Treatment of massive thoracolumbar wounds and vertebral osteomyelitis following scoliosis surgery

Closure of thoracolumbar wounds and vertebral osteomyelitis after scoliosis surgery often proves difficult due to tautness and lack of usable tissue, and the resulting dead space containing metallic fixation devices is predisposed to infections and complications. The authors present their experience with 33 patients in whom massive thoracolumbar wounds and vertebral osteomyelitis developed following scoliosis surgery. Postoperative infection, due to the lack of vascularized tissue and presence of metallic hardware near the wound, is common and extremely counterproductive; within these cavernous wounds lie infected vertebrae, metallic hardware, and bone graft. The use of a modified and extended latissimus dorsi myocutaneous flap to close and supply blood to wounds in the lower thoracic and thoracolumbar areas is described. This surgical approach, predicated on effective débridement along with reconstruction by transposition of vascularized tissue, allows the wound to close and drastically decreases the risk of postoperative infection. Furthermore, for wounds already infected, the procedure allows for closure and increased blood supply to the area, thus giving the wound a much greater ability to heal. For wounds involving the lumbosacral area, the authors combine this with a transposed gluteus maximus muscle flap to obtain coverage over the caudal extent of the wound. In this study, all flaps accomplished their intended purpose: to secure the healing of once-infected wounds and to allow preservation of orthopedic instrumentation and bone graft. Follow-up revealed no flap losses, pseudarthroses, or loss of orthopedic instrumentation in the study group.     

Demonstration of the Rat Ischemic Skin Wound Model

The propensity for chronic wounds in humans increases with ageing, disease conditions such as diabetes and impaired cardiovascular function, and unrelieved pressure due to immobility. Animal models have been developed that attempt to mimic these conditions for the purpose of furthering our understanding of the complexity of chronic wounds. The model described herein is a rat ischemic skin flap model that permits a prolonged reduction of blood flow resulting in wounds that become ischemic and resemble a chronic wound phenotype (reduced vascularization, increased inflammation and delayed wound closure). It consists of a bipedicled dorsal flap with 2 ischemic wounds placed centrally and 2 non-ischemic wounds lateral to the flap as controls. A novel addition to this ischemic skin flap model is the placement of a silicone sheet beneath the flap that functions as a barrier and a splint to prevent revascularization and reduce contraction as the wounds heal. Despite the debate of using rats for wound healing studies due to their quite distinct anatomic and physiologic differences compared to humans (i.e., the presence of a panniculus carnosus muscle, short life-span, increased number of hair follicles, and their ability to heal infected wounds) the modifications employed in this model make it a valuable alternative to previously developed ischemic skin flap models.     

Presuturing--a new technique for closing large skin defects: clinical and experimental studies

We have developed a new technique termed presuturing for aiding in the closure of large skin defects which may have otherwise required a skin graft or flap. This technique is based on biomechanical properties of skin (creep, stress relaxation) which allow skin to stretch beyond its inherent extensibility. Presuturing is performed under local anesthesia and consists of plicating intact skin over the area of planned excision the night prior to operation. Experimental studies in a pig model showed the decrease in force required to close a standard-sized wound to be 40.1 percent less than control (p less than 0.001). Fourteen patients who underwent wide excision of skin lesions had their wounds presutured. All but one wound could be closed primarily without undermining. Presuturing seems to be an easy and clinically useful technique in aiding the primary closure of large defects.     

Uses of the rectus femoris myocutaneous flap.

The rectus femoris myocutaneous flap is quite useful for definitive immediate coverage of complex wounds within its territorial arc. We describe 4 cases to illustrate the capabilities of this flap. The indications for, the anatomy of, and the surgical technique for transfer, as well as the functional sequelae in two nonparaplegic patients are discussed.     

The oblique rectus abdominis musculocutaneous flap: revisited clinical applications

The authors present their experience with a previously described but infrequently used variation of the rectus abdominis myocutaneous flap. Skin paddles angled obliquely from the line of the rectus abdominis and toward the rib cage were successfully carried on periumbilical perforators from the inferior epigastric system. Skin paddle dimensions ranged from 6.5 to 12 cm in width and from 10 to 27 cm in length in 14 consecutive patients. In six of the 14 patients, the flap was used intraabdominally to obliterate radiated pelvic defects and to close radiated vaginal defects. Five flaps were placed externally to repair radiated wounds of the perineum, thigh, and trunk, and the remaining three cases were performed as free tissue transfers. One cadaver injection study was performed to redemonstrate the preferential flow of fluid in a superior-oblique direction from periumbilical perforators. Termed the oblique rectus abdominis musculocutaneous ("ORAM") flap, this flap variation has significant advantages in terms of ease of dissection and versatility over its flap cousins the vertical rectus abdominis musculocutaneous flap and the transverse rectus abdominis musculocutaneous flap.     

The fasciocutaneous flap: a conservative approach to the exposed knee joint

The exposed knee joint poses a challenge to the reconstructive surgeon. The currently popular approach to the repair of exposed knee joints is use of muscle flaps. However, this leaves the patient with a deficit. We have therefore begun using the fasciocutaneous flap as an initial approach to this problem. In seven patients, aged 28 to 74 years, fasciocutaneous flaps have been the reconstructive procedure of choice for repair of exposed knee joints. One patient with a very large open wound required a concomitant medial gastrocnemius muscle flap. One minor wound separation occurred in a paraplegic patient with severe spasm. No other complications occurred. Follow-up ranged from 3 to 12 months, with good success in wound closure. An approach to small and intermediate wounds is presented in which the V-Y technique is used to obviate the need for skin grafting of the donor site.     

Compromised Wound Healing in Ischemic Type 2 Diabetic Rats

Ischemia is one of the main epidemic factors and characteristics of diabetic chronic wounds, and exerts a profound effect on wound healing. To explore the mechanism of and the cure for diabetic impaired wound healing, we established a type 2 diabetic rat model. We used an 8weeks high fat diet (HFD) feeding regimen followed by multiple injections of streptozotocin (STZ) at a dose of 10mg/kg to induce Wister rat to develop type 2 diabetes. Metabolic characteristics were assessed at the 5th week after the STZ injections to confirm the establishment of diabetes mellitus on the rodent model. A bipedicle flap, with length to width ratio 1.5, was performed on the back of the rat to make the flap area ischemic. Closure of excisional wounds on this bipedicle flap and related physiological and pathological changes were studied using histological, immunohistochemical, real time PCR and protein immunoblot approaches. Our results demonstrated that a combination of HFD feeding and a low dose of STZ is capable of inducing the rats to develop type 2 diabetes with noticeable insulin resistance, persistent hyperglycemia, moderate degree of insulinemia, as well as high serum cholesterol and high triglyceride levels. The excision wounds on the ischemic double pedicle flap showed deteriorative healing features comparing with non-ischemic diabetic wounds, including: delayed healing, exorbitant wound inflammatory response, excessive and prolonged ROS production and excessive production of MMPs. Our study suggested that HFD feeding combined with STZ injection could induce type 2 diabetes in rat. Our ischemic diabetic wound model is suitable for the investigation of human diabetic related wound repair; especically for diabetic chronic wounds.     

Electromagnetic flowmetry--an experimental method for continuous blood flow measurement using a new island flap model

We describe a reliable experimental method for direct, continuous measurement of the rate of blood flow in an island skin flap, using an electromagnetic flowmeter applied to the artery of the flap. The canine saphenous island flap model, developed as part of this study, is a large (11 x 14 cm) island flap, based solely on the saphenous artery (2 mm in diameter). We describe the anatomy of the flap and the method of raising it. Electromagnetic flowmetry is the only method of blood flow determination that provides immediate, continuous, and quantitative measurement of flow. We describe the principles and pitfalls of the electromagnetic flowmeter and the numerous rules of practice that must be observed to obtain consistent results. A validation study was carried out, in which we simultaneously measured arterial inflow with the flowmeter and venous outflow from the flap using direct collection. This study was based on the assumption that at any point in time the arterial and venous rate of flow were equal. We present the results of the study, which show an extremely close linear relationship between the measured and actual rates of flow. We intend to use this experimental method to study the factors that affect the rate of blood flow in free skin flap transfer.     

The posterior calf fascial free flap

Six posterior calf fascial free flaps were employed to reconstruct defects of the upper and lower extremities. One flap failed due to a constricting dressing. Two flaps sustained partial loss secondary to bleeding and hematoma formation. One flap dehisced at the distal suture line due to mobility of an underlying fracture. All surviving flaps eventually healed and resulted in stable, thin coverage. Donor-site morbidity has been minimal. Shortcomings of this flap model have been defined in the peculiarities of its thinness, diffuse vascular oozing, the extent of the vascular territory, and in postoperative monitoring. These problems are analyzed and recommendations for their resolution are presented. Fascia represents a unique tissue which offers an exciting new dimension in the reconstruction of certain defects--particularly those in which thinness is a desirable option. In the posterior calf model, the inclusion of fat represents an alternative modification that allows the surgeon to tailor the design to a variety of problems where fascia alone is too thin and a cutaneous flap is too thick. This concept may find its greatest application in wounds involving the hand or foot. We believe that this and other fascial flap prototypes may offer an ideal solution for reconstruction of major wounds of the extremities.     

The groin flap in reparative surgery of the hand

The historical literature of the use of axial vascular pattern flaps from the hypogastric and iliofemoral regions in reparative surgery of the hand is concisely reviewed. Thirty-six iliofemoral (groin) flaps were utilized for delayed primary resurfacing and secondary reconstruction of defects of the hand and forearm. Two flaps (6 percent) were complicated by partial necrosis. We caution against the immediate resurfacing (within 24 hours of injury) of acute crushed hand wounds by distant flaps. The immediate application of a healthy flap on a soiled or crushed wound invites complications of local tissue necrosis, infection, and subsequent loss of the flap. When distant flaps are indicated for coverage of acute hand wounds, delayed primary coverage following complete removal of all nonviable tissue is a safe and reliable regimen. It is advantageous to design the serviceable portion of the flap on the distal area of the vascular territory of the groin flap. Thoughtful yet "radical" defatting can be performed on the lateral portion of the groin flap territory. Constructed in this way, the long medial base of the groin flap allows freedom for movement at the wrist and metacarpophalangeal and interphalangeal joints, thus decreasing edema and stiffness. In the management of soft-tissue defects in the hand requiring distant flap coverage, we choose to utilize the conventional groin flap in preference to the microvascular free flap when both techniques will deliver equal results.     

Bilobed latissimus dorsi flap for a decubitus ulcer

A case is presented of a bilobed latissimus dorsi flap. The advantage of this flap is to close a large defect without having to resort to a skin graft for closure of the donor-site defect. The advantages of this procedure are as follows: Well-vascularized, stable coverage for decubitus ulcers. Acceptable cosmetic deformity. Avoidance of a skin graft. Decreasing the length of hospitalization.     

Management of complex groin wounds: preferred use of the rectus femoris muscle flap

This study reviews our experience with the rectus femoris muscle flap for complex groin wound reconstruction. Over the past 5 years, the rectus femoris has become our routine method of groin wound reconstruction. The rectus femoris is harvested through a midanterior incision extending over the distal two-thirds of the thigh. The muscle is elevated on its pedicle and transposed into the groin wound defect either directly or through an intervening skin bridge. Hospital and outpatient records were reviewed for all patients undergoing groin wound reconstruction with this technique from 1999 through 2003. Thirty-seven rectus femoris muscle flaps were performed in 33 patients. The mean patient age was 65.3 years (range, 25 to 88 years). Thirty groin wounds (81.1 percent) occurred after infrainguinal revascularization, 23 (76.7 percent) of which contained prosthetic material. Five (21.7 percent) of these wounds had their prosthetic material removed at the time of reconstruction. The remaining seven groin wounds (18.9 percent) occurred after femoral vessel cannulation for either cardiac or transplant surgery. There were no intraoperative mortalities and no anastomotic hemorrhages. There were no flap losses. Thirty-five of the 37 treated wounds healed (94.6 percent), 26 primarily (70.3 percent) and nine (24.3 percent) after delayed healing and contracture. Reoperation was performed in one patient for flap readvancement and in three patients for prosthetic graft removal after initial flap reconstruction. Two patients (6.1 percent) died during their hospitalization with persistent open groin wounds after flap reconstruction. All muscle flap donor incisions healed, with only two (5.4 percent) experiencing minimal delayed healing. There were no donor-site wound infections and no donor sites required reoperation. Thirty-three groin wounds (89.2 percent) demonstrated culture-positive microbial infection, 15 (45.5 percent) of which were polymicrobial. The 30-day mortality rate was 15.2 percent and the 6-month mortality rate increased to 27.2 percent, with multisystem organ failure as the most common cause. The rectus femoris muscle flap is an effective and reliable means of complex groin wound reconstruction. The muscle flap is dependable and the donor site is not problematic, even in the presence of peripheral vascular disease. On the basis of our clinical results, we believe that the rectus femoris muscle flap is the flap of choice for groin wound reconstruction.     

The lower trapezius musculocutaneous flap revisited: versatile coverage for complicated wounds to the posterior cervical and occipital regions based on the deep branch of the transverse cervical artery

The clinical role of the lower trapezius musculocutaneous flap varies within the literature. Many describe its use in the reconstruction of the lateral neck and facial regions, but very few refer to its use in the posterior cervical and occipital regions. Different vascular pedicles have also been described and effectively used. A retrospective analysis was conducted, reviewing the authors' experience with 13 patients who suffered complex open wounds to the posterior cervical and occipital regions that were treated with a lower trapezius muscle or musculocutaneous flap. All flaps were based on the deep branch of the transverse cervical artery. This pedicle was used to support a relatively large skin segment over the distal portion of the lower trapezius muscle, a margin that, in the authors' experience, extends at least 1 cm beyond the muscular margin. Postoperatively, patients were evaluated based on complications, residual shoulder function, and aesthetic outcome. In addition to the clinical study, cadaveric dissection of the trapezius muscle was conducted on 22 specimens, and the vascular anatomy was confirmed by direct visualization. The authors' experience indicates that the lower trapezius musculocutaneous flap, when based on the deep branch of the transverse cervical artery, provides a reliable alternative for the reconstruction of complicated wounds in the posterior cervical and occipital regions, with the added capability of providing richly vascularized tissue to compromised wounds as far cephalad as the vertex of the skull.     

The serratus anterior free-muscle flap: experience with 100 consecutive cases

We report free serratus transplantation in 100 consecutive patients, 10 in combination with the latissimus muscle and 2 with rib. Transplantation was performed for extremity soft-tissue coverage, contour correction, and facial reanimation. Twenty-two patients received serratus transplantation as part of complex reconstruction requiring multiple microvascular transplants. Overall success was 99 percent, with a single flap failure. Four patients suffered partial flap loss. Emergent reexploration for suspected vascular occlusion was infrequent, required in six flaps (6.0 percent), with an 83 percent salvage rate. Significant complications occurred in 18 percent of recipient sites and 12 percent of donor sites, with eight patients developing seroma/hematoma. No scapular winging was noted, and all patients retained full shoulder range of motion. The serratus muscle flap is a highly reliable flap characterized by a consistently long pedicle, excellent malleability, and multipennate anatomy permitting coverage of complex three-dimensional wounds and consistent performance as a functional transplant. Underlying rib can be included as a myo-osseous flap to expand the versatility of this flap.     

Reconstruction of large nasal defects with a combination of local flaps based on the aesthetic subunit principle

Herein is described a technique that uses a combination of local flaps to reconstruct large defects involving the nasal dorsum and cheek. The flaps used are a transposition flap elevated from the area adjoining the defect and bilateral cheek advancement flaps. This technique leaves all suture wounds at borders of the aesthetic subunits that have been described previously. Color and texture matches were good and symmetrical. The transposition flap can be modified according to whether the defect includes the nasal tip. After raising the cheek advancement flap, it is also possible to use a dog-ear on the nasolabial region for any alar defects. Nine patients were treated using this procedure. The technique is very reliable (no complications such as congestion and skin necrosis in our series) and is easy to perform. One patient had palpebral ectropion after the operation and underwent secondary repair. In this series, defects measuring 45 x 30 mm in maximum diameter and including the nasal dorsum, nasal tip, ala, and cheek were treated.     

Inverted-U parascapular flap for the treatment of axillary burn scar contracture

In this paper we report the technique of using an inverted-U parascapular flap for treating axillary scar contracture. The advantages of using this inverted-U flap are that it is possible to close the donor site by primary suturing, it is possible to cover a large skin defect, and it is possible to construct either a cavity or a swelling in the skin-defect region.     

Closure of hemicorporectomy with bilateral subtotal thigh flaps

Hemicorporectomy is typically performed with a circumferential truncal incision, and the wound is closed primarily. Wound disruption is a common complication, especially at the base of the wound closure and posteriorly at the lumbar vertebral level. We report a case of the use of bilateral subtotal thigh flaps for the closure of a hemicorporectomy wound in a patient with a defect extending up to the high lumbar region. The subtotal thigh flap is a well-vascularized thick flap that provides a firm support for the abdominal viscera and is a large flap that can be used to close even a high lumbar defect.     

The pectoralis major for single-stage reconstruction of the difficult wounds of the orbit and pharyngoesophagus

This paper reports the results of reconstructions of difficult wounds in the head and neck area with musculocutaneous flaps in 20 patients. Twelve patients had reconstructions following cranial and orbital resections, and eight patients had reconstructions of the pharyngoesophagus. There were four wound complications, all of which healed without further surgical procedures. The pectoralis major musculocutaneous flap continues to be the most versatile flap for reconstructions at a variety of sites in the head and neck area. Contrary to other reports, it has not been bulky, it has been used without previous delays of the skin paddle, it has not required skin grafts to close the donor sites, and it has been used without difficulty in five female patients.     

The parascapular flap for treatment of lower extremity disorders

The parascapular flap was used as a free microvascular transfer for soft-tissue resurfacing of 11 lower extremities. The diagnoses included four cases of osteomyelitis, three cases of vascular ulceration, one case of combined osteomyelitis and vascular ulceration, two cases of posttraumatic heel defects, and one case of extensive soft-tissue contracture overlying a posttraumatic defect of the femur. All cases were successful clinically. Anatomically, the parascapular flap is supplied by the cutaneous parascapular artery, a branch of the circumflex scapular artery, which itself derives from the subscapular artery. Flap territory may reach 15 x 30 cm, and the vascular pedicle can extend 14 cm if the subscapular artery is taken. Advantages of this flap include the constancy, length, and caliber of the vascular pedicle; the length and width attributes, which allow both coverage of large wounds and primary closure of the donor defect; and an absence of disruption of musculoskeletal function.     

Geometric limit of multiple local Limberg flaps: a flap design.

The Limberg rhombic flap is a reliable and widely used technique in head and neck surgery. Since Limberg introduced his original design in 1946, several modifications of the technique have been described. Although a single Limberg flap is frequently used at the face to close small to medium defects, multi-Limberg flap techniques can help the surgeon to cover moderate to large defects of the extremities, trunk, and back. In this study, a design of four neighboring local Limberg flaps to cover a moderate to large defect without using a skin graft is introduced. It is believed that this design is the geometric limit of multiple Limberg flaps that can entirely cover a single large rhombic defect, because one Limberg flap unit can only be adjoined by three others, one from the tip and two from the sides. This flap design of four local Limberg flaps is also the only geometrically possible design that can keep all the bases of these four flaps free of incisions if one attempts to prepare four small Limberg flaps around a large rhombic defect.