Surgical Flap and Graft Reconstruction Workshop for Dermatology Residents

Background: Traditional models for teaching surgical principles focus primarily on the apprenticeship theory;however there has been a trend in surgical education to certifying competency in a simulation environment prior to working with patients. Many surgical models emphasize learning the technical and manual dexterity skills necessary to be a surgeon, yet few focus on obtaining the theoretical and abstract skills needed for planning complex cutaneous surgical repairs with flaps and grafts. We developed and evaluated a novel surgical flaps and grafts workshop for residents through the Department of Dermatology. Methods: Participants received a 60 minute PowerPoint lecture focusing on the basic principles of cutaneous repair with flaps and grafts, with examples and explanation of each of the four main types of flaps and grafts. The participants then received nine photocopies of Mohs micrographic surgery defects with instructions to design three repairs, focusing on functional and aesthetic outcome. Hypothetical and actual repair designs were then discussed in an open forum format. Anonymous surveys administered to 11 dermatology residents assessed their knowledge level, confidence level, and likelihood of using flaps and grafts pre- and post-workshop using Likert scales. Overall experience was also assessed. A paired sample Wilcoxon Signed Rank Test was used for analysis, since the data was non-parametrically distributed. Results: There was a statistically significant increase in confidence performing flaps post workshop (p = 0.0469). There was also an increase in knowledge of flaps and grafts, confidence in planning flaps and grafts, and confidence in performing grafts post workshop, but these findings did not reach statistical significance. The workshop had no effect on expected future use of flaps and grafts. Conclusions: The surgical workshop is a novel simulation teaching tool for learning basic principles and design of flaps and grafts in cutaneous surgery.

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.

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.

ANALYSIS OF EFFECT AND COMPLICATION ON SURGICAL TREATMENT OF CAROTID BODY TUMORS IN 46 CASES

Objective.To describe the effects of surgical treatment a nd complications in46patients with carotid body tumor.Method.Retrospe ctive study on surgical treatment and complications was carried out in46case s of CBT which were surgically treated with different kind of procedures.Resul t.All procedures performed successfully except that the CBT was not excised in 4cases.No operative mortality was observed.There were2postoperative hemiple gia,4hypoglossal nerve impairment ,2glossopharyngeal nerve impairment ,1va gus nerve impairment ,and1accessory nerve impairment.One patient presented p ostoperative cranial nerve impairment in glossopharyngeal,vagus and hypoglossa l nerves.Two patients developed local recurrence during the long-term follow-up.Conclusion.Complete surgical excision was possible in each patient if th e diagnosis had been cor-rectly made through selective preoperative angiography ,vessel ultrasound Doppler and other examinations.Reasonable surgical procedur e and Matas training were necessary to the successful surgical treatment and t hus decrease the complicative incidence rate of carotid chemodectomas.

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.

The improvement of vocal function by reconstruction of tongue with combination flaps of levator scapula , middle scalene and buccinator musculomucosal

Objective In search of a way of simple and less hurting immediate reconstruction of tougue . Methods The levator scapula flap and the medial scalene flap were applied in 13 cases with cancer of tougue after neck dissection for the immediate reconstruction of ora bottom and tongue muscle defect , Then the buccinator musculomucosal flap was applied for the immediate reconstruction of ora bottom and tongue mucous membrane defect . Results There were not flap necrosis and ora bottom fistala in all cases. The swallowing and speech rehabilitations following surgical treatment for tongue cancer were acceptable. Conclusions This surgical procedure of reconstruction of tongue and ora bottom is successful and simple, easy to perform.

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.

Macro-micro-anatomy of myocutaneous flaps on the dorsum of foot

Thirty feet of Chinese adult cadavers were dissected under an operativemicroscope to observe the extensor hallucis brevis and extensor digitorum brevisand their vessels and nerves in order to design myocutaneous flaps.It was be-lieved that the lateral tarsal artery and the lateral branch of the deep peronealnerve are the best choice to be included in the pedicle when muscle flaps ormyocutaneous flaps are to be obtained from the dorsum of foot.The size of themuscles may be enlarged both laterally and medially as the clinicalcondition requires.

Rhomboid Flap vs. Keystone Perforator Island Flap (KPIF) in the Treatment of Pilonidal Sinus Disease: Comparison of Short-Term Results

Background: Pilonidal disease is a chronic inflammatory disease of the sacrococcygeal region that mainly affects young people. Its incidence is 26 cases per 100,000 persons. Although many techniques have been described, there is no consensus on the treatment of pilonidal sinus disease (PSD). Materials and Methods: This study included 30 patients with PSD who were treated between May 2014 and September 2017. All cases underwent excision and flap reconstruction. The operative time, postoperative complications, the length of hospital stay, painless sitting and walking time, patient satisfaction and recurrence were evaluated prospectively. Results: The results of this prospective, randomized and comparative study are based on experience of a single surgical centre. All patients were followed up 18 months after discharge from the hospital. There is a difference in surgery durations (minutes) between the two groups (33.86 ± 2.89 min. in “keystone” flap vs. 41.26 ± 4.19 in the “rhombic” flap group) (p = 0.001). There were no significant differences in the length of hospital stay, painless sitting and walking time or patient satisfaction. The total complication rate was 66.6% after rhomboid flap compared with 6.6% after keystone flap. There was no flap necrosis. Conclusions: Both of these methods have shown to be successful in treatment of PSD. The KPIF is associated with the advantages of very simple design, abundant blood supply from the perforator vessels and lower rate of complication.

Limited thoracoplasty and free musculocutaneous flap transposition for postpneumonectomy empyema: A case report

BACKGROUND Empyema is a severe complication following pneumonectomy that is associated with high morbidity and mortality rates.Although there are a wide variety of treatment options,successful management remains challenging when this condition is combined with a large cavity in very thin patients who had previously undergone a posterolateral thoracotomy.CASE SUMMARY We reported the case of a thin,63-year-old man with a progressive pulmonary cyst who underwent left pneumonectomy via posterolateral thoracotomy 23 years ago.After an initially uneventful postoperative course,he was readmitted with empyema and a large cavity 21 years after surgery.He was successfully treated with limited thoracoplasty,followed by free vastus lateralis musculocutaneous flap transposition.CONCLUSION This case highlights that the treatment mode of limited thoracoplasty and free vastus lateralis musculocutaneous flap transposition is safe and effective for the management of postpneumonectomy empyema with a large cavity in thin patients who had previously undergone a posterolateral thoracotomy.

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.

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.

Does the advantage of transcutaneous oximetry measurements in diabetic foot ulcer apply equally to free flap reconstruction?

BACKGROUND Transcutaneous oxygen pressure(TcpO2)is a precise method for determining oxygen perfusion in wounded tissues.The device uses either electrochemical or optical sensors.AIM To evaluate the usefulness of TcpO2 measurements on free flaps(FFs)in diabetic foot ulcers(DFUs).METHODS TcpO2 was measured in 17 patients with DFUs who underwent anterolateral thigh(ALT)-FF surgery and compared with 30 patients with DFU without FF surgery.RESULTS Significant differences were observed in the ankle-brachial index;duration of diabetes;and haemoglobin,creatinine,and C-reactive protein levels between the two groups.TcpO2 values were similar between two groups except on postoperative days 30 and 60 when the values in the ALT-FF group remained<30 mmHg and did not increase>50 mmHg.CONCLUSION Even if the flap is clinically stable,sympathectomy due to adventitia stripping during anastomosis and arteriovenous shunt progression due to diabetic polyneuropathy could lead to low TcpO2 values in the ALT-FF owing to its thick fat tissues,which is supported by the slow recovery of the sympathetic tone following FF.Therefore,TcpO2 measurements in patients with DFU who underwent FF reconstruction may be less accurate than in those who did not.

Comparison of semilunar coronally repositioned flap with gingival massaging using an Ayurvedic product(irimedadi taila) in the treatment of class-Ⅰ gingival recession: A clinical study

AIM: To study the comparison in terms of root coverage the effect of gingival massaging using an ayurvedic product and semilunar coronally repositioned flap(SCRF) to assess the treatment outcomes in the management of Miller's class Ⅰ gingival recessions over a-6mo period. METHODS: The present study comprised of total of 90 sites of Miller's class-Ⅰ gingival recessions in the maxillary anteriors, the sites were divided into three groups each comprising 30 sites, Group Ⅰ-were treated by massaging using a Placebo(Ghee) Group Ⅱ-were treated by massaging using an ayurvedic product(irimedadi taila). Group Ⅲ-were treated by SCRF. Clinical parameters assessed included recession height, recession width, probing pocket depth, width of attached gingiva, clinical attachment level and thickness of keratinized tissue. Clinical recordings were performed at baseline and 6 mo later. The results were analyzed to determine improvements in the clinical parameters. The comparison was done using Wilcoxon signed rank test. The overall differences in the clinical improvements between the three groups was done using Kruskal-Wallis test. The probability value(P-value) of less than 0.01 was considered as statistically significant.RESULTS: Non-surgical periodontal therapy and gingival massaging improves facial gingival recessions and prevents further progression of mucogingival defects. Root coverage was achieved in both the experimental groups. The SCRF group proved to be superior in terms of all the clinical parameters.CONCLUSION: Root coverage is significantly better with semilunar coronally repositioned flap compared with the gingival massaging technique in the treatment of shallow maxillary Miller class Ⅰ gingival recession defects.

The experimental stady of new clavicle flap transpo-sition for the repair of ischemic necrosis of femoral head and nonunion of proximal end

AIM：To provide a new way of operation for repairing fracture necrosis of proximal humerrus.METHODS:Observing the course,branches and distributions of thoracoacromia artery on 40 sides of abult cadaveric.RESULTS:(1)Sending off 3 to 5 periosteal branches with diameter of 0.3 to 0.5mm along the acromial branch of thoracoacromial,which distributed at the middle outboard and formed the part of acromial artery net.The acromial length was (5.1±0.5)cm with diameter of (1.2±0.2)mm.(2)Sending off 1 to 3 periosteal branches with diameter of (0.2 to 0.5)mm from the clavicular branches of thoracoactomial artery,which distributes at the inside part one second.The length was (2.0±0.1)cm with diameter of (1.2±0.2)mm.CONCLUSION:A new operation can be designed for repairing fracture necrosis of proximal humerus by transposing clavicle periosteal(bone) flap with the acromial branch of toracoacromial artery.

Modified Scleral Flap Incision to Reduce Corneal Astigmatism after Intraocular Lens Implantation

Purpose:To investigate a simple method during extracapsular cataract extraction with posteior chamber intraocular lens implantation in order to reduce surgically induced corneal astig-matism.Methods:A modified scleral flap incision was used in the extracapsular cataract extraction with intraocular lens implantation and the postoperative changes in conreal astigmatism was observed.Results:The peak value of postoperative corneal astigmatism was3.60D,and the corneal astigmatism regression was 2.11D,surgically induced astigmatism was less significant in modified scleral flap incision group than that in convention-al limbal incison group(P<0.05).Conclusions:The modified scleral flap inciston is an ideal incision for cataract ex-traction with intraocular lens implantation when phacoemulsifier is not avaliable.Eye Science1995;11:136-139.

延期乳房再造中应用单蒂TRAM皮瓣移植重建自然形态的乳房

目的:探讨乳癌根治术后延期乳房再造中应用单蒂腹部横形腹直肌肌皮瓣(transverse rectus abdominis musculocu taneous,TRAM)重塑自然形态乳房的方法。方法:2004年7月～2007年10月,笔者应用单蒂TRAM皮瓣对15例患者进行延期乳房再造。于较正常侧高1～2cm的位置设计患侧新乳房下皱襞,切除范围为新乳房下皱襞与乳癌根治术后切口瘢痕之间的皮肤,TRAM皮瓣修复瘢痕切除后创面。结果:所有患者术后随访4～26个月,平均随访15.2个月,效果优10例,良3例,一般2例。2例患者出现TRAM皮瓣II区皮下脂肪坏死,经引流后愈合,1例患者乳房下皱襞较健侧低,二期修复后手术效果为优。结论:本组病例应用的技术有利于再造乳房呈现自然形态,避免明显补丁样畸形。

Boariflap治疗长段医源性输尿管损伤Ⅰ期与Ⅱ期手术的比较

目的探讨Ⅰ期Boari flap治疗长段医源性的输尿管与Ⅱ期同种手术的疗效。方法通过回顾性研究39例长段医源性的输尿管损伤患者,并根据手术时机将其分为两组,分别为Ⅰ期手术组(A组)12例与Ⅱ期手术组(B组)27例,对两组患者的手术时间,术中出血量,尿管拔出时间,住院天数,双J管拔出时间等指标进行比较。结果两组手术均成功完成,两组患者各项指标对比差异无统计学意义;其中21例患者(A组7例,B组14例)术后随访6个月～1年,两组患者均恢复良好,积水明显缓解,差异无统计学意义。结论Ⅰ期行Boari flap在治疗长段医源性的输尿管损伤的疗效与Ⅱ期修复差异并无统计学意义,且大大减轻了患者心理、生理及经济上的负担,值得在临床推广。