System describing surgical field extension associated with flap reconstruction after resection of a superficial malignant soft tissue tumor

BACKGROUND Flap reconstruction after resection of a superficial malignant soft tissue tumor extends the surgical field and is an indicator for potential recurrence sites.AIM To describe a grading system for surgical field extension of soft tissue sarcomas.METHODS Grading system:CD-grading is a description system consisting of C and D values in the surgical field extension,which are related to the compartmental position of the flap beyond the nearby large joint and deeper extension for the pedicle,respectively.C1/D1 are positive values and C0/D0 are negative.With a known location,1/0 values can be"p"(proximal),"d"(distal),and"b"(in the tumor bed),and the description method is as follows:flap type,CxDx[x=0,1,p,d or b].RESULTS Four representative patients with subcutaneous sarcomas who underwent reconstruction using fasciocutaneous flaps are presented.The cases involved a distal upper arm(elbow)synovial sarcoma reconstructed using a pedicled latissimus dorsi(pedicled flap:CpDp);a distal upper arm(elbow)pleomorphic rhabdomyosarcoma reconstructed using a transpositional flap from the forearm(transpositional flap:CdD0);an undifferentiated pleomorphic sarcoma in the buttocks reconstructed using a transpositional flap(transpositional flap:C0D0);and a myxofibrosarcoma in the buttocks reconstructed using a propeller flap from the thigh(pedicled flap:CdDd).CONCLUSION The reconstruction method is chosen by the surgeon based on size,location,and other tumor characteristics;however,the final surgical field cannot be determined based on preoperative images alone.CD-grading is a description system consisting of C and D values in the surgical field extension that are related to the compartmental position of the flap beyond the nearby large joint and deeper extension for the pedicle,respectively.The CD-grading system gives a new perspective to the flap reconstruction classification.The CD-grading system also provides important information for follow-up imaging of a possible recurrence.

When the Combination of a Chinese Flap and Dufourmentel Makes It Possible to Treat a Hopeless Case of Squamous Cell Carcinoma of the Upper Lip

Cancers of the lip are the leading cause of labial defects, and treatment is essentially surgical. The success of a repair is assessed by two essential criteria: The functional character of the lip (restoration of continence allowing feeding) and the aesthetic quality of the repair. However, for many patients from countries whose medical infrastructure does not allow them to undertake complex reconstructions locally, medical transfers represent their only chance of treatment. The aim of this article is to share with you an extreme clinical case of labial reconstruction, the management of which was a real challenge, using two major flaps: the free ante-brachial flap and the DUFOURMENTEL-type bi-pediculated scalp flap.

Nasal sill reconstruction with the Abbe flap after skin cancer resection:A case report

Local flaps are widely known as the best option for partial nasal reconstructions depending on donor tissue laxity,vascularization,and defect shape and size.The nasolabial flap is used more often in the nasal sill.For larger defects,greater tissue mobilization with larger scars or free flaps is required.Historically,the Abbe flap has been used for lip reconstruction in patients with cleft lip deformities.It allows less retraction than other local flaps or skin grafts in patients with large defect sizes and great defect depths.This study reported on the application of the Abbe flap for nasal sill reconstruction on a 71-year-old female patient with nasal sill basal cell carcinoma who had undergone resection surgery with a posterior lip switch operation with satisfactory results.The application of the Abbe flap could be considered in patients with multiple previous surgeries and at risk for necrosis.

Measurement of combined flap thickness for reconstruction of decubitus ulcer using computed tomography

BACKGROUND Various reconstruction options have been introduced to treat decubitus ulcers.A combined flap that takes advantage of the fasciocutaneous and muscle flaps has been proven to be effective in reconstructing decubitus ulcers in previous studies.However,no studies have measured combined flap thickness.This is the first study to demonstrate the superiority of the combined flap by measuring its thickness using enhanced abdominopelvic computed tomography(APCT).AIM To evaluate combined flap modality as a useful reconstruction option for decubitus ulcers using measurements obtained through APCT.METHODS Fifteen patients with paraplegia who underwent combined flap surgery for reconstruction of decubitus ulcers between March 2020 and December 2021 were included.The defects in the skin and muscle components were reconstructed separately.The inner gluteus muscle flap was split and manipulated to obliterate dead space.The outer fasciocutaneous flap was transposed to cover the muscle flap and opening of the decubitus ulcer.Subsequently,we performed enhanced APCT at 3 wk and 6 mo postoperatively to measure the flap thickness.RESULTS The mean flap thickness was 32.85±8.89 mm at 3 wk postoperatively and 29.27±8.22 mm at 6 mo postoperatively.The flap thickness was maintained without any major complications such as contour deformities or recurrence.CONCLUSION Although there was a significant decrease in flap thickness as measured by APCT,the combined flap provided sufficient padding and maintained its thickness even at 6 mo after reconstruction,suggesting that the combined flap modality may be a useful reconstruction option for patients with paraplegic decubitus ulcers.

Nasolabial perforator flap for nasal defects

Nasal defects can be reconstructed with a nasolabial perforator flap,resulting in good aesthetic outcomes based on the facial subunit principle,owing to the combined advantages of the traditional nasolabial flap and the perforator flap.However,the localization of perforators makes the clinical application of a nasolabial perforator flap difficult.This review aims to provide a comprehensive summary of the nasolabial perforator flap from anatomical,methodological,and clinical application aspects,intending to provide plastic surgeons with a reference on conducting nasal reconstruction with a nasolabial perforator flap.

Surgical treatment of anal stenosis

Anal stenosis is a rare but serious complication of anorectal surgery, most commonly seen after hemorrhoidectomy. Anal stenosis represents a technical challenge in terms of surgical management. A Medline search of studies relevant to the management of anal stenosis was undertaken. The etiology, pathophysiology and classification of anal stenosis were reviewed. An overview of surgical and non-surgical therapeutic options was developed. Ninety percent of anal stenosis is caused by overzealous hemorrhoidectomy. Treatment, both medical and surgical, should be modulated based on stenosis severity. Mild stenosis can be managed conservatively with stool softeners or fiber supplements. Sphincterotomy may be quite adequate for a patient with a mild degree of narrowing. For more severe stenosis, a formal anoplasty should be performed to treat the loss of anal canal tissue. Anal stenosis may be anatomic or functional. Anal stricture is most often a preventable complication. Many techniques have been used for the treatment of anal stenosis with variable healing rates. It is extremely difficult to interpret the results of the various anoplastic procedures described in the literature as prospective trials have not been performed. However, almost any approach will at least improve patient symptoms.

Scrotal septal flap and two-stage operation for complex hypospadias:A retrospective study

BACKGROUND Complex hypospadias is a surgical challenge.AIM To present the long-term outcomes of two-stage repair of complex hypospadias using a scrotal septal flap.METHODS This was a retrospective study of patients with complex hypospadias who were operated on between January 1st,2001,and January 1st,2019,at a single hospital using a scrotal septal flap(two-stage surgery)or prepuce flap(one-stage surgery;control group).In the scrotal group,the urethra was first repaired using oral mucosa;in the second stage,a scrotal septal flap was used as a second impermeable layer.Maximal/average urinary flow rates after surgery were compared.All patients were followed for≥6 mo(range:6-96 mo).RESULTS Ninety-seven patients were included(46 in the scrotal group and 51 in the prepuce group).The maximal urinary flow rate was 15.4±2.1 mL/s in the scrotal group and 14.3±3.0 mL/s in the control group(P=0.035).The average urinary flow rate was 8.4±2.3 mL/s in the scrotal group and 7.5±1.5 mL/s in the control group(P=0.019).The proportion of patients achieving good therapeutic effects was higher in the scrotal group than in the control group[24(52.2%)vs 16(31.4%),P=0.042;34(73.9%)vs 25(49.0%),P=0.014].The scrotal flap two-stage surgery was independently associated with a higher maximal urinary flow rate(OR=2.416,95%CI:1.026-5.689,P=0.044)and with a higher average flow rate(OR=2.484,95%CI:1.054-5.854,P=0.038).CONCLUSION In complex hypospadias,a scrotal septal flap could be a versatile and reliable option for resurfacing the penis.

Extended pectoralis major myocutaneous flap in head and neck reconstruction

Although the pectoralis major myocutaneous flap is often used in head and neck reconstruction, the extension of the skin paddle beyond the inferior limits of the muscle has not been well described. We aim to clarify the design and application of this extended flap in head and neck reconstruction. In this retrospective study, consecutive cases of extended pectoralis major myocutaneous flap reconstruction of post-ablative head and neck defects at a single tertiary referral center were included for analysis. In 7 cases an extended pectoralis major flap was utilized, in which the skin paddle was extended beyond the inferior border of the pectoralis major to include the rectus sheath. Skin and soft tissue as well as composite defects of the oral cavity, parotid/temporal region and neck were reconstructed. All flaps healed satisfactorily with no loss of skin viability. The extended pectoralis major myocutaneous flap is robust and has versatile applications for reconstruction of large, high and three dimensionally complex defects in the head and neck region.

Clinical Analysis of Pectoralis Major Myocutaneous Flap for Reconstruction of Tissue Defects after Pharyngolaryngeal Cancer Surgery

Objective: To explore the methods and effects of pectoralis major myocutaneous flap in pharyngolaryngeal cancer surgery. Methods: Among 23 cases of pharyngolaryngeal cancer patients, the surgical procedure was based on pathologic conditions, and the surgical defects were repaired by pectoralis major myocutaneous flap. Results: Among 23 patients, there were 1 case of skin flap necrosis, 4 cases of pharyngeal fistula, 1 case of hypopharyngeal esophageal stenosis;except 1 case of pharyngeal fistula died of carotid artery rupture caused by infection, 1 case of hypopharyngeal esophageal stenosis required a gastric tube, and the rest patient’s swallowing function is normal. Conclusion: The blood supply of pectoralis major myocutaneous flap is reliable with the tissue volume enough for reconstruction. It turns out to improve patient survival and postoperative quality of life with the application of pharyngolaryngeal cancer surgery.

Reconstruction surgery in head and neck cancer patients amidst the COVID-19 pandemic:Current practice and lessons for the future

The coronavirus disease 2019(COVID-19)pandemic has imposed a radical change in daily life and work routine.In this context,health systems have suffered important and serious repercussions in all fields.Among the changes brought about by the state of global health emergency,adjustments to guidelines,priorities,structures,professional teams,and epidemiological data stand out.In light of this,the oncological field has witnessed several changes in the approach to cancer,whether due to delay in diagnosis,screening deficit,personnel shortage or the psychological impact that the pandemic has had on cancer patients.This article focuses on the management of oral carcinoma and the surgical approaches that oral and maxillofacial specialists have had at their disposal during the health emergency.In this period,the oral and maxillofacial surgeons have faced many obstacles.The proximity of maxillofacial structures to the airways,the need of elective and punctual procedures in cancerous lesions,the aggressiveness of head and neck tumors,and the need for important healthcare costs to support such delicate surgeries are examples of some of the challenges imposed for this field.One of the possible surgical'solutions'to the difficulties in managing surgical cases of oral carcinoma during the pandemic is locoregional flaps,which in the pre-COVID-19 era were less used than free flaps.However,during the health emergency,its use has been widely reassessed.This setback may represent a precedent for opening up new reflections.In the course of a long-term pandemic,a reassessment of the validity of different medical and surgical therapeutic approaches should be considered.Finally,given that the pandemic has highlighted vulnerabilities and shortcomings in a number of ways,including the issues of essential resource shortages,underinvestment in public health services,lack of coordination and versatility among politicians,policymakers and health leaders,resulting in overloaded health systems,rapid case development,and high mortality,a more careful analysis of the changes needed in different health systems to satisfactorily face future emergencies is essential to be carried out.This should be directed especially towards improving the management of health systems,their coordination as well as reviewing related practices,even in the surgical field.

Modified Z-Plasty for Reconstruction of Webbed Scar Contractures

Rationale: Webbed scar contractures deformity caused by burns and other factors will lead to joint disorders and affect the mental health of patients, resulting in a severe decline in quality of life. Rapid, effective and less complicated surgical methods can help patients with post-burn rehabilitation. Objective: This article argues that a modified Z-plasty can quickly improve the range of motion caused by webbed scar contractures in joint areas, including surgical methods, postoperative care and prognosis. Methods and Results: The study took place from 2018 to 2022. Thirty-two patients with joint scar contracture deformity, with a mean age of 32.5 years, were included in the study. All patients underwent contracture scar revision and modified Z-plasty repair under anesthesia. All the flaps survived and the joint function was improved. Compared with the traditional Z-plasty, the duration of the operative procedure of the modified Z-plasty was significantly shorter, more surrounding scar tissue was mobilized, and the effectiveness of postoperative scar contracture release was better. Discussions: The modified Z-plasty for scar contracture deformity in joint area is simple, rapid, effective and easy to manage.

溶栓治疗挽救游离皮瓣术后误用血凝酶致静脉血管危象1例

1 临床资料患者,男,48岁,因“右耳闷塞感4个月余,咽痛伴牙痛2个月余”入院。专科查体见I度张口受限,右侧腭舌弓隆起,扁桃体不大,被推挤向对侧,右颈部轻微压痛。颅面部MRI及颈部增强CT提示,右侧口咽部及咽旁颅底间隙囊实性占位伴钙化(图1A,图1B)。纤维鼻咽喉镜示右后鼻孔及鼻咽部肿物,表面黏膜光滑。于2019-09-10行气管切开+右侧颅底肿瘤切除+右侧根治性颈淋巴结清扫+右侧上颌骨次全切+下颌骨部分切除+颈外动脉结扎+游离股前外侧皮瓣切取移植+腭咽成形术。

Is anoplasty superior to scar revision surgery for posthemorrhoidectomy anal stenosis?Six years of experience

BACKGROUND Anal stenosis is a rare but frustrating condition that usually occurs as a complication of hemorrhoidectomy.The severity of anal stenosis can be classified into three categories:mild,moderate,and severe.There are two main surgical treatments for this condition:scar revision surgery and anoplasty;however,no studies have compared these two approaches,and it remains unclear which is preferrable for stenoses of different severities.AIM To compare the outcomes of scar revision surgery and double diamond-shaped flap anoplasty.METHODS Patients with mild,moderate,or severe anal stenosis following hemorrhoidectomy procedures who were treated with either scar revision surgery or double diamond-shaped flap anoplasty at our institution between January 2010 and December 2015 were investigated and compared.The severity of stenosis was determined via anal examination performed digitally or using a Hill-Ferguson retractor.The explored patient characteristics included age,sex,preoperative severity of anal stenosis,preoperative symptoms,and preoperative adjuvant therapy;moreover,their postoperative quality of life was measured using a 10-point scale.Patients underwent proctologic follow-up examinations one,two,and four weeks after surgery.RESULTS We analyzed 60 consecutive patients,including 36 men(60%)and 24 women(40%).The mean operative time for scar revision surgery was significantly shorter than that for double diamondshaped flap anoplasty(10.14±2.31[range:7-15]min vs 21.62±4.68[range:15-31]min;P<0.001).The average of length of hospital stay was also significantly shorter after scar revision surgery than after anoplasty(2.1±0.3 vs 2.9±0.4 d;P<0.001).Postoperative satisfaction was categorized into four groups:45 patients(75%)reported excellent satisfaction(scores of 8-10),13(21.7%)reported good satisfaction(scores of 6-7),two(3.3%)had no change in satisfaction(scores of 3-5),and none(0%)had scores indicating poor satisfaction(1-2).As such,most patients were satisfied with their quality of life after surgery other than the two who noticed no difference due owing to the fact that they experienced recurrences.CONCLUSION Scar revision surgery may be preferable for mild anal stenosis upon conservative treatment failure.Anoplasty is unavoidable for moderate or severe stenosis,where cicatrized tissue is extensive.

Phalloplasty following penectomy for penile cancer

Objective:Penile reconstruction or phalloplasty following penectomy can be offered where the functional penile length is inadequate for a man to void while standing or to have sexual intercourse.Phalloplasty is usually staged due to the complex surgical techniques required.This narrative review describes the technical concepts and summarises the contemporary outcomes following phalloplasty in this challenging cohort.Methods:A retrospective review of the English literature was performed between January 1946 till November 2021.The data were synthesised and complemented by the expert opinion of the authors with 20 years of experience in this field.The flaps are ideally designed with an integrated urethra or alternatively,a further free flap urethroplasty can be offered.Phallo-plasty is further complicated following penectomy by scarring from the previous surgery and the potential loss of structures that would normally be present at the recipient site.Results:There are limited published data with a total of 19 men recorded in the literature.Only the radial artery forearm free flap and anterolateral thigh flap have been described in this cohort of patients.Functional outcomes including standing micturition,sensation in the neo-phallus,and the ability to orgasm are good.Overall quality of life and satisfaction was also good despite the high risk for long-term complications of the neophallus and donor site.Conclusion:Phalloplasty following penectomy requires microsurgical transfer of a free flap or a pedicled flap to reconstruct a neophallus.An erectile device is inserted at a later stage to facilitate sexual intercourse,if desired.Surgical scarring from penectomy and the potential loss of vasculature that would normally be present at the recipient site may further complicate reconstruction.Surgical and functional outcomes are acceptable based on the limited published experience to date.

Recovery of brachial plexus injury after bronchopleural fistula closure surgery based on electrodiagnostic study:A case report and review of literature

BACKGROUND Axillary thoracotomy and muscle flap are muscle-and nerve-sparing methods among the surgical approaches to bronchopleural fistula(BPF).However,in patients who are vulnerable to a nerve compression injury,nerve injury may occur.In this report,we present a unique case in which the brachial plexus(division level),suprascapular,and long thoracic nerve injury occurred after BPF closure surgery in a patient with ankylosing spondylitis and concomitant multiple joint contractures.CASE SUMMARY A 52-year-old man with a history of ankylosing spondylitis with shoulder joint contractures presented with right arm weakness and sensory impairment immediately after axillary thoracotomy and latissimus dorsi muscle flap surgery for BPF closure.During the surgery,the patient was positioned in a lateral decubitus position with the right arm hyper-abducted for approximately 6 h.Magnetic resonance imaging and ultrasound revealed subclavius muscle injury or myositis with brachial plexus(BP)compression and related neuropathy.An electrodiagnostic study confirmed the presence of BP injury involving the wholedivision level,long thoracic,and suprascapular nerve injuries.He was treated with medication,physical therapy,and ultrasound-guided injections.Ultrasoundguided steroid injection at the BP,hydrodissection with 5%dextrose water at the BP and suprascapular nerve,and intra-articular steroid and hyaluronidase injection at the glenohumeral joint were performed.On postoperative day 194,the pain and arm weakness were resolved,and a follow-up electrodiagnostic study showed marked improvement.CONCLUSION Clinicians should consider the possibilities of multiple nerve injuries in patients with joint contracture,and treat each specific therapeutic target.

保留乳房手术及外侧组织瓣乳房成型治疗乳腺癌的应用体会

1997-2 0 0 2年对 18例早期原发乳腺癌 (Tis T2 A)进行保留乳房 +外侧组织瓣乳房成形术。结果 18例手术均获成功 ,切口Ⅰ期愈合 ,乳头无坏死。 10例患者术后随访 2年以上 ,均无肿瘤局部复发及转移。初步研究结果提示 ,应用外侧软组织皮瓣 (lateraltissueflap ,LTF)乳房成型 ,有良好临床效果和使用价值。

下咽癌同步放化疗后并发下咽部溃疡胸大肌皮瓣修复1例

下咽癌是头颈部常见恶性肿瘤之一,治疗方法包括手术、放疗、同步放化疗等,其中根治性同步放化疗易导致局部放射性溃疡且伴感染经久不愈,严重影响患者生活质量。我科采用胸大肌肌皮瓣修复下咽癌根治性同步放化疗后并发下咽部放射性溃疡累及颈动脉患者1例,取得满意疗效,现报告如下。

锁骨上皮瓣修复头颈缺损9例临床分析

目的 探讨锁骨上皮瓣在头颈肿瘤缺损修复中的应用。方法 回顾性分析2017年1月~2020年12月于扬州大学附属苏北人民医院收治的应用锁骨上皮瓣修复头颈缺损的9例患者临床资料,通过研究其头颈肿瘤缺损的原因、术前放疗史、手术方式、皮瓣尺寸及术后愈合情况等因素,探讨锁骨上皮瓣的制备技巧、应用指征及术后并发症的处理。结果 9例患者均为男性,年龄51~79岁。3例一期修复包括1例下咽癌,1例舌根恶性肿瘤,1例鼻咽癌继发颈部淋巴结转移癌;6例二期修复包括1例下咽癌术后继发颈部淋巴结转移癌,1例喉癌术后继发气管造瘘口癌,1例喉及食管癌术后吻合口瘘,3例下咽癌术后咽瘘。2例咽瘘患者采用锁骨上皮瓣联合胸大肌皮瓣修复缺损,7例患者单独采用锁骨上皮瓣修复。术中所取锁骨上皮瓣宽度为4~8 cm,长度为6~15 cm。8例术后随访皮瓣存活,1例术后皮瓣坏死,清创换药后愈合。1例下咽癌术后患者皮瓣存活,但食管入口肿瘤复发予以放射性粒子植入,局部未控,术后第11个月死亡。结论 锁骨上皮瓣是喉咽及颈部皮肤术后缺损较为理想的修复组织瓣,技术比较成熟,术中应注意皮瓣血管的保护,治疗效果比较可靠。

Operative Technique for Correction of Gigantomastia,Using the Superior Pedicle,with Special Care for the Nipple-Papillary Grafts:A 13-Year Retrospective Study

This is a retrospective study on gigantomastia correction in obesity facing the technique of nipple-areolar grafts and its complexity. The main question is the technical-surgical care during its execution aiming to achieve reparative results that can return to these women the desire to live with better quality of life and health. Method: We performed a retrospective study of all obese patients with severe gigantomastia who underwent reduction mammaplasty with an operative technique using the superior pedicle, with special care for the nipple-papillary grafts. The study was carried out at a single institution between 2001 and 2013, in a total of 30 cases. This operative technique was presented at first time in 1980, with no changes up to now. We emphasized the perfect decortication of the areola and nipples until they were translucent after the maneuvers of Schwartzman and subsequent grafts operated in both breasts. Results: Results were considered satisfactory, from the reparative and aesthetic point of view, emphasizing the degree of improvement observed in women undergoing technique. Discussion: We can say that during all this time of aesthetic and therapeutic-restorative surgery, due to its realization in a single surgical time, there was big impact on the aesthetics of patients and on their families, even taking into account possible complications in the post-operative. Conclusion: The superior pedicle technique, performed as described here, is a safe and reliable procedure in patients with severe gigantomastia.

Reconstruction of mandible with fibular flap and dental implant distractor:a new approach

OBJECTIVE: To study the application of dental implant distractor (DID) in mandibular functional reconstruction. METHODS: We designed a new device named DID, which includes the permanent dental implant and the temporary distractor in itself. It is specially designed for fibula wider distraction in mandible reconstruction. Twenty-five sets of DID devices were put into 8 patients (6 men and 2 women) during operation. Two patients suffered from ameloblastoma of the mandible, 2 from odontogenic cyst of the mandible, 1 from fibrous dysplasia, and the other 3 from malignant tumor of the mandible. The age of 8 patients ranged from 19 to 67 (mean 46.8) years. RESULTS: During postoperative 2 - 15 months follow up, 7 patients were found to be successful. The clinical examination and X-ray film showed the normal shape of the mandible and the osteointegration of the implants were solid enough to withstand the denture force. Others had the DID removed because of inflammation. Two of the patients successfully worn the fixed dental prosthesis. The outcomes was satisfying. CONCLUSION: The DID device specially designed for mandibular reconstruction with fibular flap can help to simplify convenient procedures to a single surgery.