The foot fillet flap for ischial pressure sore reconstruction: A new indication.

INTRODUCTION: The main cause of ischial pressure sores in paraplegic patients is prolonged sitting without pressure relief. These wounds are subject to recurrence and may need repeated reconstruction with local flaps. When all options are exhausted, the total thigh flap is the last resort. Disarticulation of the hip joint impairs stability even when sitting and causes subsequently very high discomfort. In this manuscript, we describe an alternative to the total thigh flap to avoid hip disarticulation: the foot fillet flap. MATERIALS & METHODS: This study was performed on four patients at the department of Plastic & Reconstructive Surgery of the Ghent University Hospital, Belgium. Inclusion criteria were the following: paraplegic patients affected by recurrent pressure sores, exhaustion of all local options and adequate vascular status of the lower extremities. RESULTS: All patients were kept in an air-fluidized bed for two weeks and progressed well during their post-operative course. Healing time varied from 12 to 29 days and suction drains were removed after 15 days as in any standard pressure sore flap. Hospital stay varied from 18 to 42 days. CONCLUSION: The pedicled foot fillet flap is a valuable alternative to the total thigh flap. Coverage of large, recurrent, pressure sores in the ischial, trochanteric or sacral region is ideal due to the thick glabrous plantar skin, shock-absorbing fibrofatty subcutaneous tissue and underlying muscles provided by the sole of the foot. Furthermore, coxofemoral disarticulation, mandatory in a total thigh flap, that leads to instability while sitting, is avoided.

Reconstruction of the face with skin-grafted muscle flaps: optimizing the aesthetic outcome.

BACKGROUND: Cutaneous facial defects repaired with perforator or fasciocutaneous flaps do not always give optimal aesthetic results due to excess bulk and colour mismatch. The authors present their experience in reconstruction of cutaneous facial defects with skin-grafted free muscle flaps. MATERIALS AND METHODS: From May 2004 to May 2006, 9 serratus anterior, 2 gracilis and 1 vastus lateralis skin-grafted free muscle flaps were used on 12 patients, after cancer excision in 11 cases and after hardware exposure in 1 case. Full thickness skin grafts were taken from the supraclavicular skin in 3 cases, from the groin in 1 case and from the muscle donor site in 8. RESULTS: No major complications were observed. Results were excellent in terms of contour and colour match. In the elderly, FTSGs taken from the muscle harvesting incision seem to eventually make a good colour match with the facial skin. No relevant donor site morbidity was observed with the muscles used in this series. CONCLUSIONS: In the search for good aesthetic results in facial skin reconstruction, skin-grafted muscle flaps permit optimal contour and colour match to be achieved with little donor site morbidity and a shorter operating time.

Posterior compartment of the lower leg reconstruction with free functional rectus femoris transfer after sarcoma resection.

A 72-year-old man with the third recurrence of a low-grade liposarcoma of the right lower leg came to our attention seeking limb-salvage surgery. The tumour was removed en bloc with all the superficial posterior compartment of the leg. Appropriate foot flexion was restored by means of a free-functional rectus femoris musculocutaneous flap harvested from the ipsilateral thigh. The patient was kept on a postoperative splint for 6 weeks. Three months after the operation, clinical and elecromyographic signs of reinnervation were observed. The patient was able to walk, run and climb stairs and no donor-site morbidity was observed. Thigh extension was rated M4, comparable to the contralateral thigh. Foot flexion, without any postoperative exercise, was rated M3 with a 30 degrees excursion. To the best of our knowledge, this is the first report of reconstruction of the posterior compartment of the leg r with a free functional rectus femoris flap. We believe this muscle could be the ideal option for such reconstruction.

Free style facial artery perforator flap for one stage reconstruction of the nasal ala.

UNLABELLED: The nasolabial skin is the ideal donor site for nasal ala reconstruction. The classic techniques involve a two-stage procedure to reconstruct an aesthetically pleasing nasal ala. A one-stage technique for reconstruction of the nasal ala with a free style nasolabial perforator flap is presented in this article. PATIENTS AND METHODS: The technique has been used in eight patients between November 2004 and June 2007. In most of the cases (seven out of eight) the whole alar subunit was reconstructed. RESULTS: Besides a small distal 2mm necrosis in one flap--which healed without further treatment--all the flaps healed uneventfully with aesthetically pleasing results using the one-stage technique. CONCLUSIONS: The free style perforator nasolabial island flap has become the method of choice in the authors' institution for nasal ala reconstruction, especially when the defect involves the whole subunit. It allows one-stage reconstruction with very similar tissue and a concealed scar in the natural groove.

Retroauricular skin: a flaps bank for ear reconstruction.

BACKGROUND: The retroauricular skin has always been given much attention by the reconstructive surgeon for ear and face reconstruction because it is richly vascularised, as many anatomical investigations show, it is hidden behind the ear, its skin is very similar to that of ear and face. All these reasons make it an ideal donor site for ear reconstruction. The authors propose their own algorithm for reconstruction of every kind of anterior defects of the auricle with different Retroauricular Island Flaps (RIFs) based on the location and size of the defect developed over a 16 years single institution's experience with a series of 216 consecutive cases. MATERIALS AND METHODS: 216 patients have undergone ear reconstruction with RIFs from 1999 to 2006. In 52 a Superior Pedicle RIF (SP-RIF) was used for defects of the upper half of the auricle. In 68 cases a Perforator RIF (P-RIF) was used for conchal reconstruction. In 96 cases an Inferior Pedicle RIF (IP-RIF) was used for reconstruction of nonmarginal and superficial marginal defects of the auricle. RESULTS: No flap failure was recorded. Excellent morphological reconstruction was obtained with these flaps with no sequealae at the donor site in terms of form and function. Only in the case of P-RIFs the sulcus becomes flat in its central part, but this has never affected the possibility of wearing spectacles. The SP-RIFs may sometimes show some signs of venous stasis that invariably resolve in the first two postoperative days. CONCLUSIONS: The retroauricular skin may be considered a flaps bank for ear reconstruction. It offers in fact a great variety of island flaps that are suitable for every kind of loss of substance of the ear, have a safe vascularisation, skin of similar colour and texture, are easy to harvest under local anaesthesia on an outpatient basis and cause no relevant morbidity at the donor site. Location and size of the defects lead the choice between the different types of RIFs.

Further application of the bilobed flap: the split bilobed flap for reconstruction of composite posterior auricular and mastoid defects.

In this article a modified bilobed flap from mastoid and lateral neck skin for reconstruction of complex defects of the posteromedial surface of the auricle and mastoid skin, with the preservation of the retroauricular sulcus, is described. Reconstruction of the postero-medial auricular surface has almost never been a concern for reconstructive surgeons. It is in fact a shaded area with little aesthetic relevance and direct closure, skin grafting and even secondary healing are used for skin cancer defects repair. Also mastoid skin defects can be repaired with simple techniques such as skin grafts or transposition flaps from the remaining mastoid skin or from the neck. On the other hand, cancers involving the postero-medial auricular surface, the retroauricular sulcus and the mastoid skin require wide and deep resections that involve the posterior auricular muscles and reach the perichondral and periosteal surfaces. Direct closure with undermining, if feasible, will obliterate the retroauricular sulcus causing asymmetry with the contralateral ear and, if defects are cephalad will impair the possibility of wearing spectacles, thus leaving functional and aesthetic impairment. Transposition flaps from the remaining mastoid skin, due to the lack of skin laxity, are not feasible because the donor site cannot be closed. Two patients, both affected by basal cell carcinoma involving the posteromedial auricular surface and the mastoid skin have been treated with this flap. In both cases the use of the modified bilobed flap described in this article allowed preservation of the retroauricular sulcus and closure of the donor site. Scars were hidden along minimal tension lines and the possibility of wearing spectacles along with sensitivity all over the reconstructed area were maintained.

An innervated retroauricular skin flap for total earlobule reconstruction.

In this article, the authors describe a technique for total earlobule reconstruction in a patient who underwent earlobule excision for basal cell carcinoma. The reconstruction was by means of an innervated retroauricular skin flap, folded double. The flap presented preserved skin sensitivity over all the reconstructed area, which is compromised by those techniques using a cranially or medially based flap which lead to the reconstruction of an insensible earlobule. This is a very important aspect of this technique, especially for those who wear pendant earrings, since a non-sensitive lobule would be more vulnerable to traumas causing laceration. In addition, it allows a good aesthetic result without evident donor site scars. Further investigation is needed to decide if this method is suitable for other types of total earlobule loss (e.g. congenital, traumatic), or not.

Thalassaemic men affected by erectile dysfunction treated with transurethral alprostadil: case report.

The aim of this controlled clinical study, performed in a specialized institutional unit for thalassaemic men, was to consider the possibility of restoring erection in beta-thalassaemic patients with erectile dysfunction by administering E(1) prostaglandins (alprostadil) transurethrally. Four patients affected by beta-thalassaemia, aged between 32 and 52 years, and having an erectile dysfunction were included in the study. Each patient was given 500 microg alprostadil in the distal urethra. Response was evaluated by the erection assessment scale. The main outcome measures were: (i) the clinical study; (ii) FSH, LH, total and free testosterone plasma concentrations; and (iii) basal and dynamic Doppler sonography of cavernous arteries. The treatment produced a response of 3-4 on the erection assessment scale. Average minimum response time was 20 min, while average maximum response time was about 60 min. There was no evidence of significant side effects. Our hypothesis is that the delayed reaction was due to organ damage induced by iron load, causing a reduction or absence of elasticity in the interstitial tissue of the corpora cavernosa. Thus, we believe that treatment with alprostadil can be considered an effective, non-invasive therapy for thalassaemic patients with erectile dysfunction.