Predictable closure of the abdominoperineal resection defect: a novel two-team approach.

BACKGROUND: Primary closure of the perineum at the time of abdominoperineal resection (APR) is seldom successful. Several factors are known to adversely affect healing, including neoadjuvant chemoradiation, tension, contamination, and fluid collection. This study evaluates a 2-team approach for resection and routine perineal closure in a single stage. STUDY DESIGN: After tumor resection, the abdominal and perineal closures are performed simultaneously by 2 separate teams. A competent closure of the perineal defect is achieved with bilateral V-to-Y inferior gluteal artery perforator fasciocutaneous flaps (BIGAP) mobilizing buttock skin, fat, and gluteal muscle fascia for inset into the defect. No muscle is elevated with the flaps and no attempt is made to obliterate the deepest aspects of the pelvic defect. RESULTS: Beginning in August 2010, 18 consecutive patients who underwent APR for distal rectal (n = 14) and anal carcinoma (n = 4) were included in the study. All patients had received neoadjuvant chemoradiation therapy. Primary healing was achieved in 16 of 18 patients with a completely tension-free closure. One patient required debridement and secondary closure. Another patient had an unresectable tumor, which invaded the flap closure. Minor healing problems were seen in 7 patients. CONCLUSIONS: BIGAP flaps provide sufficient tissue to predictably provide primary closure of the perineal defect. Perineal wound healing morbidity is dramatically reduced compared with primary simple closure of this defect. Early results indicate that this method of perineal closure offers a straightforward and predictable method that is comparable in efficacy to other methods using pedicled flaps for perineal closure.

Integra acellular collagen as a vascular carrier for skin flap prefabrication in rats.

In this study, the feasibility of Integra acellular collagen used as a vascular carrier in skin flap prefabrication was examined. In all, 20 Sprague--Dawley rats were randomly divided into 3 groups. The saphenous vascular bundle was used as the vascular carrier. In group 1 (n = 8), an arteriovenous fistula was made by anastomosis of distal saphenous artery and vein. An Integra patch (2 × 3 cm²) was placed underneath the vascular bundle. In group 2 (n = 6), an Integra patch was placed on the top of the saphenous vessels, which remained intact. In group 3 (n = 6), an arteriovenous fistula was made without Integra implant. Two weeks after the initial management, a skin flap (2 × 3 cm² in size) was raised and replaced in each group. The survival of the flaps and histology were evaluated at 7 days after flap replacement. The results showed that the average survival area in group 1 was 98% ± 2%. No flap survival was observed in group 2. The mean survival area in group 3 was 29% ± 6%. The differences among all 3 groups were significant (P < 0.05). Although the mean survival area in group 3 was significantly lower than that in group 1 (P < 0.001), it was significantly higher than that in group 2. Histology showed that the Integra patch was incorporated into the adjacent connective tissue, and increased amounts of neovascularization were seen between the collagenous sheets and dermis in group 1. In conclusion, this study demonstrated that Integra acellular collagen can incorporate into the adjacent tissue as a vascular carrier and induce angiogenesis in flap prefabrication. This biomaterial can provide a scaffold for supporting and enhancing the survival of a vascular prefabricated skin flap. The results indicate that this material is an ideal biomaterial for flap prefabrication and may be used for this clinical purpose in the future.

The aesthetic correction of the ptotic breast by the procedure of nipple-areola transposition - a contemporary translation and commentary.

'No vertical scar' techniques of breast shaping have received increasing attention during the last decade and are sometimes viewed as 'new' methods. In this article, we provide a comprehensive introduction to the roots of this procedure. Raymond Passot has to be credited with the original design of 'no vertical scar' methods. We provide a contemporary translation of his original article written in French in 1925. The historical context of this new procedure was researched using original sources that were in French and German languages. The evolution of the procedure and its reception by Passot's contemporaries up to 1932 are examined, which give insight into the concepts of blood supply to the breast, shaping techniques and the aetiopathology of breast deformities in the pre-World War II era, which were successfully developed by the Austrian-German school of thought, resulting in the birth of modern breast shaping surgery based on Passot's 'no vertical scar' procedure. The lasting truths discovered in that era were frequently reinvented in the subsequent decades in English without crediting the original authors.