First-line treatment of deep sternal infection by a plastic surgical approach: superior results compared with conventional cardiac surgical orthodoxy

A majority of cardiac surgeons manage deep sternal infection with sternal wound debridement, rewiring, and closed drainage, with or without antibiotic saline tube irrigation (the traditional approach). The authors' experience with the traditional approach was unsatisfactory; therefore, they undertook a radical change in management: an immediate plastic surgical approach. Hence, deep sternal infection was managed by immediate debridement followed by a bilateral pectoralis major myocutaneous advancement flap with greater omental transposition (PMOFR). This is the first such study reporting the effect of this strategy on the rate of eradication of deep sternal infection, intensive care unit stay, total hospital length of stay, major complications, mortality, intermediate survival, and patient satisfaction, as compared with the traditional approach used by cardiac surgeons at the authors' institution.All patients who developed a deep sternal infection from 1993 through 1998 at a tertiary teaching hospital were included. In the PMOFR group (nine patients), after a diagnosis of clinical sternal wound infection, debridement was performed immediately, either if sternal dehiscence occurred or in the absence of clinical dehiscence, if the patient or the sternotomy wound did not clinically improve with medical therapy within 48 hours from suspected diagnosis. Open irrigation and packing for 2 to 4 days was followed by treatment with a PMOFR. In the group treated using the traditional approach (12 patients), no predetermined plan was present. Thus, at the cardiac surgeon's discretion, wound debridement was undertaken, followed by closed drainage (three patients), closed tube irrigation (six patients), and open granulation with delayed plastic surgery (three patients).The incidence of major complications (PMOFR, 22 percent; traditional approach, 92 percent; p = 0.001), intensive care unit readmission (PMOFR, 0 percent; traditional approach, 58 percent; p = 0.005), total hospital length of stay (PMOFR, 32 days; traditional approach, 79 days; p = 0.001), reoperation rates (PMOFR, 0 percent; traditional approach, 100 percent; p = 0.001) and in-hospital 30-day mortality rate (PMOFR, 0 percent; traditional approach, 33 percent; p = 0.05) were superior in the PMOFR group. At a mean follow-up of 2 years, freedom from recurrence of the infection (PMOFR, 100 percent; traditional approach, 11.5 percent; p = 0.005) and overall survival rate (PMOFR, 100 percent; traditional approach, 50 percent; p = 0.005) were also superior with PMOFR. A majority of patients in the PMOFR group (90 percent) had no functional or cosmetic complaints secondary to the procedure.A predetermined plan of immediate debridement followed by treatment with PMOFR rapidly, reliably, and effectively eradicated deep sternal infection. This translated to reduced length of stay and need for additional surgery, improved survival, and excellent intermediate freedom from deep sternal infection, with minimal patient dissatisfaction. The traditional approach to managing deep sternal infection was thus abandoned.     

Use of the SpaceMaker balloon in sternal wound closure: comparison with other techniques.

Sternal wound infection is surgically treated by debridement of the infected sternum and closure of the defect with a muscular flap. These operations tend to be long, stressful, and time-consuming and to involve heavy blood loss. To facilitate wound closure, the SpaceMaker balloon was applied intraoperatively to expand the pectoralis major muscles and enable tensionless closure with musculocutaneous flaps. The aim of the present study was to compare the effectiveness and feasibility of this technique with a variety of others described in the literature. The study population consisted of 40 consecutive patients with sternal wound infection following median sternotomy who were treated with the advancement flap, turnover flap, transposition flap, or SpaceMaker balloon-assisted advancement flap technique (n = 10 each). The balloon-assisted technique was associated with a shorter length of operation and fewer blood transfusions than the other methods. Furthermore, there was no need for reoperation and there were no cases of skin necrosis. In conclusion, closure with the SpaceMaker balloon-assisted bilateral pectoralis major musculocutaneous flap may serve as an adjunctive measure in the treatment of sternal wound infection. This technique seems to have advantages over simple pectoralis major musculocutaneous advancement, particularly for midsternal wounds.     

Reconstruction of infant thoracic wounds

From 1985 through 1987, five of eight infants with thoracic wounds at Yale-New Haven Hospital underwent chest-wall reconstruction. In total, the eight infants underwent 17 procedures (including multiple open resuscitations) exclusive of the reconstructive operations. Patients undergoing reconstruction ranged from 1 to 10 months of age and 3 to 7 kg in weight. All reconstructed patients underwent bilateral pectoralis major advancement flaps, with three of the five patients each requiring the simultaneous use of a rectus abdominis flap. With 2 to 18 months of follow-up, healing was complete in all five of the reconstructed patients, with two prosthetic pulmonary-systemic shunts and two outflow tract patches thus salvaged. These patients were found to be distinct from their adult counterparts, with special critical care requirements and expectedly delicate muscular anatomy. The gratifying results now expected in adults with sternal wound complications can be achieved in their infant counterparts. Furthermore, the group of patients whose chests cannot initially be closed owing to resultant cardiac compression may look to sternocostal debridement and flap reconstruction as a means of not only achieving wound closure, but of effectively increasing their mediastinal volume and compliance. Questions about skeletal development remain unanswered and demand further follow-up.     

Management of sternal wounds with bilateral pectoralis major myocutaneous advancement flaps in 114 consecutively treated patients: refinements in technique and outcomes analysis

Because life-threatening sternal wound complications can occur following sternotomy, the optimal management of sternal wound infections remains an important topic. To decrease morbidity following operative treatment of these patients, the authors made a number of refinements in their treatment protocol over the past several years, particularly with regard to the extent of débridement, method of flap apposition, and management of drains. The purpose of this study was to obtain specific outcomes data by reviewing a large series of patients treated by a single surgeon. In this series of 114 consecutive sternal wounds treated by the senior author (Ascherman), patients were managed almost exclusively with débridement and immediate closure with bilateral pectoralis major myocutaneous advancement flaps. There were no intraoperative deaths. The 30-day perioperative mortality rate was 7.9 percent, with only one death directly related to sternal infection. Nineteen patients (16.7 percent) experienced postoperative morbidity, including partial wound dehiscences (5 percent), skin edge necrosis (5 percent), and seromas (3.5 percent). The authors advocate single-stage management of complicated sternal wounds with immediate débridement and bilateral pectoralis major myocutaneous advancement flaps. The procedure is rapid and effective. Refinements in technique have significantly lowered morbidity.     

Internal fixation of the sternum in median sternotomy dehiscence.

Sternal dehiscence may be defined as separation of the bony sternum and manubrium following median sternotomy. It may occur at any time postoperatively and has various etiologies. Restoration of sternal integrity in sternal dehiscence is a challenging problem, particularly when associated with deep-seated infection. This report reviews a single-stage technique that virtually eliminates the infected sternotomy wound and provides anatomic reduction and stabilization of the sternum. Complete debridement of infected and/or nonviable soft tissue, bone, and cartilage is followed by pulse irrigation. Parallel stainless steel mandibular reconstruction plates are then placed on each side of the remaining sternum and wired together. One or more transmanubrial compression plates may be added. Bilateral pectoralis major musculocutaneous flap advancement and primary skin closure is performed over two to three closed suction drains. From January of 1994 to July of 1996, this technique was used by the same surgeon in 26 male and 4 female patients aged 43 to 78 years (mean = 61). Indications for the operation were sternal dehiscence with infection (osteomyelitis and/or mediastinitis) in 14 patients and sternal dehiscence without infection in 16 patients. All patients survived to discharge with mean time on the ventilator, intensive care unit length of stay, and postoperative length of stay of 0.7, 2, and 8 days, respectively. Choice and duration of antibiotics were based on culture results and operative findings. Subsequent hardware removal was necessary in one patient for hardware loosening and three patients for late periplate infection. A closed wound was eventually achieved in all 30 patients, and sternal stability was restored in 29 patients. In the management of sternal dehiscence, the described technique of internal fixation can provide anatomic sternal reduction and stabilization, elimination of infection, and wound closure in a single-stage operation. Successful outcomes were achieved despite the presence of severe infection.     

Vacuum-assisted closure in the treatment of sternal wound infection after cardiac surgery

Aim: Vacuum-assisted closure (VAC) was primarily designed for the treatment of pressure ulcers or chronic, debilitating wounds. Recently, VAC has become an encouraging treatment modality for sternal wound infection after cardiac surgery, providing superior results to conventional treatment strategies. Methods: From November 2004 to September 2006, 34 patients, undergoing VAC therapy for sternal wound infection following cardiac surgery, were prospectively evaluated. Ten patients (29 %) were treated for superficial sternal wound infection and 24 (71 %) for deep sternal wound infection. The median age was 69.9 years (range 48 to 82) and the median BMI was 33.4 kg/m(2) (range 28 to 41). Twenty patients (59 %) were women and 19 patients (59 %) were diabetics. Owing to sternal wound infection complications, 16 patients (47 %) were readmitted to the department. VAC was used following the previous failure of the conventional treatment strategy in 7 patients (21 %). Results: Thirty-three patients (97 %) were treated successfully. One patient (3 %) died of multiple organ failure. The overall length of hospitalization was 34.6 days (range 9 to 62). The median number of dressing changes was 4.6 (range 3 to 10). The median VAC treatment time until surgical closure was 9.2 days (range 6 to 21 days). VAC therapy was solely used as a bridge to definite wound closure. Three patients (9 %) with chronic fistula were re-admitted 1 to 6 months after VAC therapy. Conclusions: VAC therapy is a safe and reliable option in the treatment of sternal wound infection in cardiac surgery. VAC therapy should be considered an effective adjunct to conventional treatment modalities for the treatment of extensive and life-threatening wound infections following cardiac surgery, particularly in the presence of risk factors.     

Primary treatment of the infected sternotomy wound with muscle flaps: a review of 211 consecutive cases

Between 1978 and 1987, 15,595 median sternotomies were performed at Emory University Hospitals. Sternal wound infections developed in 246 patients (1.6 percent). Mediastinitis was present in 211 patients, while superficial infections were detected in the remaining 35 patients. Debridement and muscle or omental flap closure were performed in all instances of mediastinitis, with an overall mortality rate of 5.3 percent. The results of this treatment are reviewed, and the evolution of current therapeutic guidelines is described. When compared with closed-catheter irrigation and open granulation techniques, flap closure is shown to result in a fourfold decrease in mortality, an increased success of primary therapy, and a diminished length of hospitalization following treatment. This evidence supports the conclusion that debridement and flap closure should be considered the primary therapy for patients with poststernotomy mediastinitis.     

The integrated approach to suppurative mediastinitis: rewiring the sternum over transposed omentum

Acute mediastinitis after cardiopulmonary procedures remains a devastating complication and a challenge to the reconstructive surgeon. A review of the literature and our own experience confirm the need for early aggressive drainage followed by timely reconstruction. In carefully selected patients, the sternum may be reclosed, provided that omental tissue has been transposed into the defect between the myocardium and the posterior cortex of the sternum. The technique is outlined and the results are analyzed and compared with three additional patient subgroups: (1) sternal wounds rewired over drains, (2) sternal wounds rewired with drains and irrigation catheters, and (3) wounds closed by sternal excision and muscle-flap transposition. To date, nine omental transfers have been performed with complete success. Mediastinal drainage routinely ceases after 3 to 5 days, and hospitalization has averaged 10 to 14 days. Early open debridement allows establishment of drainage and permits close evaluation of the character of the bony sternum. Muscle flaps may then be used in those patients with multiply fractured or frankly necrotic sternal tissue, while sternal closure over omental flaps may be used in all other patients. Adherence to this protocol has allowed for bacteriologic control of the wound, minimal morbidity, and no mortality.     

Wound complications after median sternotomy: A study of 61 patients from a consecutive series of 9,279

Among a consecutive series of 9,279 sternotomies performed during a period of 2(1/2) years, 61 (0.66%) patients developed significant wound complications. Of these, 58 (95.1%) survived. Sternal infection occurred in 36 patients (0.39%). Predisposing factors included chronic obstructive pulmonary disease, diabetes mellitus, obesity, closed chest massage, prolonged assisted ventilation, and excessive bleeding after operation. Positive end expiratory pressure (PEEP) did not, in itself, predispose to sternal dehiscence. Intermittent positive pressure breathing (IPPB) treatments caused excessive coughing, which may have increased the likelihood of dehiscence. Disposable drapes and expeditious surgery probably contributed to the low incidence of wound infection. Early diagnosis, surgical debridement, rewiring and primary closure with substernal drainage, without continuous antibiotic irrigation, resulted in satisfactory resolution in most patients.     

Immediate closure of traumatic upper arm and forearm injuries with the latissimus dorsi island myocutaneous pedicle flap

This paper reports the authors' experience with latissimus dorsi island pedicle flaps in the acute treatment of massive arm injuries. Seven patients with upper arm injuries and four patients with forearm injuries were treated with latissimus dorsi pedicle flaps. All cases involved massive soft-tissue loss and open fractures. Primary healing of wounds occurred without complications in 10 of 11 patients; the eleventh developed a wound infection. There were no instances of flap loss or vascular complications. This report compares and discusses surgical management options and details the importance of robust, immediate soft-tissue coverage for optimal functional recovery. Contrary to traditional thought, delay in definitive wound closure may be unnecessary when aggressive debridement is followed by acute flap closure.     

First Evidence of Sternal Wound Biofilm following Cardiac Surgery

Management of deep sternal wound infection (SWI), a serious complication after cardiac surgery with high morbidity and mortality incidence, requires invasive procedures such as, debridement with primary closure or myocutaneous flap reconstruction along with use of broad spectrum antibiotics. The purpose of this clinical series is to investigate the presence of biofilm in patients with deep SWI. A biofilm is a complex microbial community in which bacteria attach to a biological or non-biological surface and are embedded in a self-produced extracellular polymeric substance. Biofilm related infections represent a major clinical challenge due to their resistance to both host immune defenses and standard antimicrobial therapies. Candidates for this clinical series were patients scheduled for a debridement procedure of an infected sternal wound after a cardiac surgery. Six patients with SWI were recruited in the study. All cases had marked dehiscence of all layers of the wound down to the sternum with no signs of healing after receiving broad spectrum antibiotics post-surgery. After consenting patients, tissue and/or extracted stainless steel wires were collected during the debridement procedure. Debrided tissues examined by Gram stain showed large aggregations of Gram positive cocci. Immuno-fluorescent staining of the debrided tissues using a specific antibody against staphylococci demonstrated the presence of thick clumps of staphylococci colonizing the wound bed. Evaluation of tissue samples with scanning electron microscope (SEM) imaging showed three-dimensional aggregates of these cocci attached to the wound surface. More interestingly, SEM imaging of the extracted wires showed attachment of cocci aggregations to the wire metal surface. These observations along with the clinical presentation of the patients provide the first evidence that supports the presence of biofilm in such cases. Clinical introduction of the biofilm infection concept in deep SWI may advance the current management strategies from standard antimicrobial therapy to anti-biofilm strategy.     

Reconstruction of the mediastinal trachea with a tubed pectoralis major myocutaneous flap

A young patient with a massive postirradiation recurrence of thyroid cancer invading the larynx and mediastinal trachea had been treated by resecting the larynx and trachea to within three rings of the carina. A mediastinal tracheostomy was avoided by using a tubed pectoralis major myocutaneous flap to replace the ablated trachea. The flap, transferred into the mediastinum subclavicularly, was connected to the tracheal stump and exteriorized as a cervical tracheostomy. This resulted in direct closure of the donor site and primary healing. Four years after the operation, the patient remains free of disease and is tolerating the neotrachea without difficulty or complications. The technique described is offered as an alternative to conventional mediastinal tracheostomy methods, which have acknowledged shortcomings.     

The role of local fasciocutaneous flaps in total burn wound management.

The majority of acute burn wounds or delayed reconstructions are best managed simply with a skin graft. However, if vascularized tissue is mandatory, the local fasciocutaneous flap may have an important role in providing a single-stage technique for obtaining tissue nearly identical in color, texture, and consistency to that of the defect being restored. This review of 182 consecutive burn patients needing surgery found that they underwent 233 separate episodes for skin grafting. Appropriately, only a fraction of this number required some form of vascularized flap, with 14 patients having 21 local fasciocutaneous flaps. Six were elevated in previously skin-grafted regions, which is an advantage peculiar to this flap type. Three flaps (14 percent) suffered major complications requiring a second surgical intervention. Only six of all flaps were used for acute burn wounds, but two of the three complications accrued in this subset, with one directly attributable to wound infection. Since most flaps were required for either coverage or release of contractures about joints, it has been recommended that the initial surgical approach for treatment of the acute wound in these regions be altered to preserve the fascial plexus whenever possible to permit the use of this simple and expedient alternative if it is needed later.     

Vacuum assisted closure for the treatment of sternal wounds: the bridge between débridement and definitive closure

A method to refine the treatment of sternal wounds using Vacuum Assisted Closure (V.A.C.) therapy as the bridge between débridement and delayed definitive closure is described. A retrospective review of 35 consecutive patients with sternal wound complications over a 2-year period (March of 1999 to March of 2001) was performed. The treatment of sternal wounds with traditional twice-a-day dressing changes was compared with the treatment with the wound V.A.C. device. An analysis of the number of days between initial débridement and closure, number of dressing changes, number and types of flaps needed for reconstruction, and complications was performed. Eighteen patients were treated with traditional twice-a-day dressing changes and 17 patients were treated with V.A.C. therapy alone. The two groups were similar regarding age, sex, type of cardiac procedure, and type of sternal wound. The V.A.C. therapy group had a trend toward a shorter interval between débridement and closure, with a mean of 6.2 days, whereas the dressing change group had mean of 8.5 days. The V.A.C. therapy group had a significantly lower number of dressing changes, with a mean of three, whereas the twice-a-day dressing change group had a mean of 17 (p < 0.05). Reconstruction required an average of 1.5 soft-tissue flaps per patient treated with traditional dressing changes versus 0.9 soft-tissue flaps per patient for those treated with V.A.C. therapy (p < 0.05). Before closure, there was one death among patients undergoing dressing changes and three in the V.A.C. therapy group, all of which were unrelated to the management of the sternal wound. Patients with sternal wounds who have benefited from V.A.C. therapy alone have a significant decrease in the number of dressing changes and number of soft-tissue flaps needed for closure. Finally, the V.A.C. therapy group had a trend toward a decreased number of days between débridement and closure.     

A new classification for the standardization of nomenclature in free flap wound closure

A profusion of terms are currently used to describe free flap wound closure. It is important to broadly standardize nomenclature when embarking on a comparison of functional outcomes between institutions. Therefore, a series of 68 "emergency" (within 24 hours) free flaps performed by a single surgeon were reviewed with respect to a total experience of 188 free tissue transfers to formulate a consistent nomenclature applicable to free flap wound closure in general. The nomenclature presented divides free flap closure into three categories: "primary free flap closure" (12 to 24 hours), "delayed primary free flap closure" (2 to 7 days), and "secondary free flap closure" (after 7 days). This system is analogous to the standard terms "primary," "delayed primary," and "secondary wound closure." It is consistent with known biologic and microbiologic principles of wound closure in general and should provide a simple basis for classifying free flap wound closure. Illustrative examples are presented to highlight the classification scheme.     

Operative management and outcome of complex wounds following total knee arthroplasty.

This study describes the treatment protocol for and the outcome of the management of complex wounds around total knee replacements. An analysis of 28 patients (29 knees) with complex defects who had surgery between January 1, 1986, and July 30, 1996, was performed. A specific management protocol was applied to each knee on the basis of the size and depth of the wound, the presence of infection, and the quality of soft tissue. Primary treatment included local wound care, debridement, and skin grafting or coverage with a fasciocutaneous flap, pedicled muscle flap, or free muscle transfer. Postoperatively, knees were evaluated using the Knee Society objective score. Successful salvage of the lower extremity was obtained in 28 knees (97 percent) and of the knee prosthesis in 24 of 29 knees (83 percent). Secondary plastic surgery procedures were necessary in five knees (17 percent), and secondary orthopedic procedures were necessary in four knees (14 percent). Successful salvage of total knee arthroplasty in the presence of a complex wound requires early identification of infection, aggressive irrigation and debridement, and early appropriate soft-tissue coverage. The use of our proposed algorithm will facilitate management of these complex wounds.     

Complications after reconstruction by plate and soft-tissue free flap in composite mandibular defects and secondary salvage reconstruction with osteocutaneous flap

Reconstruction of composite defects of the mandible is a challenging problem. Although the use of an osteocutaneous free flap, alone or in combination with another soft-tissue free flap, is generally accepted to be optimal, the bony reconstruction is sometimes undervalued, especially when the cancer is advanced. In such situations, reconstruction is often performed with a reconstruction plate covered with a soft-tissue free flap. Between January of 1997 and July of 2000, 80 patients with composite or extensive composite oromandibular defects underwent treatment with a reconstruction plate and a soft-tissue free flap. All of the patients were male, and the ages of the patients at the time of treatment ranged from 32 to 78 years (mean, 51 years). Tumors were classified as stage IV in 56 patients (70 percent), whereas the remaining 24 patients (30 percent) had recurrent carcinomas. The titanium mandibular reconstruction system manufactured by Stryker (Freiburg, Germany) was used to bridge the mandibular defects. The soft-tissue free flaps used for wound and plate coverage were as follows: anterolateral thigh flap (n = 75), radial forearm flap (n = 3), transverse rectus abdominis myocutaneous flap (n = 1), and tensor fasciae latae flap (n = 1). Five patients with recurrent carcinomas and 10 with stage IV carcinomas (18.75 percent) died 2 to 6 months after the operation and were excluded from the study. The remaining 65 patients were monitored for an average follow-up period of 22 months (range, 6 to 40 months). During that period, one or more complications occurred for 45 patients (69.2 percent). Plate exposure was the most common complication and was observed for 30 patients (46.15 percent). Twenty of the 65 patients (30.8 percent) required secondary salvage reconstruction with a fibula osteoseptocutaneous flap. The decision to perform a secondary salvage procedure was based on the general health of the patient, the extent of local disease, and the severity of the complications. Patients underwent salvage operations after an average of 11.5 months (range, 6 to 26 months). The major reasons for the second operation were as follows: reconstruction plate exposure (n = 12), soft-tissue deficiency and mandibular contour deformation of the lateral face (n = 7), intraoral contracture and lack of a gingivobuccal sulcus (n = 6), trismus (n = 4), and osteoradionecrosis of the mandible (n = 2). The total flap survival rate was 90 percent (18 of 20 free flaps). In two cases, the skin paddles of the fibula osteoseptocutaneous flaps exhibited partial failure and were revised with pedicled pectoralis major and deltopectoral flaps. The reconstruction plate and free soft-tissue flap procedure for the reconstruction of composite defects of the oromandibular region has many late complications, which eventually necessitate reconstruction of the mandible with an osteocutaneous free flap.     

Outcome of scalp donor sites in 450 consecutive pediatric burn patients

The scalp is a useful and reliable donor site in pediatric burn patients that can be multiply harvested with minimal morbidity. Healing complications, however, may include alopecia and chronic folliculitis. To investigate scalp donor-site morbidity, a consecutive series of 2478 pediatric burn patients treated over a 10-year period were reviewed. A total of 450 of these patients had scalp donor sites for wound closure. Percent of total body surface area burned was 46+/-23 percent (mean+/-standard deviation), and the mean number of sequential scalp donor-site harvests was 2.2+/-2 (range, 1 to 10) with mean intervals between harvesting of 6+/-0.6 days. Ten patients (2.2 percent) had related complications. Eight patients developed scalp folliculitis, with Staphylococcus sp as the predominant organism (80 percent). Two patients were managed successfully with wound care alone; the other six patients required surgical debridement and split-thickness skin grafting to achieve wound healing. These eight patients developed varying degrees of alopecia. Two patients developed alopecia without previous folliculitis. Six patients required reconstructive surgery, which consisted of primary closure (3), staged excision (1), and tissue expansion (2). A number of variables were examined to determine any differences in the group that had complications compared with the group of patients that did not. No differences in age, sex, race, burn type, burn size, septic episodes, time to wound closure, or number of times the scalp was harvested were detected. Healed second-degree burns to the scalp that were subsequently taken as donor sites seemed to be a risk factor (p < 0.05) for folliculitis and alopecia. Our study confirms that scalp donor sites are reliable with low morbidity. Complications include alopecia and chronic folliculitis that can be avoided by meticulous technique and avoidance of previously burned areas.     

The inhibition of skeletal changes in a rat burn model with a local muscle flap

The effects of early wound closure using a local muscle flap on the development of periosteal new bone formation in a rat burn model were studied. Following a full-thickness burn to one hind limb, periosteal new bone formation along the tibial diaphysis was measured by the use of the fluorochrome agent calcein and an image-analysis system. Prostaglandin E levels, a known inflammatory mediator, from the bone beneath the burn also were measured. Periosteal new bone formation was inhibited by 50 percent in animals that had debridement and wound closure with a gastrocnemius muscle flap and skin graft on postburn day 2 compared to untreated controls or animals closed with skin grafts only. There was a trend toward reduced prostaglandin E measurements from tibial sections in the early closure group compared to untreated controls. This study demonstrates that early wound closure using a local muscle flap inhibits the periosteal new bone formation which is possibly associated with the inflammation in a rat burn model.     

Free fibula osteoseptocutaneous-pedicled pectoralis major myocutaneous flap combination in reconstruction of extensive composite mandibular defects

Lateral composite mandibular defects resulting from excision of advanced oral carcinoma often require mandible, intra-oral lining, external face, and soft-tissue bulk reconstruction. Ignorance of importance soft-tissue deficit in those patients may cause significant morbidity and functional loss. Such defects, therefore, can be reconstructed best with a double free flap technique. However, this procedure may not be feasible for every patient or surgeon. An alternative procedure is a free fibula osteoseptocutaneous flap combined with a pedicled pectoralis major myocutaneous flap. This combination was used in reconstruction of extensive composite mandibular defects in 14 patients with T3/T4 oral squamous cell carcinoma. All patients were men, and the average age was 54.3 years. The septocutaneous paddle of the fibula flap was used for the mucosal lining of the defects while the bony part established the rigid mandibular continuity. The pectoralis major flap then covered the external skin defect in the face and cheek, and the dead spaces left by the extirpated masticator muscles, buccal fat, and parotid gland. One free fibula flap failed totally, and one pectoralis major flap developed marginal necrosis. At the time of final evaluation, nine patients (64.3 percent) were alive, surviving an average of 25.7 months. All patients eventually regained their oral continence and an acceptable cosmetic appearance. In conclusion, the fibula osteoseptocutaneous flap plus regional myocutaneous flap choice is a successful and technically less demanding alternative to the double free flap procedures in reconstruction of extensive lateral mandibular defects.