The extended latissimus dorsi flap in repair of anterior abdominal wall defects

Large abdominal wall defects (ventral hernias) can be difficult to repair. Some defects are not amenable to primary repair or the use of synthetic mesh because of repeated recurrence or wound infection. In complicated situations such as that mentioned above, the extended latissimus dorsi muscle flap has been used to repair upper and middle abdominal wall defects. This method has been utilized in six patients, and there has been no recurrence of the defect or evidence of a lumbar hernia. The follow-up has been from 7 to 66 months. The extended latissimus dorsi muscle flap has proven to be an excellent alternative in the repair of complicated abdominal wall defects.     

子宫脱垂患者子宫主韧带和阴道前壁组织神经丝蛋白的表达及意义

目的探讨子宫脱垂(Uterine prolapse,UP)患者子宫主韧带和阴道前壁中神经丝蛋白(Neurofilament protein,NFP)组织的表达及其与子宫脱垂临床因素的关系。方法应用免疫组织化学S-P法对50例子宫脱垂患者的子宫主韧带和阴道前壁组织中神经丝蛋白表达进行测定,并与10例对照组组织对比,结合子宫脱垂的临床参数进行分析。结果免疫组化结果显示子宫脱垂患者阴道壁、主韧带组织中神经丝蛋白表达的阳性率为28.0%、32.0%,明显低于对照70.0%、80.0%,Ⅱ度子宫脱垂患者阴道壁、主韧带组织中神经丝蛋白表达阳性表达率明显低于Ⅲ+Ⅳ度子宫脱垂组(45.45%vs14.29%、50.0%vs17.86%)。结论子宫脱垂患者子宫主韧带和阴道前壁组织中神经丝蛋白表达下降,并与脱垂程度相关,提示神经丝蛋白可能在子宫脱垂的发生发展中起重要的作用。     

Use of pectoralis major muscle flaps to repair defects of anterior chest wall.

We closed defects of the anterior chest wall in 6 patients, using either unilateral or bilateral pectoralis major muscle flap transpositions. In 4 of these patients the defect was stabilized with autogenous rib grafts, and none of these had a flail chest. All of the transposed muscle flaps remained viable and innervated. The deformities and the functional disturbances resulting from the transpositions were minimal.     

A 3D finite element model of anterior vaginal wall support to evaluate mechanisms underlying cystocele formation

ObjectivesTo develop a 3D computer model of the anterior vaginal wall and its supports, validate that model, and then use it to determine the combinations of muscle and connective tissue impairments that result in cystocele formation, as observed on dynamic magnetic resonance imaging (MRI).MethodsA subject-specific 3D model of the anterior vaginal wall and its supports were developed based on MRI geometry from a healthy nulliparous woman. It included simplified representations of the anterior vaginal wall, levator muscle, cardinal and uterosacral ligaments, arcus tendineus fascia pelvis and levator ani, paravaginal attachments, and the posterior compartment. This model was then imported into ABAQUS? and tissue properties were assigned from the literature. An iterative process was used to refine anatomical assumptions until convergence was obtained between model behavior under increases of abdominal pressure up to 168 cm H₂O and deformations observed on dynamic MRI.ResultsCystocele size was sensitive to abdominal pressure and impairment of connective tissue and muscle. Larger cystocele formed in the presence of impairments in muscular and apical connective tissue support compared to either support element alone. Apical impairment resulted in a larger cystocele than paravaginal impairment. Levator ani muscle impairment caused a larger urogenital hiatus size, longer length of the distal vagina exposed to a pressure differential, larger apical descent, and resulted in a larger cystocele size.ConclusionsDevelopment of a cystocele requires a levator muscle impairment, an increase in abdominal pressure, and apical and paravaginal support defects.     

Significance of extensive hyperkeratosis on cervical/vaginal smears

OBJECTIVE: To assess the significance of reporting hyperkeratosis on cervical/vaginal (CV) smears. STUDY DESIGN: Cases diagnosed with extensive hyperkeratosis (E-HK) and without prior or concurrent history of neoplasia, squamous intraepithelial lesion or atypical squamous cells of undetermined significance (ASCUS) were retrieved from our files for the period January 1994-August 2001. E-HK is defined in our practice as patches of anucleated squames with irregular, angulated edges present in at least 5 low-power (10 x eyepiece and 10 x objective) fields on a conventional CV smear. On liquid-based preparations, we use 3 low-power fields. Only cases with a follow-up CV smear and/or cervical biopsy (CB) were selected. RESULTS: Among 328 cases of E-HK, 138 patients met the study selection criteria. Eighty-one cases had negative CV smears and/or CB, 17 (12.3%) patients had persistent E-HK, and a subsequent diagnosis of ASCUS or higher was made in 40 patients (28.9%). Among the 40 cases with subsequent abnormalities, 13 (9.4%) were diagnosed with ASCUS, 24 (17.4%) with HPV or dysplasia, and 3 (2.1%) with malignancy. CONCLUSION: While isolated, anucleate squames may have no clinical importance in patient management, E-HK can be a significant marker of underlying neoplastic disease. This should be kept in mind as one decides how to report CV cytology based on 2001 Bethesda System recommendations.     

Modified Antia-Buch repair for full-thickness upper pole auricular defects

Various reconstructive techniques have been described for repair of full-thickness upper pole auricular defects. The wedge excision commonly used for treatment of upper pole tumors allows excision and reconstruction in a single stage. However, this technique suffers from major deficiencies. We apply the concept of crescentic scaphal excision and the Antia-Buch advancement-rotation flap principle to repair various full-thickness upper pole auricular defects resulting from excision of skin lesions in eight consecutive patients. The technique achieves a natural auricular shape in three dimensions with minimal disruption of the anatomic landmarks and avoids conspicuous scars. It has several advantages over the original Antia-Buch repair and other techniques used for reconstruction of full-thickness upper pole auricular defects.     

Extended V-Y latissimus dorsi musculocutaneous flap for anterior chest wall reconstruction

Patients presenting advanced breast tumors are usually subject to major resections of the anterior chest wall tissue. Flaps taken from the abdominal wall, such as the TRAM, the external oblique flap, and the thoracoabdominal flap are frequently used for closure of this type of lesion. In this study, a different shape was planned for the skin island from the latissimus dorsi musculocutaneous flap with primary closure in V-Y for the correction of major lesions in the anterior chest wall after mastectomies occasioned by advanced breast cancer. The technique was used on eight female patients, between November of 1998 and July of 1999, victims of advanced breast cancer, who had been submitted to radical mastectomies with major resections of the cutaneous tegument. It was possible to make primary closure of lesions in the anterior chest wall, the preoperative areas of which varied between 15 x 15 and 29 x 14 cm (vertical x horizontal). This technical variant permitted use of the flap without the need to create tunnels for its advancement and rotation. It also proved to be easy to perform and presented a low morbidity rate, with three patients presenting minor complications that did not require correction through any further surgical intervention. Closure was obtained in the donor and recipient sites without the use of skin grafts or other more major procedures. According to the authors, this procedure is a viable alternative in repairing large defects in the anterior chest wall.     

Latissimus dorsi free flaps for total repair of extensive lower leg injuries in children

A well-established belief is that with crushed and contaminated wounds closure should be delayed. However, an emergency procedure involving very thorough debridement, complete reconstruction of all injured tissues, and cover by a latissimus dorsi free flap in the same operation is evaluated in 15 children presenting with severe injuries to the lower limb. It is felt that the procedure is superior to the established method because it is a one-stage procedure that minimizes the danger of infection, prevents growth impairment, shortens hospitalization, and allows early mobilization, thus being, in some cases, a limb-saving procedure.