction 3D-MRP (p<0.001).

Contrast-enhanced MR angiography of the epigastric and hepatic regions: visibility in three-dimensional reconstructions.

PURPOSE: We applied the Maximum Intensity Projection method (MIP method), volume rendering method (VR method) and Shading process in reconstruction of arteries, portal veins and hepatic veins using Contrast-enhanced MR Angiography (MRA) in the epigastric region and examined its usefulness. In addition, the visibility of tumor vessels in the liver was evaluated using original images. SUBJECTS AND METHODS: The subjects were 85 patients. Abdominal dynamic imaging was performed using the efgre3d sequence. We reconstructed MRA for stereoscopic images using the MIP, VR, or VR + Shading process method and evaluated the visibility rates and score of each artery, portal vein and hepatic vein. The visibility of tumor vessels in the liver was also evaluated from original images obtained using MRA. RESULTS: In the arterial phase, the VR method and shading process yielded greater visibility than the MIP method. The average score was highest in the shading process followed by the VR method, and then the MIP method. In the portal phase, there was little difference in visibility among the reconstruction methods. The average score with the MIP method was slightly, but not significantly, higher than with the VR method and Shading process. For the hepatic veins, visibility rates of each three-dimensional reconstruction image were markedly lower than in original images. Tumor vessels were visualized over 85% using MRA. CONCLUSION: The VR method and Shading process were useful for evaluation of arteries. The MIP method was useful for evaluation of the portal vein. Original images were useful for evaluation of the hepatic veins. Contrast-enhanced MRA of the epigastric and hepatic regions was clinically quite useful in that it permitted evaluation of all vessels including arteries, portal vein and other veins throughout the liver as well as evaluation of tumor vessels.