Partial Gluteus Muscle Flap for Treatment of Chronic, Recalcitrant Pilonidal Cyst Disease.

Background: Pilonidal cyst disease is a challenging condition requiring excision and wound management when it is chronic and symptomatic. Primary closure of the excision site can lead to high recurrence rates, necessitating flap-based reconstruction. This article discusses the use of a partial gluteus maximus muscle flap to address recurrent pilonidal disease and reduce its recurrence. Methods: From 2014 to 2021, 11 patients aged 14-31 with recurrent pilonidal cysts underwent two-stage surgery involving excision and wound debridement by general surgery, followed by plastic surgery for wound closure using the partial gluteus muscle flap. Results: Eleven patients were included in the study (four women and seven men). The mean age was 23 ± 5.2, and the average body mass index was 28.59 (±6.7). The mean number of previous procedures was 2.25 (range, 2-3). Operative time was 158.7 ±â€…37 minutes. The average length of stay when both procedures were done in the same admission was 8 ± 6 days (range 3-21 days) and when procedures were done separately, the length of hospital stay after the wound closure using a partial gluteus muscle flap was 3 days, and the range for reliable follow-up was 1.6-7 years postoperatively. In our study cohort of 11 patients, the majority, specifically seven individuals, experienced uneventful healing. However, a subset of patients encountered complications. Three patients developed an infection recurrence: one was treated conservatively, and one required reoperation with resolution of symptoms, and one patient also experienced wound dehiscence, which was closed with a small procedure. Conclusion: Partial gluteal muscle flap offers a promising approach for treating recalcitrant, difficult-to-treat pilonidal disease in young adults, enhancing wound healing and reducing the risk of recurrence.

Treatment of Intrathecal Drug Pump Flipping Using Fascial Flaps: A Technical Description and Case Series.

BACKGROUND AND OBJECTIVES: Intrathecal drug therapy is a common treatment for dystonia, pain, and spasticity using implanted pump and catheter systems. Standardized management of intrathecal drug pump (ITDP) migration and flipping has not been well established in the literature. This study reports the use of soft tissue to address less common pump complications such as pump flipping, migration, and difficulty in medication refill. METHODS: A retrospective chart review of intrathecal pump cases performed by two surgeons between February 2020 and August 2022 was conducted. Patients with complications such as pump flipping, migration, or challenges in medication refill treated with soft tissue flaps were included. Patient demographics, comorbidities, and perioperative data were collected. RESULTS: A total of five patients with ITDP complicated by pump flipping, migration, malposition, or difficulty in medication refill that were treated using fascial flaps were included in the study. Three technical considerations when revising ITDP complications are secure pump anchoring, reliable wound closure, and ease of pump medication refill. Cases 1 and 2 demonstrate the technique of secure pump anchoring with a rectus fascial flap. Cases 3 and 4 show a technique to achieve reliable vascularized wound closure, and case 5 describes a technique to solve an uncommon problem of a thick subcutaneous abdominal tissue preventing the refill of the ITDP medication. CONCLUSION: Soft tissue flaps may serve as a treatment option for patients with uncommon ITDP complications. De-epithelialized dermal fasciocutaneous or fascial flaps may be developed to anchor the pump more securely. Cross-discipline collaboration may further delineate the technique, benefits, and outcomes of this approach.

Internal iliac artery aneurysm masquerading as a sciatic nerve schwannoma: illustrative case.

BACKGROUND: Schwannomas are common peripheral nerve sheath tumors. Imaging techniques such as magnetic resonance imaging (MRI) and computed tomography (CT) can help to distinguish schwannomas from other types of lesions. However, there have been several reported cases describing the misdiagnosis of aneurysms as schwannomas. OBSERVATIONS: A 70-year-old male with ongoing pain despite spinal fusion surgery underwent MRI. A lesion was noted along the left sciatic nerve, which was believed to be a sciatic nerve schwannoma. During the surgery for planned neurolysis and tumor resection, the lesion was noted to be pulsatile. Electromyography mapping and intraoperative ultrasound confirmed vascular pulsations and turbulent flow within the aneurysm, so the surgery was aborted. A formal CT angiogram revealed the lesion to be an internal iliac artery (IIA) branch aneurysm. The patient underwent coil embolization with complete obliteration of the aneurysm. LESSONS: The authors report the first case of an IIA aneurysm misdiagnosed as a sciatic nerve schwannoma. Surgeons should be aware of this potential misdiagnosis and potentially use other imaging modalities to confirm the lesion before proceeding with surgery.

Parastomal Hernia Repair Using a Silo Biologic Mesh.

BACKGROUND: A parastomal hernia (PSH) is an enlargement of the stoma's original opening through the abdominal wall's musculature around a colostomy, ileostomy, or urostomy. Its incidence can be up to 48%. The described methods for its repair have high recurrence rate.This article presents a 3-dimensional silo technique for PSH repair (PSH-R). The aims of this technique are to enhance the structural strength of the tunnel wall, to reinforce both the sidewalls and the fascia above and below the muscular opening, and to maintain a stable stoma opening. METHODS: All consecutive patients undergoing PSH-R with the silo technique between January 2009 and May 2018 by 2 plastic surgeons were included. The outcome parameters of interest were hernia recurrence and wound-related complications. RESULTS: This study reports 22 patients (9 male, 13 female) with a mean age of 66.7 years and an average body mass index of 29.2. The variety of ostomy types included 10 colostomies, 7 ileostomies, and 5 urostomies. Postoperatively, there were 3 surgical site infections, 1 seroma, and 2 wound healing delays. Six patients were readmitted, 3 of those because of small bowel obstruction. These 3 cases all required reoperation, in addition to 1 operative revision for stoma retraction. During our average follow-up of 19.9 months, 3 cases of PSH recurrence were diagnosed for a recurrence rate of 13.6%. CONCLUSIONS: This silo technique is associated with favorable complication and low recurrence rates compared with the available techniques in surgical literature. In our practice, it has established itself as a new and safe technique for complex or recurrent PSHs and should be considered in a surgeon's armamentarium. This technique has become our standard for treatment of recurrent PSHs.

Immediate Soft-Tissue Reconstruction for Chronic Infected Tibia Nonunions Treated with an Ilizarov Frame.

There are multiple options available for the management of large tibial defects. The Ilizarov frame is one of the most widely used techniques due to the physiological bone growth and the symmetrical distribution of axial forces permitting adequate bone distribution. However, disadvantages still remain including obtaining additional soft-tissue access for defect coverage. We present our experience with soft-tissue reconstruction for chronic infected tibial nonunions using free tissue transfers simultaneously with Ilizarov device placement. A retrospective review was performed from 2014 to 2016 of patients presenting with a chronically infected tibia nonunion and treated by our senior orthopedic and plastic surgeons. Demographic data, comorbidities, intraoperative details and postoperative outcomes were collected. A total of 6 patients were identified with a mean age of 46.2 ± 11.6 years. Complete flap survival and resolved active infection were achieved in 5 of our patients, 4 demonstrated body union on imaging, and all of them reached complete ambulance. Flap revisions with allografting for partial flap loss were performed in 1 patient. Preoperative planning is critical for immediate lower extremity reconstruction in the setting of an Ilizarov frame. From our institutional experience, free tissue transfer can safely be placed after frame placement.

Impact of Metabolic Syndrome on the Morbidity and Mortality of Patients Undergoing Panniculectomy.

BACKGROUND: Metabolic syndrome (MetS) is defined as the concomitant disease process of obesity and at least two of the following variables: diabetes, hypertension, hypertriglyceridemia, or reduced high-density lipoprotein. These entities are well established as risk factors for complications following surgery. Obese patients are particularly prone to the development of MetS. The authors therefore aimed at elucidating the impact of MetS on the perioperative panniculectomy outcomes. METHODS: The American College of Surgeons National Surgical Quality Improvement Program database was analyzed for all primary procedures of panniculectomy from 2010 through 2015. The cases were stratified based on the presence or absence of MetS and evaluated for demographic data, intraoperative details, and their morbidity and mortality within 30 days after surgery. RESULTS: A total of 7030 cases were included in this study. Patients with MetS (6.2%) were of significantly worse health, required more emergency admissions (p = 0.022), longer hospitalization (p < 0.001), and more frequently inpatient procedures (p < 0.001) compared to the control group without MetS (3.8%). Plastic surgery was the predominant specialty operating on 79.5% of all cases. Surgical (23.3 vs. 8.7%) complications, readmission (8.7 vs. 3.0%), and reoperations (6.9 vs. 3.1%) rates were all significantly higher in patients with MetS that those without (p < 0.001). One fatality occurred in each cohort (0.23 vs. 0.02%, p = 0.010). CONCLUSION: Comorbidities are not uncommon in patients undergoing panniculectomy, especially in those diagnosed with MetS. Health-care providers need to be aware of the increased morbidity and mortality in this high-risk subgroup and need to consider preoperative optimization and management before proceeding with surgery. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Techniques for labia minora reduction: an algorithmic approach.

BACKGROUND: Aesthetic reduction of the labia minora has gained popularity, and a number of different techniques have been described. Each procedure has its own set of advantages and disadvantages. However, no algorithm has been defined for pairing the degree of deformity with the optimal surgical procedure. METHODS: Patients were stratified into one of four groups based on labial size. The surgeon chose one of three reduction techniques based on the degree of labial hypertrophy and the patient's aesthetic preferences for labial edge color and contour. Three reduction techniques were used including the edge excision technique, the inferior wedge resection technique, and deepithelialization reduction labioplasty. The success of aesthetic reduction was evaluated, as was symptomatic relief. RESULTS: The 12 procedures performed included five deepithelialization techniques, four edge excision techniques, and three inferior wedge resection techniques. As reported, 92% of the patients were "very satisfied" with their aesthetic and functional results. The complications were minimal, with three patients experiencing minor wound healing difficulties that resolved spontaneously. One patient who underwent the edge excision technique was "not satisfied" and complained of overreduction. CONCLUSION: The authors found all three techniques for labia minora reduction to be useful in different clinical situations. A novel algorithm is described for matching the optimal surgical technique for each patient based on her degree of hypertrophy and aesthetic goals.

Vesicoacetabular fistula in a chronically infected total hip arthroplasty.

Fistula formation between the bladder and acetabulum related to total hip arthroplasty (THA) is rare, and few cases have been documented. Common features of the reported cases include a defect in the medial wall of the acetabulum, a chronically infected THA, a history of bladder injury, vesicocutaneous fistulas, and a history of pelvis radiation exposure. We report the case of a vesicoacetabular fistula discovered during antibiotic spacer placement in a woman with a chronically infected THA. The patient received bilateral ureteral stents extending from the renal pelvis to the urethra. Three months later, the patient was free of infection and was able to undergo reimplantation arthroplasty.

Asian blepharoplasty.

One of the defining features between an individual of Asian descent and someone of Western descent is the presence of an upper eyelid crease. Approximately 50% of Asians do not have an upper eyelid crease. The double eyelid operation, or creation of a supratarsal crease, is the most common cosmetic procedure requested in Asia and the third most common procedure requested by Asian Americans. In this comprehensive article, we explore the art of creating an eyelid crease in the individual who either does not have a crease or has an indistinct crease. We will review the history of the development of Asian blepharoplasty, explain the anatomy of the Asian eyelid and how it differs from the Caucasian eyelid, and clarify how this anatomy then translates to differences in external appearance. The two main schools of surgical techniques will be discussed along with pearls, pitfalls, and personal observations.

Plastic surgery management in pediatric meningococcal-induced purpura fulminans.

Purpura fulminans associated with meningococcemia is a devastating disease in children. The tissue loss can be extensive and difficult to determine at the outset. The authors suggest a strategy to manage these wounds with the goal of preserving as much tissue and function as possible. At the present time, conservative therapy to the wounds appears to be the best course in the initial, critical phase, as long as no active local purulence is found. Debridement or amputation is performed when the nonviable tissue margins are delineated. Temporary coverage with allograft may be required; definitive coverage is accomplished when the local tissue perfusion has recovered. Future revisions are often necessary to improve these children's quality of life.

Ulceras diabeticas del pie / Diabetic foot ulcers

Como los diabeticos viven hoy en dia hasta una edad mayor, son mas sensibles a las complicaciones de su enfermedad. Las ulceras del pie se han covertido en un problema importante para estos pacientes, cuya mejor solucion es la prevencion mediante educacion. Cuando se presentan las ulceras, se debe actuar con base en los principios y metodos de tratamiento que aceleran la cicatrizacion. Un tratamiento idoneo de las ulceras diabeticas del pie con frecuencia puede salvar la extremidad o, como minimo, devolverle al paciente la ambulacion y la independencia