Carramaschi Fábio R.
Full Text Available The rejection of allotransplantation of epigastric microsurgical flaps and the effect of immunosuppression have been studied in 58 rats. Three sets of experiments were planned: (1 Wistar Furth isogenic donors and receptors (control set; (2 Brown Norway donors and Wistar Furth receptors (rejection set; and (3 Brown Norway donors and Wistar Furth immunosuppressed receptors (cyclosporin A set. Cyclosporin A (10 mg/kg/d treated rats had a transplantation survival rate of up to 30 days: 83.3% among isogenic animals and 60% among allogeneic. There was 100% rejection by the 9th day after the transplantation in allogeneic non-immunosuppressed rats. Biopsies embedded with historesin were taken from the flap and normal contralateral skin (used as control on the 3rd, 7th, 15th, and 30th days after the surgery. A quantitative study of infiltrating lymphocytes in the flaps, with and without cyclosporin A, was done by evaluating the local inflammatory infiltrate. A significant increase in the number of lymphocytes among the rejection and immunosuppressed groups was seen, as compared to the isogenic set. Local lymphocytosis in allogeneic non-immunosuppressed transplantations reached its highest level on the 3rd day after surgery, before gross findings of rejection, which could only be seen by naked eye on the 5th or 6th day. Therefore, we conclude that cyclosporin A is effective in preserving allogenic transplantation in rats. Biopsies of transplanted areas may contribute to earlier diagnosis of the need for immunosuppressive therapy.
Duncumb, Joseph W; Miyagi, Kana; Forouhi, Parto; Malata, Charles M
Abdominal free flaps for microsurgical breast reconstruction are most commonly harvested based on the deep inferior epigastric vessels that supply skin and fat via perforators through the rectus muscle and sheath. Intact perforator anatomy and connections are vital for subsequent optimal flap perfusion and avoidance of necrosis, be it partial or total. The intraflap vessels are delicate and easily damaged and it is generally advised that patients should avoid heparin injection into the abdominal pannus preoperatively as this may compromise the vascular perforators through direct needle laceration, pressure from bruising, haematoma formation, or perforator thrombosis secondary to external compression. We report three cases of successful deep inferior epigastric perforator (DIEP) flap harvest despite patients injecting therapeutic doses of low molecular weight heparin into their abdomens for thrombosed central venous lines (portacaths™) used for administering primary chemotherapy in breast cancer.
Joseph W. Duncumb
Full Text Available Abdominal free flaps for microsurgical breast reconstruction are most commonly harvested based on the deep inferior epigastric vessels that supply skin and fat via perforators through the rectus muscle and sheath. Intact perforator anatomy and connections are vital for subsequent optimal flap perfusion and avoidance of necrosis, be it partial or total. The intraflap vessels are delicate and easily damaged and it is generally advised that patients should avoid heparin injection into the abdominal pannus preoperatively as this may compromise the vascular perforators through direct needle laceration, pressure from bruising, haematoma formation, or perforator thrombosis secondary to external compression. We report three cases of successful deep inferior epigastric perforator (DIEP flap harvest despite patients injecting therapeutic doses of low molecular weight heparin into their abdomens for thrombosed central venous lines (portacaths™ used for administering primary chemotherapy in breast cancer.
Damen, Tim H C; Morritt, Andrew N; Zhong, Toni; Ahmad, Jamil; Hofer, Stefan O P
Multiple preoperative, intraoperative and postoperative decisions can influence the outcome of microsurgical breast reconstruction. We have simplified the decision-making process by incorporating a number of algorithms into our microsurgical breast reconstruction practice and critically review our results in this study. Prospectively maintained databases for all microsurgical breast reconstructions performed by a single surgeon over a nine-year period were examined to determine: patient demographics; operative details including flap choice, donor and recipient vessel selection; and, details of intraoperative and early postoperative (406 Consecutive free flap microsurgical breast reconstructions (164 unilateral and 121 bilateral) were performed in 285 patients over the study period. Deep inferior epigastric artery perforator (DIEP) flaps (88%, n=359) were used most commonly followed by muscle-sparing transverse rectus abdominis musculocutaneous (MS-TRAM) flaps (11%, n=44), and fascial-sparing TRAM (FS-TRAM) flaps (0.7%, n=3). One-hundred-seventy-one (48%) DIEP flaps were based on a single perforator while 188 (52%) had multiple perforators. The internal mammary (IM) artery and vein were used as the recipient vessels for 99% (n=403) of flaps. A second venous anastomosis was required for 11.8 percent (n=48) of flaps. Partial flap failure occurred in nine (2.2%) flaps while total flap failure occurred in two flaps (0.5%). Minimum follow-up was three months. Incorporating a number of algorithms into our practice has enabled us to simplify the decision-making processes involved in microsurgical breast reconstruction and to consistently obtain successful surgical outcomes. Copyright © 2013 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Keith S. Hansen
Full Text Available Autologous breast reconstruction utilizing a perforator flap is an increasingly popular method for reducing donor site morbidity and implant-related complications. However, aberrant anatomy not readily visible on computed tomography angiography is a rare albeit real risk when undergoing perforator flap reconstruction. We present an operative case of a patient who successfully underwent a bilateral breast reconstruction sourced from a unilateral abdominal flap divided into deep superior epigastric artery and superficial circumflex iliac artery flap segments.
Gerressen, Marcus; Pastaschek, Claudia Inge; Riediger, Dieter; Hilgers, Ralf-Dieter; Hölzle, Frank; Noroozi, Nelson; Ghassemi, Alireza
The reconstruction of extended soft tissue and bony defects in the maxillofacial region with microsurgical flaps is considered to be the therapy of first choice. The aim of this retrospective study was to detect different influencing factors concerning flap survival. We examined the data of 406 patient cases (121 female and 285 male cases; mean age, 57 years) undergoing reconstruction with a microsurgical flap in our facility between 1998 and 2010. In these cases 326 soft tissue flaps (radial forearm flap, scapula flap, latissimus dorsi flap, anterolateral thigh flap, lateral arm flap, and jejunum flap) and 80 bony flaps (fibula flap and deep circumflex iliac artery flap) were examined. Evaluated parameters were, among others, the timing of reconstruction, defect localization, and recipient vessels used (external vs internal jugular system), as well as anticoagulative management. We statistically analyzed data by means of a χ(2) test, taking account of the odds ratio with P < .05, which was deemed significant. The overall flap survival rate was approximately 92%, without any gender- or age-specific differences. Primary reconstructions proceeded distinctly more successfully than secondary reconstructions (P < .01). Likewise, the defect localization exerted a significant effect on the survival rate (P = .01), with a more caudal localization affecting flap survival positively. Finally, neither the anticoagulation regimen nor the choice of recipient vein system exercised an influence on the survival rate. Microsurgical tissue transfer is a convenient and reliable method in maxillofacial surgery, provided that one is aware of the determining factors for success. Copyright © 2013 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.
Bosc, R; Fitoussi, A; Pigneur, F; Tacher, V; Hersant, B; Meningaud, J-P
The augmented reality on smart glasses allows the surgeon to visualize three-dimensional virtual objects during surgery, superimposed in real time to the anatomy of the patient. This makes it possible to preserve the vision of the surgical field and to dispose of added computerized information without the need to use a physical surgical guide or a deported screen. The three-dimensional objects that we used and visualized in augmented reality came from the reconstructions made from the CT-scans of the patients. These objects have been transferred through a dedicated application on stereoscopic smart glasses. The positioning and the stabilization of the virtual layers on the anatomy of the patients were obtained thanks to the recognition, by the glasses, of a tracker placed on the skin. We used this technology, in addition to the usual locating methods for preoperative planning and the selection of perforating vessels for 12 patients operated on a breast reconstruction, by perforating flap of deep lower epigastric artery. The "hands-free" smart glasses with two stereoscopic screens make it possible to provide the reconstructive surgeon with binocular visualization in the operative field of the vessels identified with the CT-scan. Copyright © 2017 Elsevier Masson SAS. All rights reserved.
Hamdi, Moustapha; Van Landuyt, Koenraad; Ulens, Sara; Van Hedent, Eddy; Roche, Nathalie; Monstrey, Stan
Pedicled superior epigastric artery perforator (SEAP) flaps can be raised to cover challenging thoracic defects. We present an anatomical study based on multidetector computerized tomography (MDCT) scan findings of the SEA perforators in addition to the first reported clinical series of SEAP flaps in anterior chest wall reconstruction. (a) In the CT scan study, images of a group of 20 patients who underwent MDCT scan analysis were used to visualise bilaterally the location of musculocutaneous SEAP. X- and Y-axes were used as landmarks to localise the perforators. The X-axis is a horizontal line at the junction of sternum and xyphoid (JCX) and the Y-axis is at the midline. (b) In the clinical study, seven pedicled SEAP flaps were performed in another group of patients. MDCT images revealed totally 157 perforators with a mean of 7.85 perforators per patient. The dominant perforators (137 perforators) were mainly localised in an area between 1.5 and 6.5 cm from the X-axis on both sides and between 3 and 16 cm below the Y-axis. The calibre of these dominant perforators was judged as 'good' to 'very good' in 82.5% of the cases. The average dimension of the flap was 21.7x6.7 cm. All flaps were based on one perforator. Mean harvesting time was 110 min. There were no flap losses. Minor tip necrosis occurred in two flaps. One of them was treated with excision and primary closure. Our clinical experience indicates that the SEAP flap provides a novel and useful approach for reconstruction of anterior chest wall defects. CT-based imaging allows for anatomical assessment of the perforators of the superior epigastric artery (SEA).
Full Text Available [english] Background: A tremendous number of free flaps have been developed in the past. As the surgical result depends not only on a successful flap transfer but also on the harvest, this paper details the procedures for undertaking the first total endoscopic harvest of a serratus fascia flap for free flap transplantation to the lower leg. Patient and methods: In September 2012 we performed the first total endoscopic serratus anterior fascia free flap harvest. The incision of 2.5 cm length was made 10 cm in front of anterior muscle border of the latissimus dorsi at level with the midthorax. After insertion of a flexible laparoscopic single port system we started CO gas insufflation. We used this setting to meticulously prepare a neo cavity between atissimus dorsi and M. serratus anterior. The vessels were dissected and the thoraco-dorsal nerve was separated. With a second auxiliary incision we used a clamp to support the raising of the fascia flap from the underlying muscle. Finally we clipped the vessels to the latissimus dorsi muscle and the flap vessels at the Arteria and Vena axillaris. The flap was extracted via the 2.5 cm incision.Results: We were able to perform a total endoscopic harvest of a serratus fascia flap for free flap reconstruction of soft tissues. With this new operative technique we were able to avoid a long skin incision, which in our view lowers the morbidity at the harvest area.Conclusion: We describe a new method for the total endoscopic harvest of the serratus fascia flap for free flap transfer. The flap was harvested within reasonable time and following surgery leaves the patient with minimal donor site morbidity compared to the open technique.
Lam, D L; Mitsumori, L M; Neligan, P C; Warren, B H; Shuman, W P; Dubinsky, T J
Autologous breast reconstructive surgery with deep inferior epigastric artery (DIEA) perforator flaps has become the mainstay for breast reconstructive surgery. CT angiography and three-dimensional image post processing can depict the number, size, course and location of the DIEA perforating arteries for the pre-operative selection of the best artery to use for the tissue flap. Knowledge of the location and selection of the optimal perforating artery shortens operative times and decreases patient morbidity.
Chae, Michael P; Hunter-Smith, David J; Rostek, Marie; Smith, Julian A; Rozen, Warren Matthew
Optimizing preoperative planning is widely sought in deep inferior epigastric artery perforator (DIEP) flap surgery. One reason for this is that rates of fat necrosis remain relatively high (up to 35%), and that adjusting flap design by an improved understanding of individual perforasomes and perfusion characteristics may be useful in reducing the risk of fat necrosis. Imaging techniques have substantially improved over the past decade, and with recent advances in 3D printing, an improved demonstration of imaged anatomy has become available. We describe a 3D-printed template that can be used preoperatively to mark out a patient's individualized perforasome for flap planning in DIEP flap surgery. We describe this "perforasome template" technique in a case of a 46-year-old woman undergoing immediate unilateral breast reconstruction with a DIEP flap. Routine preoperative computed tomographic angiography was performed, with open-source software (3D Slicer, Autodesk MeshMixer and Cura) and a desktop 3D printer (Ultimaker 3E) used to create a template used to mark intra-flap, subcutaneous branches of deep inferior epigastric artery (DIEA) perforators on the abdomen. An individualized 3D printed template was used to estimate the size and boundaries of a perforasome and perfusion map. The information was used to aid flap design. We describe a new technique of 3D printing a patient-specific perforasome template that can be used preoperatively to infer perforasomes and aid flap design.
Echazarreta-Gallego, Estíbaliz; Pola-Bandrés, Guillermo; Arribas-Del Amo, María Dolores; Gil-Romea, Ismael; Sousa-Domínguez, Ramón; Güemes-Sánchez, Antonio
Breast prostheses exposure is probably the most devastating complication after a skin sparing mastectomy (SSM) and implant-based, one-stage, breast reconstruction. This complication may occur in the immediate post-operative period or in the weeks and even months after the procedure. In most cases, the cause is poor skin coverage of the implant due to skin necrosis. Eight consecutive cases of implant exposure (or risk of exposure) due to skin necrosis in SSM patients over a period of 5 years, all patients were treated using a random epigastric rotation flap, executed by the same medical team. A random epigastric flap (island or conventional rotation flap) was used to cover the skin defect. All the patients completed the procedure and all prostheses were saved; there were no cases of flap necrosis or infection. Cases of skin necrosis after SSM and immediate implant reconstruction, in which the implant is at risk of exposure, can be successfully treated with a random epigastric rotation flap.
Lee, Yoon Jae; Kim, Hak Young; Han, Hyun Ho; Moon, Suk-Ho; Byeon, Jun Hee; Rhie, Jong Won; Ahn, Sang Tae; Oh, Deuk Young
Reduced tissue damage is a theoretical advantage of using an ultrasonic harmonic scalpel. We hypothesized that the harmonic scalpel would outperform electrocautery in deep inferior epigastric perforator flap surgery, possibly resulting in a shorter operative time and reduced postoperative drainage and pain. Between January and August 2015, 24 consecutive patients were assigned to immediate deep inferior epigastric perforator flap elevation (12 for bipolar electrocautery and 12 for harmonic scalpel). The main outcome variables were total operative time, flap elevation time (starting from the fascia incision), and drainage volume. We compared the number of perforators isolated and the Moon and Taylor classification of the pedicle. Data were tested for normality using the Kolmogorov-Smirnov test before analysis. Continuous variables were compared by Wilcoxon rank-sum test. Data were analyzed using the statistical software SAS, version 9.3 (SAS Institute, Cary, NC, USA). Both groups were comparable with respect to clinical characteristics (mean age, body mass index, and flap weights). There was a statistically significant difference in the operative time between dissection with the harmonic scalpel and electrocautery (305.2 vs. 380.3 min, respectively, p = 0.002). The flap elevation time was reduced, particularly when using the harmonic scalpel where its usage seems crucial for dissecting deep inferior epigastric perforators (59.8 vs. 145.9 min, respectively, p electrocautery. Copyright © 2016 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Rosson, Gedge D; Shridharani, Sachin M; Magarakis, Michael; Manahan, Michele A; Stapleton, Sahael M; Gilson, Marta M; Flores, Jaime I; Basdag, Basak; Fishman, Elliot K
Three-dimensional computed tomographic angiography (3D CTA) can be used preoperatively to evaluate the course and caliber of perforating blood vessels for abdominal free-flap breast reconstruction. For postmastectomy breast reconstruction, many women inquire whether the abdominal tissue volume will match that of the breast to be removed. Therefore, our goal was to estimate preoperative volume and weight of the proposed flap and compare them with the actual volume and weight to determine if diagnostic imaging can accurately identify the amount of tissue that could potentially to be harvested. Preoperative 3D CTA was performed in 15 patients, who underwent breast reconstruction using the deep inferior epigastric artery perforator flap. Before each angiogram, stereotactic fiducials were placed on the planned flap outline. The radiologist reviewed each preoperative angiogram to estimate the volume, and thus, weight of the flap. These estimated weights were compared with the actual intraoperative weights. The average estimated weight was 99.7% of the actual weight. The interquartile range (25th to 75th percentile), which represents the "middle half" of the patients, was 91-109%, indicating that half of the patients had an estimated weight within 9% of the actual weight; however, there was a large range (70-133%). 3D CTA with stereotactic fiducials allows surgeons to adequately estimate abdominal flap volume before surgery, potentially giving guidance in the amount of tissue that can be harvested from a patient's lower abdomen. Copyright © 2011 Wiley-Liss, Inc.
Saint-Cyr, Michel; Lakhiani, Chrisovalantis; Cheng, Angela; Mangum, Michael; Liang, Jinyang; Teotia, Sumeet; Livingston, Edward H.; Zuzak, Karel J.
The selection of well-vascularized tissue during DIEP flap harvest remains controversial. While several studies have elucidated cross-midline perfusion, further characterization of perfusion to the ipsilateral hemiabdomen is necessary for minimizing rates of fat necrosis or partial fat necrosis in bilateral DIEP flaps. Eighteen patients (29 flaps) underwent DIEP flap harvest using a prospectively designed protocol. Perforators were marked and imaged with a novel system for quantitatively measuring tissue oxygenation, the Digital Light Hyperspectral Imager. Images were then analyzed to determine if perforator selection influenced ipsilateral flap perfusion. Flaps based on a single lateral row perforator (SLRP) were found to have a higher level of hemoglobin oxygenation in Zone I (mean %HbO2 = 76.1) compared to single medial row perforator (SMRP) flaps (%HbO2 = 71.6). Perfusion of Zone III relative to Zone I was similar between SLRP and SMRP flaps (97.4% vs. 97.9%, respectively). These differences were not statistically significant (p>0.05). Perfusion to the lateral edge of the flap was slightly greater for SLRP flaps compared SMRP flaps (92.1% vs. 89.5%, respectively). SMRP flaps had superior perfusion travelling inferiorly compared to SLRP flaps (88.8% vs. 83.9%, respectively). Overall, it was observed that flaps were better perfused in the lateral direction than inferiorly. Significant differences in perfusion gradients directed inferiorly or laterally were observed, and perforator selection influenced perfusion in the most distal or inferior aspects of the flap. This suggests broader clinical implications for flap design that merit further investigation.
The vacuum-assisted closure (VAC) device has a wide range of clinical applications, including treatment of infected surgical wounds, traumatic wounds, pressure ulcers, wounds with exposed bone and hardware, diabetic foot ulcers, and venous stasis ulcers. Increased release of growth factors has been described, leading to improved vascularization and thereby formation of new tissue. The system is also used in burn surgery for reconstructive purposes. In this case report, a patient suffered from a third-degree burn injury to the dorsum of the hand with exposure of tendons, necessitating the use of a flap reconstruction. The patient was treated with a superficial inferior-epigastric artery-based flap and the VAC system was applied in a created glove-like shape. Hastened attachment of the flap onto the exposed fingers was observed after 4 days. The author reports on the additional use of the VAC system to hasten flap attachment in a patient with a burn injury to the dorsum of the hand.
A. R. Gagnon
Full Text Available Con el desarrollo de los colgajos miocutáneos de recto abdominal (TRAM, el abdomen inferior ha sido reconocido como la principal área dadora de tejidos autólogos de alta calidad, especialmente útiles en reconstrucción mamaria. Más recientemente la habilidad para obtener componentes adiposocutáneos similares sin sacrificar el músculo recto ha revolucionado el campo de la Cirugía Reconstructiva. El advenimiento de los colgajos de perforantes ha permitido a los cirujanos plásticos lograr los mismos buenos resultados estéticos que con los colgajos miocutáneos tradicionales, pero con un considerable descenso en la morbilidad del área donante. Con los colgajos de perforantes de la arteria epigástrica inferior profunda (DIEP y de la arteria epigástrica inferior superficial (SIEA, los pacientes han incrementado sus opciones de reconstrucción. Este artículo revisa la anatomía quirúrgica de la pared abdominal relativa a los colgajos SIEA y DIEP. Se explican detalladamente los pasos principales para la preparación preoperatoria, la técnica quirúrgica y los cuidados postoperatorios. Se discuten las ventajas y desventajas y se presen- tan los trucos técnicos que pueden ayudar a mejorar el resultado final. Además se ilustran con ayuda de casos clínicos las indicaciones típicas y atípicas.Following the development of the transverse rectus abdominis myocutaneous (TRAM flap, the lower abdomen has been recognized as a prime source of high quality autogenous tissue, especially useful in breast reconstruction. More recently, the ability to harvest a similar adipocutaneous component without sacrifice of the rectus muscle has revolutionized the field of reconstructive surgery. The advent of perforator flaps has allowed plastic surgeons to achieve the same highly esthetic results as with the former myocutaneous flaps while significantly decreasing the donor site morbidity. With the deep inferior epigastric artery perforator (DIEP flap and
Di Lorenzo, Sara; Zabbia, Giovanni; Corradino, Bartolo; Tripoli, Massimiliano; Pirrello, Roberto; Cordova, Adriana
BACKGROUND Basal cell carcinoma (BCC) greater than 5 cm in diameter is called giant basal cell carcinoma (GBCC), or super giant basal cell carcinoma if it has a diameter larger than 20 cm. Giant BCC only accounts for 0.5% of BCCs and super giant BCC is exceedingly rare. On account of their rarity, there are no established guidelines for GBCC treatment. CASE REPORT We describe a peculiar case of an 82-year-old woman with a GBCC carcinoma of the lower abdominal wall. The tumor was surgically removed with ipsilateral inguinal lymph nodes and the abdominal wall was reconstructed immediately with a pedicled deep inferior epigastric artery perforator (DIEP) flap. CONCLUSIONS Treatment of giant basal cell carcinoma is often difficult, especially in elderly patients with poor general health and multiple pathologies. The pedicled DIEP flap is rotated to cover the loss of substance without tension, and it is easy to harvest and transfer. This flap allowed a good result without local or systemic complication. We present this report as a reminder of the occasional occurrence of extremely aggressive BCCs. We believe that, especially for rare tumors like these, it is very useful for the entire scientific community to publish these cases and the therapeutic strategies used to treat them.
Full Text Available Abstract Background Mastectomy in the context of breast malignancy can have a profoundly negative impact on a woman’s self-image, impairing personal, sexual and social relationships. The deep inferior epigastric perforator (DIEP flap and implants are the two commonest reconstructive modalities that can potentially overcome this psychological trauma. The comparative data on clinical outcomes and costs of the two modalities is limited. We aim to synthesise the current evidence on DIEP versus implants to establish which is the superior technique for breast reconstruction, in terms of clinical outcomes and cost-effectiveness. Methods A comprehensive search will be undertaken of EMBASE, MEDLINE, Google Scholar, CENTRAL and Science citation index databases (1994 up to August 2017 to identify studies relevant for the review. Primary human studies evaluating clinical outcomes and cost of DIEP and implant-based reconstruction in context of breast malignancy will be included. Primary outcomes will be patient satisfaction and cosmetic outcome from patient-reported outcome measures (scores from validated tools, e.g. BREAST-Q tool, complications and cost-analysis. The secondary outcomes will be duration of surgery, number of surgical revisions, length of stay, availability of procedures and total number of clinic visits. Discussion This will be the first systematic review and meta-analysis in available literature comparing the clinical outcomes and cost-effectiveness of DIEP and implants for breast reconstruction. This review is expected to guide worldwide clinical practice for breast reconstruction. Systematic review registration PROSPERO CRD42017072557 .
Sweta Kumari Singh
Full Text Available Background: The aim of the present study was to compare the root coverage of localized gingival recession (GR using modified coronally advanced flap (CAF (Sanctis and Zucchelli's technique and root conditioning 24% ethylenediaminetetraacetic acid (EDTA when done under magnification and without magnification. Materials and Methods: A total of 20 sites were taken with Miller's Class I GR (10 in test and 10 in control. All clinical parameters were recorded at baseline, 1 month, and 3 months. CAF and root conditioning were done with 24% EDTA. Surgical procedure at test site was carried under magnification ×3.5 and at control site was done without magnification. Results: Plaque index, gingival index, clinical attachment level, probing depth, width of keratinized tissue (WKT, recession depth (RD, and recession width (RW at baseline and 3 months were compared using Student's t- test. Mean WKT at baseline in control and test group was 4.22 ± 2.05 and 3.22 ± 1.09 which increased to 4.56 ± 1.59 and 4.50 ± 0.94, respectively, at 3 months. RD at baseline in control and test groups was 2.56 ± 0.53 and 2.67 ± 0.87 which reduced to 1.83 ± 0.71 and 1.22 ± 1.20, respectively. RW at baseline in control and test group was 3.56 ± 1.13 and 3.67 ± 0.50 which decreased to 3.06 ± 1.01 and 1.72 ± 1.39, respectively. All the clinical parameters were statistically not significant between control and test groups. Mean visual analog scale (VAS at 7 days postoperatively in control and test groups was 1.78 ± 0.97 and 0.22 ± 0.44, respectively. The VAS scores were found to be significantly lower in the test group at both 3rd and 7th day postoperatively showing less pain in test group. Conclusion: Microsurgery offers less pain and enhanced outcomes when compared to traditional macrosurgery.
Hage, J. Joris; Woerdeman, Leonie A. E.; Smeulders, Mark J. C.
The forearm part of the extended lateral arm flap may be separately raised on the most distal septocutaneous perforator of the posterior collateral radial artery. This truly distal lateral arm flap shares most of the advantages of the radial forearm flap and is associated with less donor site
Schoeller, Thomas; Huemer, Georg M; Wechselberger, Gottfried
The transverse musculocutaneous gracilis (TMG) flap has received little attention in the literature as a valuable alternative source of donor tissue in the setting of breast reconstruction. The authors give an in-depth review of their experience with breast reconstruction using the TMG flap. A retrospective review of 111 patients treated with a TMG flap for breast reconstruction in an immediate or a delayed setting between August of 2002 and July of 2007 was undertaken. Of these, 26 patients underwent bilateral reconstruction and 68 underwent unilateral reconstruction, and 17 patients underwent reconstruction unilaterally with a double TMG flap. Patient age ranged between 24 and 65 years (mean, 37 years). Twelve patients had to be taken back to the operating room because of flap-related problems and nine patients underwent successful revision microsurgically, resulting in three complete flap losses in a series of 111 patients with 154 transplanted TMG flaps. Partial flap loss was encountered in two patients, whereas fat tissue necrosis was managed conservatively in six patients. Donor-site morbidity was an advantage of this flap, with a concealed scar and minimal contour irregularities of the thigh, even in unilateral harvest. Complications included delayed wound healing (n = 10), hematoma (n = 5), and transient sensory deficit over the posterior thigh (n = 49). The TMG flap is more than an alternative to the deep inferior epigastric perforator (DIEP) flap in microsurgical breast reconstruction in selected patients. In certain indications, such as bilateral reconstructions, it possibly surpasses the DIEP flap because of a better concealed donor scar and easier harvest.
Tu, Yiji; Chen, Zenggan; Lineaweaver, William Charles; Zhang, Feng
Several recipient vessels can be used in free microsurgical fibula flaps (MFFs) for the treatment of avascular necrosis of the femoral head (ANFH). Few articles investigate the influence of different recipient vessels on outcomes of MFF for ANFH. A comprehensive literature search of databases including PubMed-Medline, Ovid-Embase, and Cochrane Library was performed to collect the related studies. The Medical Subject Headings used were "femur head necrosis" and "bone transplantation." The relevant words in title or abstract included but not limited to "fibula flap," "fibular flap," "vascularized fibula," "vascularized fibular," "free fibula," "free fibular," "femoral head necrosis," "avascular necrosis of femoral head," and "ischemic necrosis of femoral head." The methodological index for nonrandomized studies was adopted for assessing the studies included in this review. Finally, 15 studies encompassing a total of 1267 patients (1603 hips) with ANFH were pooled in the overall analysis. Recipient vessels for MFF included the ascending branch of the lateral circumflex femoral artery and vein in 8 studies, descending branch of the lateral circumflex femoral artery and vein in 2 studies, second perforating branch of the deep femoral artery and vein in 4 studies, and inferior gluteal artery and vein in 1 study. Preoperative and postoperative average Harris hip score and pooled analyses of the rate of conversion, radiographic progression, and hip surgery-related complications showed no significant difference on the outcomes of MFF on ANFH between using different recipient vessels. Different recipient vessels did not affect outcomes in MFF procedures for ANFH. High-quality randomized controlled trials and prospective studies would be necessary to clarify reliable advantages and disadvantages between different recipient vessels. Until then, surgeons are justified in using ascending branch of the lateral circumflex femoral artery and vein, descending branch of the lateral
Vargas, Christina R; Koolen, Pieter G; Anderson, Katarina E; Paul, Marek A; Tobias, Adam M; Lin, Samuel J; Lee, Bernard T
Mastectomy skin necrosis represents a significant clinical morbidity after immediate breast reconstruction. In addition to aesthetic deformity, necrosis of the native mastectomy skin may require debridement, additional reconstruction, or prolonged wound care and potentially delay oncologic treatment. This study aims to evaluate patient and procedural characteristics to identify predictors of mastectomy skin necrosis after microsurgical breast reconstruction. A retrospective review was performed of all immediate microsurgical breast reconstructions performed at a single academic center. Patient records were queried for age, diabetes, active smoking, previous breast surgery, preoperative radiation, preoperative chemotherapy, body mass index, mastectomy type, mastectomy weight, flap type, autologous flap type, and postoperative mastectomy skin flap necrosis. There were 746 immediate autologous microsurgical flaps performed by three plastic surgeons at our institution during the study period. The incidence of mastectomy skin flap necrosis was 13.4%. Univariate analysis revealed a significantly higher incidence of mastectomy skin necrosis in patients with higher mastectomy weight (P mastectomy type. Multivariate analysis demonstrated statistically significant associations between mastectomy skin necrosis and both increasing mastectomy weight (odds ratio 1.348 per quartile increase, P = 0.009) and diabetes (odds ratio 2.356, P = 0.011). Increasing mastectomy weight and coexisting diabetes are significantly associated with postoperative mastectomy skin necrosis after microsurgical reconstruction. These characteristics should be considered during patient counseling, procedure selection, operative planning, and intraoperative tissue viability assessment. Copyright © 2015 Elsevier Inc. All rights reserved.
Hummelink, S.L.; Verhulst, A.C.; Maal, T.J.J.; Hoogeveen, Y.L.; Schultze Kool, L.J.; Ulrich, D.J.O.
BACKGROUND: Determining the ideal volume of the harvested flap to achieve symmetry in deep inferior epigastric artery perforator (DIEP) flap breast reconstructions is complex. With preoperative imaging techniques such as 3D stereophotogrammetry and computed tomography angiography (CTA) available
Full Text Available While most small to medium defects of the scalp can be covered by local flaps, large defects or complicating factors like a history of radiotherapy often require a microsurgical reconstruction.Several factors need to be considered in such procedures. A sufficient preoperative planning is based on adequate imaging of the malignancy and a multi-disciplinary concept. Several flaps are available for such reconstructions, of which the latissimus dorsi and anterior lateral thigh flaps are the most commonly used ones.In very large defects, combined flaps such as a parascapular / latissimus dorsi flaps can be highly useful or necessary. The most commonly used recipient vessels for microsurgical scalp reconstructions are the superficial temporal vessels, but various other feasible choices exist. If the concomitant veins are not sufficient, the jugular veins represent a safe backup alternative but require a vessel interposition or long pedicle. Postoperative care and patient positioning can be difficult in these patients but can be facilitated by various devices. Overall, microsurgical reconstruction of large scalp defects is a feasible undertaking if the mentioned key factors are taken into account.
Serafin, Donald; Georgiade, Nicholas G.
Since 1974, 69 patients with extensive defects have undergone reconstruction by microsurgical composite tissue transplantation. Using this method, donor composite tissue is isolated on its blood supply, removed to a distant recipient site, and the continuity of blood flow re-established by microvascular anastomoses. In this series, 56 patients (81%) were completely successful. There have been eight (12%) failures, primarily in the extremities. There have been five (7%) partial successes, (i.e., a microvascular flap in which a portion was lost requiring a secondary procedure such as a split thickness graft). In those patients with a severely injured lower extremity, the failure rate was the greatest. Most of these were arterial (six of seven). These failures occurred early in the series and were thought to be related to a severely damaged recipient vasculature. This problem has been circumvented by an autogenous interpositional vein graft, permitting more mobility of flap placement. In the upper extremity, all but one case were successful. Early motion was permitted, preventing joint capsular contractures and loss of function. Twenty-three cases in the head and neck region were successful (one partial success). This included two composite rib grafts to the mandible. Prolonged delays in reconstruction following extirpation of a malignancy were avoided. A rapid return to society following complete reconstruction was ensured. Nine patients presented for reconstruction of the breast and thorax following radical mastectomy. All were successfully reconstructed with this new technique except one patient. Its many advantages include immediate reconstruction without delayed procedures and no secondary deformity of the donor site. Healthy, well vascularized tissue can now be transferred to a previously irradiated area with no tissue loss. This new method offers many advantages to older methods of reconstruction. Length of hospital stay and immobilization are reduced. The
Eliyas, S; Vere, J; Ali, Z; Harris, I
Non-surgical endodontic retreatment is the treatment of choice for endodontically treated teeth with recurrent or residual disease in the majority of cases. In some cases, surgical endodontic treatment is indicated. Successful micro-surgical endodontic treatment depends on the accuracy of diagnosis, appropriate case selection, the quality of the surgical skills, and the application of the most appropriate haemostatic agents and biomaterials. This article describes the armamentarium and technical procedures involved in performing micro-surgical endodontics to a high standard.
El-Sherbiny, M; Abou-Elela, A; Morsy, A; Salah, M; Foda, A
This study describes the surgical technique and outcomes of live donor renal allografts with multiple arteries in which the lower polar artery was anastomosed to the inferior epigastric artery after declamping. Between 1988 and 2004, 477 consecutive live donor renal transplants were performed, including 429 with single and 48 with multiple arteries. Anastomosis of the lower polar artery to the inferior epigastric artery was used for 15 grafts with multiple arteries. Successful revascularization of all areas of the transplanted graft was confirmed by Doppler ultrasonography in most patients and radionuclide renal scanning +/- MRA in some patients. In live donor renal transplantation with multiple arteries, the anastomosis of the lower polar artery to the inferior epigastric artery after declamping avoids prolongation of the ischemia time that occurs with other surgical and microsurgical techniques of intracorporeal and ex vivo surgeries.
Jianlong, Wu; Ruixing, Hou; Guangliang, Zhou; Jihui, Ju
To study the influence of estradiol on histomorphology of skin flaps with ischemia reperfusion injury. 48 adult male Wistar rats aged 12-14 weeks old, were randomly divided into control group (group I), ischemia-reperfusion group (group II), saline group (group III), estradiol group (group IV). Superficial epigastric artery axial flap, 3 cm x 6 cm in size, was made in the left lower quadrant abdominal of each rat. Flap model with ischemia-reperfusion injury was established by using the nondestructive micro vascular clamp to clamp the superficial epigastric artery. The general condition of the flap was observed after operation. At 7 days after operation, the survival rate of the flap was detected, the flaps were harvested to receive histology and ultrastructural observation. The neutrophils level of the superficial epigastric vein were tested. 7 days after operation, the survival rate of the flap in group IV was significantly higher than that in group II, III (P organization structure in flap.
Oh, Suk Joon; Jeon, Man Kyung; Koh, Sung Hoon
Although free flap transfer is commonly performed to reconstruct facial defects, the submandibular facial artery and vein have historically been considered as adequate recipient vessels for microsurgical reconstruction. If the vascular pedicles of the free flap are short, vein grafts are necessary. The purpose of this study was to determine the indications for and effectiveness of using the nasolabial facial vessels for midfacial reconstruction. A retrospective chart review of 6 patients undergoing microsurgical reconstruction for defects of the face revealed 6 free tissue transfers in which the nasolabial facial artery and vein were considered for use as recipient vessels. Flap success rates were evaluated. Six patients (5 men and 1 woman) underwent 6 free flap transfers. Five anterior helix free flaps were used for the reconstruction of defects in the lower third of the nose. Nasal defects were due to trauma in 4 patients and squamous cell carcinoma in 1 patient. In 1 neurofibromatosis type 1 case, a radial forearm flap was used for reconstruction of the left orbital defect. The facial artery and vein in the nasolabial fold were used as the recipient artery and vein in every case. The mean length of follow-up was 5.8 years. All flaps survived. All patients were satisfied with the degree of aesthetic improvement after surgery.Use of the facial artery and vein in the nasolabial fold for facial reconstruction is reliable and safe. The nasolabial facial artery and vein should be considered as primary recipient vessels in microsurgical reconstruction of the midface.
Faloplastia mediante colgajo libre microquirúrgio antebraquial radial con doble tunelización: A propósito de un caso Microsurgical penile reconstruction with a radial forearm free-flap and double tubularization: Case report
M. Martín Díaz
Full Text Available La reconstrucción del pene sigue siendo uno de los mayores retos de la Cirugía Plástica debido a la complejidad inherente que conlleva el conseguir tanto la forma anatómica como la función urológica del pene. El objetivo ideal del cirujano al realizar una faloplastia incluye la construcción, en una sola etapa, de un pene estéticamente aceptable y con sensibilidad erógena y táctil, que permita al paciente orinar de pie y mantener relaciones sexuales. La multitud existente de colgajos que pueden ser utilizados para la reconstrucción del pene sólo demuestra que ninguna de estas técnicas se considera ideal. Sin embargo, el colgajo radial es el que se utiliza más frecuentemente y es considerado universalmente como la técnica estándar. Las desventajas relativas de la misma son el número más elevado de fístulas que aparecen inicialmente, la cicatriz residual en el antebrazo y las complicaciones urológicas potenciales a largo plazo. Presentamos una reconstrucción de pene realizada mediante un colgajo libre radial antebraquial con un nuevo diseño geométrico bidimensional que permite la creación tridimensional de un neofalo con excelentes resultados estéticos.Reconstruction of penile defects remains one of the greatest challenges in Plastic Surgery because of the inherent complexity of restoring both the anatomical form and the urologic function of the penis. The surgeon's ideal goals in performing a phalloplasty include the construction, in one-stage procedure, of an aesthetic penis with erogenous and tactile sensation, which enables the patient to void while standing and to have sexual intercourse. The multitude of flaps used for phalloplasty only demonstrates that none of these techniques is considered ideal. Still, the radial forearm flap is the most frequently used one and universally considered as the standard technique. The relative disadvantages of this technique are the rather high number of initial fistulas, the residual
AAV vector encoding human VEGF165-transduced pectineus muscular flaps increase the formation of new tissue through induction of angiogenesis in an in vivo chamber for tissue engineering: A technique to enhance tissue and vessels in microsurgically engineered tissue.
Moimas, Silvia; Manasseri, Benedetto; Cuccia, Giuseppe; Stagno d'Alcontres, Francesco; Geuna, Stefano; Pattarini, Lucia; Zentilin, Lorena; Giacca, Mauro; Colonna, Michele R
In regenerative medicine, new approaches are required for the creation of tissue substitutes, and the interplay between different research areas, such as tissue engineering, microsurgery and gene therapy, is mandatory. In this article, we report a modification of a published model of tissue engineering, based on an arterio-venous loop enveloped in a cross-linked collagen-glycosaminoglycan template, which acts as an isolated chamber for angiogenesis and new tissue formation. In order to foster tissue formation within the chamber, which entails on the development of new vessels, we wondered whether we might combine tissue engineering with a gene therapy approach. Based on the well-described tropism of adeno-associated viral vectors for post-mitotic tissues, a muscular flap was harvested from the pectineus muscle, inserted into the chamber and transduced by either AAV vector encoding human VEGF165 or AAV vector expressing the reporter gene β-galactosidase, as a control. Histological analysis of the specimens showed that muscle transduction by AAV vector encoding human VEGF165 resulted in enhanced tissue formation, with a significant increase in the number of arterioles within the chamber in comparison with the previously published model. Pectineus muscular flap, transduced by adeno-associated viral vectors, acted as a source of the proangiogenic factor vascular endothelial growth factor, thus inducing a consistent enhancement of vessel growth into the newly formed tissue within the chamber. In conclusion, our present findings combine three different research fields such as microsurgery, tissue engineering and gene therapy, suggesting and showing the feasibility of a mixed approach for regenerative medicine.
Pap-Szekeres, Jozsef; Cserni, Gabor; Furka, Istvan; Svebis, Mihaly; Cserni, Tamas; Brath, Endre; Nemeth, Norbert; Miko, Iren
Our objective was the elaboration of a new animal model for the free transplantation of an omental flap and the examination of its viability in dogs. The cooled omental flap from the abdomen was freely transplanted to the lateral cervical region, and its blood supply was established with microsurgical anastomoses. The technique was developed in 5 dogs, and short-term survival examinations were later carried out in 3 cases by means of this method. Postoperative viability was assessed by angiography, methylene blue testing, and histology. Of the 3 transplanted grafts, 2 still survived 1 week after the operation. For technical reasons, 1 flap thrombotized. For determination of the viability of the transplanted graft, histology proved best. Vital reactions, including granulation tissue and angiogenesis, were present on the histological slides. The short-term survival of an omental flap can be ensured with microsurgical transplantation in dogs. Copyright 2003 Wiley-Liss, Inc.
Satish P Bhat
Full Text Available Introduction: Viscoelastic properties of skin in coloured ethnic groups are less favourable compared to Caucasians for executing Keystone flaps. Keystone flaps have so far been evaluated and reported only in Caucasians. The potential of Keystone flaps in a coloured ethnic group is yet unknown. Aim: This article reviews the experience to reconstruct skin defects presenting in a coloured ethnic group, by using Keystone flaps, with a review of existing literature. Design: Uncontrolled case series. Materials and Methods: This retrospective review involves 55 consecutive Keystone flaps used from 2009 to 2012, for skin defects in various locations. Patient demographic data, medical history, co-morbidity, surgical indication, defect features, complications, and clinical outcomes are evaluated and presented. Results: In this population group with Fitzpatrick type 4 and 5 skin, the average patient age was 35.73. Though 60% of flaps (33/55 in the series involved specific risk factors, only two flaps failed. Though seven flaps had complications, sound healing was achieved by suitable intervention giving a success rate of 96.36%. Skin grafts were needed in only four cases. Conclusions: Keystone flaps achieve primary wound healing for a wide spectrum of defects with an acceptable success rate in a coloured skin population with unfavorable biophysical properties. By avoiding conventional local flaps and at times even microsurgical flaps, good aesthetic outcome is achieved without additional skin grafts or extensive operative time. All advantages seen in previous studies were verified. These benefits can be most appreciated in coloured populations, with limited resources and higher proportion of younger patients and unfavorable defects.
Flores, Jaime I; Magarakis, Michael; Venkat, Raghunandan; Shridharani, Sachin M; Rosson, Gedge D
Two work-horse approaches to postmastectomy breast reconstruction are the deep inferior epigastric perforator flap and the superior gluteal artery perforator (SGAP) flap [and its variation, the lateral septocutaneous superior gluteal artery perforator flap]. Our purpose was fourfold: 1) to analyze our experience with the SGAP flaps for simultaneous bilateral breast reconstruction; 2) to analyze our experience with lateral septocutaneous superior gluteal artery perforator flaps for that procedure; 3) to compare our results with those in the literature; and 4) to highlight the importance of preoperative three-dimensional computed tomographic angiography. A retrospective chart review was completed for 23 patients who underwent breast reconstruction between December 2005 and January 2010 via an SGAP flap (46 flaps). We reviewed flap weight, ischemia time, length of stay, overall flap survival, fat necrosis development, and emergency re-exploration. Mean weights were 571.2 ± 222.0 g (range 186-1,117 g) and 568.0 ± 237.5 g (range 209-1,115 g) for the left and right buttock flap, respectively. Mean ischemia time was 129.1 ± 15.7 and 177.7 ± 24.7 minutes for the first and second flap, respectively. Mean hospital stay was 5.3 ± 2.5 days. All flaps survived. Fat necrosis developed in five flaps (10.8%), and emergency re-exploration was required in three patients (three flaps). When harvesting abdominal tissue is a poor option, the SGAP flap is an efficacious procedure for patients desiring autologous breast reconstruction, and bilateral procedures can be performed simultaneously. Copyright © 2012 Wiley Periodicals, Inc.
Santamaria, Eric; de la Concha, Erika
Microsurgical reconstruction of complex midfacial and maxillectomy defects is among the most challenging procedures in plastic surgery, and it often requires composite flaps to improve functional and aesthetic results. Various factors have been identified as having influence in the outcome of microsurgical reconstruction. In this article, the authors present their experience with immediate and delayed reconstruction of complex maxillectomy defects in a tertiary center in Mexico. The authors present a total of 37 patients with microsurgical reconstruction of a complex maxillectomy defect; 13 patients had immediate and 24 had delayed reconstructions. The authors recommend doing immediate reconstruction when feasible. Copyright © 2016 Elsevier Inc. All rights reserved.
Bodin, Frédéric; Brunetti, Stefania; Dissaux, Caroline; Erik, A Sauleau; Facca, Sybille; Bruant-Rodier, Catherine; Liverneaux, Philippe
The purpose of this report was to present the results of comparisons of anastomotic data and flap complications in the use of venous coupler in breast reconstruction with the transverse musculocutaneous gracilis (TMG) flap and the deep inferior epigastric perforator (DIEP) flap. Over a three-year period, 95 patients suffering from breast cancer were treated with mastectomy and breast reconstruction using free flaps. We performed 121 mechanical venous anastomoses for 105 flap procedures (80 DIEP and 25 TMG). The coupler size, anastomotic duration, number of anastomoses and postoperative complications were assessed for the entire series. The coupling device was perfectly suitable for all end-to-end anastomoses between the vein(s) of the flap and the internal mammary vein(s). No venous thrombosis occurred. The mean anastomotic time did not significantly differ between the DIEP (330 seconds) and TMG flap procedures (352 seconds) (P = 0.069). Additionally, there were no differences in coupling time observed following a comparison of seven coupler sizes (P = 0.066). The mean coupler size used during the TMG flap procedure was smaller than that used with the DIEP (2.4 mm versus 2.8 mm) (P TMG flap (28%) than with the DIEP flap (11%). The coupler size used was smaller for the TMG procedure and when double venous anastomosis was performed. Additionally, anastomotic time was not affected by the flap type or coupler size used or by anastomosis number. © 2014 Wiley Periodicals, Inc.
Hummelink, S; Verhulst, Arico C; Maal, Thomas J J; Hoogeveen, Yvonne L; Schultze Kool, Leo J; Ulrich, Dietmar J O
Determining the ideal volume of the harvested flap to achieve symmetry in deep inferior epigastric artery perforator (DIEP) flap breast reconstructions is complex. With preoperative imaging techniques such as 3D stereophotogrammetry and computed tomography angiography (CTA) available nowadays, we can combine information to preoperatively plan the optimal flap volume to be harvested. In this proof-of-concept, we investigated whether projection of a virtual flap planning onto the patient's abdomen using a projection method could result in harvesting the correct flap volume. In six patients (n = 9 breasts), 3D stereophotogrammetry and CTA data were combined from which a virtual flap planning was created comprising perforator locations, blood vessel trajectory and flap size. All projected perforators were verified with Doppler ultrasound. Intraoperative flap measurements were collected to validate the determined flap delineation volume. The measured breast volume using 3D stereophotogrammetry was 578 ± 127 cc; on CTA images, 527 ± 106 cc flap volumes were planned. The nine harvested flaps weighed 533 ± 109 g resulting in a planned versus harvested flap mean difference of 5 ± 27 g (flap density 1.0 g/ml). In 41 out of 42 projected perforator locations, a Doppler signal was audible. This proof-of-concept shows in small numbers that flap volumes can be included into a virtual DIEP flap planning, and transferring the virtual planning to the patient through a projection method results in harvesting approximately the same volume during surgery. In our opinion, this innovative approach is the first step in consequently achieving symmetric breast volumes in DIEP flap breast reconstructions. Copyright © 2017 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Shridharani, Sachin M; Singh, Navin K; Taylor, Jesse A; Rosson, Gedge D
We present a pilot report of "banking" the contralateral hemi-abdominal deep inferior epigastric perforator (DIEP) flap under the abdominal closure in patients undergoing unilateral autologous breast reconstruction when a hemi-abdominal flap suffices. Four patients undergoing unilateral autologous breast reconstruction with a hemi-abdominal DIEP or superficial inferior epigastric artery flap had their contralateral hemi-abdominal flap left in position, or "banked," under their abdominal closure to be used in case of failure. This novel method may be of assistance when a free microvascular hemi-abdominal flap is felt to be threatened or suspect. It provides a life-boat for the younger and experienced surgeon alike, and most importantly, for the breast cancer survivor. Economic analysis of the technique reveals that the contralateral hemi-abdominal flap should be banked more often than intuition alone would suggest. (c) 2009 Wiley-Liss, Inc.
de Weerd, Louis; Weum, Sven; Mercer, James B
The aim of this paper is to evaluate dynamic infrared thermography (DIRT) as a technique to assist in preoperative perforator selection and planning of free deep inferior epigastric perforator (DIEP) flaps. Twenty-seven patients, scheduled for secondary autologous breast reconstruction with either a free DIEP flap or superficial inferior epigastric artery flap, were included in this prospective clinical study. Preoperative mapping of perforators was performed with a hand-held Doppler and DIRT. A multidetector computer tomography scan was additionally carried out in the last 8 patients. In 23 patients a DIEP flap was used. The perforator as selected from DIRT was a suitable perforator in all DIEP flaps. The location and quality of the selected perforator from DIRT corresponded well with the multidetector computer tomography scan results. Preoperative perforator selection and planning of DIEP flaps is facilitated with the use of DIRT. The technique is noninvasive and easy to use.
Chen, Yen-Chou; Huang, Eng-Yen; Lin, Pao-Yuan
The gluteus maximus myocutaneous flap was considered the workhorse that reconstructed sacral pressure sores, but was gradually replaced by fasciocutaneous flap because of several disadvantages. With the advent of the perforator flap technique, gluteal perforator (GP) flap has gained popularity nowadays. The aim of this study was to compare the complications and outcomes between GP flaps and gluteal fasciocutaneous rotation (FR) flaps in the treatment of sacral pressure sores. Between April 2007 and June 2012, 63 patients underwent sacral pressure sore reconstructions, with a GP flap used in 31 cases and an FR flap used in 32 cases. Data collected on the patients included patient age, gender, co-morbidity for being bedridden and follow-up time. Surgical details collected included the defect size, operative time and estimated blood loss. Complications recorded included re-operation, dehiscence, flap necrosis, wound infection, sinus formation, donor-site morbidity and recurrence. The complications and clinical outcomes were compared between these two groups. We found that there was no significant difference in patient demographics, surgical complications and recurrence between these two groups. In gluteal FR flap group, all recurrent cases (five) were treated by reuse of previous flaps. Both methods are comparable, good and safe in treating sacral pressure sores. Gluteal FR flap can be performed without microsurgical dissection, and re-rotation is feasible in recurrent cases. The authors suggest using gluteal FR flaps in patients with a high risk of sore recurrence. Copyright © 2013 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Odabasi, Mehmet; Arslan, Cem; Abuoglu, Hasan; Gunay, Emre; Yildiz, Mehmet Kamil; Eris, Cengiz; Ozkan, Erkan; Aktekin, Ali; Muftuoglu, M.A. Tolga
INTRODUCTION Atypical presentations of appendix have been reported including backache, left lower quadrant pain and groin pain from a strangulated femoral hernia containing the appendix. We report a case presenting an epigastric pain that was diagnosed after computed tomography as a perforated appendicitis on intestinal malrotation. PRESENTATION OF CASE A 27-year-old man was admitted with a three-day history of epigastric pain. Physical examination revealed tenderness and defense on palpation of epigastric region. There was a left subcostal incision with the history of diaphragmatic hernia repair when the patient was 3 days old. He had an intestinal malrotation with the cecum fixed at the epigastric region and the inflamed appendix extending beside the left lobe of liver. DISCUSSION While appendicitis is the most common abdominal disease requiring surgical intervention seen in the emergency room setting, intestinal malrotation is relatively uncommon. When patients with asymptomatic undiagnosed gastrointestinal malrotation clinically present with abdominal pain, accurate diagnosis and definitive therapy may be delayed, possibly increasing the risk of morbidity and mortality. CONCLUSION Atypical presentations of acute appendicitis should be kept in mind in patients with abdominal pain in emergency room especially in patients with previous childhood operation for diaphragmatic hernia. PMID:24441442
Análisis de perforantes de la epigástrica inferior profunda con Angio TC 3D, Eco Doppler color y Doppler simple de ultrasonidos en colgajo DIEP: resultados preliminares Analysis of deep inferior epigastric perforating vessels with 3D CT angiography, color Doppler ultrasonography and Doppler in diep flaps: preliminary results
J. Castro García
Doppler ultrasound, Colour-Duplex and Angio-CT with three-dimentional reconstruction. Surgical procedure findings were considered as the reference value. The evaluation procedure included the election of the most suitable perforator vessels, taking account of the location, caliber and anatomical relationships with the muscle. The Angio-CT with three-dimentional reconstruction showed 100% specificity (CI 95% 75.3-100, and very high positive predictive value. In this way, this technique could be considered as an excellent tool for preoperative evaluation of perforators flaps. Color-Duplex showed that in 46,1% of the patients (CI 95% 19,2-74% the selected perforator matched with the intraoperatively selected. Using Doppler ultrasound only in 30,8% of the cases (IC 95% 9,1-61,4% this result was observed. In this report, Angio-CT with three-dimentional reconstruction has revealed as a very high specificity technique, that allows a great account of important information, only comparable with anatomical dissection and ahead from Doppler ultrasound and color-Dupplex.
Ricci, Joseph A; Vargas, Christina R; Ho, Olivia A; Lin, Samuel J; Tobias, Adam M; Lee, Bernard T
Postoperative free flap care has historically required intensive monitoring for 24 hours in an intensive care unit. Continuous monitoring with tissue oximetry has allowed earlier detection of vascular compromise, decreasing flap loss and improving salvage. This study aims to identify whether a fast-track postoperative paradigm can be safely used with tissue oximetry to decrease intensive monitoring and costs. All consecutive microsurgical breast reconstructions performed at a single institution were reviewed (2008-2014) and cases requiring return to the operating room were identified. Data evaluated included patient demographics, the take back time course, and complications of flap loss and salvage. A cost-benefit analysis was performed to analyse the utility of a postoperative intensive monitoring setting. There were 900 flaps performed and 32 required an unplanned return to the operating room. There were 16 flaps that required a reexploration within the first 24 hours; the standard length of intensive unit monitoring. After 4 hours, there were 7 flaps (44%) detected by tissue oximetry for reexploration. After 15 hours of intensive monitoring postoperatively, cost analysis revealed that the majority (15/16; 94%) of failing flaps had been identified and the cost of identifying each subsequent failing flap exceeded the cost of another hour of intensive monitoring. The postoperative paradigm for microsurgical flaps has historically required intensive unit monitoring. Using tissue oximetry, a fast-track pathway can reduce time spent in an intensive monitoring setting from 24 to 15 hours with significant cost savings and minimal risk of missing a failing free flap.
Full Text Available A 60-year-old male displayed sudden shrinkage of a left free rectus abdominis musculocutaneous flap, which had been grafted to his left maxilla 15 years previously. No post-reconstructive irradiation had been performed, and no late occlusion of the vascular anastomosis, local infection, recurrence of the maxillary cancer, or body weight loss was observed. However, the shrinkage amounted to approximately 50%. This is considerably more than previously reported cases of shrinkage of various free flaps, which ranged between 10% and 25%. The resultant depression was successfully augmented with a right free deep inferior epigastric artery perforator flap. The residual fat volume of the previously grafted shrunken flap was revealed to be compatible with that of the newly harvested contralateral perforator flap. Thus, the volume of the previously grafted flap may reflect the status of the intact contralateral donor site, although the mechanism of sudden flap shrinkage is unclear.
Jonas, René; Schaal, Thomas; Krimmel, Michael; Gülicher, Dirk; Reinert, Siegmar; Hoffmann, Jürgen
In a prospective study, the characteristics and benefit of an invasive measurement of oxygen partial pressure (pO(2)) with the aid of a polarographic sensor were investigated in 125 microsurgical reconstructions of the head and neck area over a period of 45 months. Measurements were performed over 96 h in eight different types of microsurgically revascularized flaps for extra- and intraoral reconstructions and were evaluated separately for each flap type. Of 125 reconstructions the system indicated malperfusion in 18 cases. Salvage surgery was performed in 17 cases due to venous thrombosis (6 cases), arterial thrombosis (3 cases), a combination of arterial and venous thrombosis (2 cases), rheological problems (3 cases), venous insufficiency by hematoma (2 cases) and kinking of vessels (1 case). In 10 cases salvage surgery was successful, 7 flaps were lost despite salvage surgery. In all these cases, the polarographic probe indicated the necessity of salvage surgery correctly. After 96 h no malperfusion was seen. Postoperatively, a common and characteristic development of the oxygen partial pressure in different types of flaps was seen. Initially, a clear increase of pO(2) could be measured. During 96 h, a slow decrease of pO(2) was observed. In conclusion polarographic measurement of pO(2) can be an excellent apparative supplement for the postoperative clinical control of microsurgically revascularized transplants. In buried flaps, this technique represents the only reliable method for transplant monitoring. Copyright © 2012 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.
Rozen, Warren Matthew; Marsh, Daniel; Chow, Whitney T.H.; Vickers, Tobias; Khan, Lubna; Miller, George S.; Hunter-Smith, David J.; Ramakrishnan, Venkat V.
Background Advances in mobile telecommunication, improved mobile internet and affordability have led to a significant increase in smartphone use within medicine. The capability of instant messaging, photography, videography, word processing, drawing and internet access allow significant potential in this small portable device. Smartphone use within medicine has grown tremendously worldwide given its affordability, improved internet and capabilities. Methods We have searched for apps specifically helpful in the perioperative care of microsurgical breast reconstructive patients. Results The useful apps have been subdivided: (I) communication apps—multimedia messaging, WhatsApp, PicSafeMedi: allow efficient communication via text, picture and video messages leading to earlier assessment and definitive management of free flaps; (II) storage apps—Notability, Elogbook: electronic storage of patient notes and logbooks of case which can be shared with others if required; (III) educational apps—FlapApp, Touch Surgery, PubMed on tap: step by step guides to surgical procedures to aid learning and medical journal database; (IV) flap monitoring app—SilpaRamanitor: free flap monitoring app based on photographic analysis for earlier detection of compromised flaps. Conclusions There has been remarkable growth in smartphones use among surgeons. Apps are being developed for every conceivable use. The future will be in wearable smart devices that allow continuous monitoring with the potential to instigate change should deviations from the norm occur. The smart watch is the start of this digital revolution. PMID:27047783
Burcharth, J; Pedersen, M S; Pommergaard, H-C
in Denmark on December 31st, 2010 was performed. Within this population all umbilical and epigastric hernia repairs from January 1st, 2006 to December 31st, 2010 were identified using data from the Danish National Hospital Register, and 5-year prevalence estimates were calculated. RESULTS: The study...... hernia repairs was seen in males aged 60-70 years with a 5-year prevalence of 0.53 % (95 % CI 0.51-0.56 %) and the highest age-specific 5-year prevalence of epigastric hernia repair was seen in 40-50 year females with a 5-year prevalence of 0.086 % (95 % CI 0.077-0.095 %). CONCLUSION: The gender and age...
Mohammad Taghi Safari
Full Text Available Eosinophilic gastroenteritis (EGE is a rare inflammatory disorder of gastrointestinal tract characterized by eosinophilic infiltration of the bowel wall. It can mimic many gastrointestinal disorders due to its wide spectrum of presentations. Diagnose is mostly based on excluding other disorders and a high suspicion. Here we report a case of 26 year old man with a history of sever epigastric pain followed by nausea, vomiting since a few days before admission with final diagnosis of EGE.
VandenBerg, James; Osei, Daniel; Boyer, Martin I; Gardner, Michael J; Ricci, William M; Spraggs-Hughes, Amanda; McAndrew, Christopher M
To compare the timing of soft-tissue (flap) coverage and occurrence of complications before and after the establishment of an integrated orthopaedic trauma/microsurgical team. Retrospective cohort study. A single level 1 trauma center. Twenty-eight subjects (13 pre- and 15 post-integration) with open tibia shaft fractures (OTA/AO 42A, 42B, and 42C) treated with flap coverage between January 2009 and March 2015. Flap coverage for open tibia shaft fractures treated before ("preintegration") and after ("postintegration") implementation of an integrated orthopaedic trauma/microsurgical team. Time from index injury to flap coverage. The unadjusted median time to coverage was 7 days (95% confidence interval, 5.9-8.1) preintegration, and 6 days (95% confidence interval, 4.6-7.4) postintegration (P = 0.48). For preintegration, 9 (69%) of the patients experienced complications, compared with 7 (47%) postintegration (P = 0.23). After formation of an integrated orthopaedic trauma/microsurgery team, we observed a 1-day decrease in median days to coverage from index injury. Complications overall were lowered in the postintegration group, although statistically insignificant. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
Full Text Available Penile amputation is an uncommon injury for which immediate surgical replantation is warranted. Microsurgical replantation is the “standard” method for penile replantation. Early replantation yields a high success and low complication rate. We report a case of a 34-year-old male who presented with amputation at the proximal penile shaft which was successfully replanted using microsurgical techniques. Minor skin necrosis was noted post-operatively which was debrided and covered with skin graft. Follow-up at 6 months showed satisfactory cosmetic appearance, normal voiding, return of sensations and erectile function. The level of evidence was V.
Berto, Raphaela; Strutz, Jürgen
Hospital facilities issue numerous risk announcements on corrosion, deformation or premature wearout of medical devices every year. As there is yet little data on the impact of reprocessing on the quality and durability of microsurgical instruments, this paper aims at evaluating the effects of the reprocessing on microsurgical instruments. Material and Methods 22 brand new microsurgical instruments for stapes surgery were being reprocessed 30 times without being used for surgery or other purposes in the interim time. After each reprocessing the instruments were examined macroscopicly and microscopicly. The results were portrayed in a photo documentation and analysed on that basis. Results Almost all devices showed mechanical damage caused by the reprocessing procedure. The increasing deterioration was often associated with missing protective caps. Furthermore contaminations and stains were apparent in several cases. Conclusions The findings illustrate that careful handling of delicate surgical devices during reprocessing is vital. They also highlight problems of protective caps. As an alternative going forward it should be considered to store microsurgical instruments statically in special racks. Georg Thieme Verlag KG Stuttgart · New York.
Galla, T J; Lukas, B; Feller, A M
In breast reconstruction, the free TRAM-flap offers many advantages over the pedicled TRAM-flap. Due to its superior perfusion, the free flap rarely develops necrosis. Shaping of the flap is easier due to the lack of the thick muscle pedicle. Because the rectus muscle is spared, there is minimal donor site morbidity. However, the necessary microvascular anastomoses reduced the acceptance of the free TRAM-flap. During a 13-months period, 51 breast reconstructions were performed in 41 patients, 31 unilateral and ten bilateral. 45 flaps served for delayed reconstruction and six flaps for immediate reconstruction. The operations were performed by two teams working simultaneously. The average operating time was 3.9 hours for unilateral and 6.9 hours for bilateral delayed reconstruction. For immediate reconstruction, 6.2 and 6.3 hours were required for uni- and bilateral procedures, respectively. In 38 flaps, the thoracodorsal vessels served as recipient vessels; 13 flaps were anastomosed to the internal mammary artery and vein. Postoperative complications were observed in 13 patients. Three vessel anastomoses had to be revised. In one flap, a partial necrosis occurred; in two flaps hematoma evacuation was necessary. Two patients suffered from fat necroses at the abdomen and one umbilicus was lost. Skin irritations and seromas at the abdomen occurred in five patients. Pulmonary embolism was diagnosed in one patient three weeks postoperatively. Abdominal hernias or bulging in the epigastric area were not observed up to 15 months after reconstruction. These results reveal a low complication rate for breast reconstruction with the free TRAM-flap. The advantages of this technique as compared to the pedicled technique are discussed.
Akram Hussain Bijli
Full Text Available Background: While contemplating any difficult soft tissue reconstruction, patient comfort and compliance is of paramount importance. Reconstruction of the volar aspect of fingers and hand by the ipsilateral pedicled flaps (groin flap, abdominal flaps is demanding as the flap inset is difficult for the surgeon and very uncomfortable for the patient. This often leads to flap complications. For the comfort of the patient, better compliance and ease of complete inset, we planned to manage soft tissue defects of the volar aspect of fingers and hand by a new contralateral pedicled lumbo-umbilical flap. This flap is based on the paraumbilical perforators of deep inferior epigastric artery. Materials and Methods: The contralateral pedicled lumbo-umbilical flap was used in eight patients with high-tension electrical burn injuries involving the volar aspect of fingers and hand. The patients were closely observed for first 6 weeks for any flap or donor site complications and then followed monthly to assess donor and recipient site characteristics for 6 months to 2 years. Results and Conclusion: Large flaps up to 8 cm × 16 cm were raised. All but one flaps survived completely. All patients were mobilised within 48 h and five were discharged in less than a week after initial inset. The flap is reliable, easy to harvest and easy to inset on the volar aspect of fingers. The arm is positioned in a very comfortable position. The main disadvantage, however, is a conspicuous abdominal scar.
Rosen, I.B.; Bell, M.S.; Barron, P.T.; Zuker, R.M.; Manktelow, R.T.
Fourteen patients underwent microsurgical free flap procedures for reconstruction after composite resection of radiation-recurrent oral cancer. The use of attached metatarsal bone in nine patients for mandibular reconstruction is in our view a significant advance in this field. Two failures occurred, one due to sepsis and one to delayed thrombosis. Our experience indicates that this procedure deserves a place in the surgical treatment of patients afflicted with oral malignancy
Full Text Available Hand burn scar contractures affect patients in aesthetic and functional aspects. After releasing these scars, the defects should be repaired. The reconstruction methods include primary suturation, Z plasty, skin grafting, local or free flaps, etc. All methods have their own advantages and disadvantages. One of the most useful flaps is the reverse ulnar perforator flap. We performed a two-staged procedure for repairing a post-burn contracture release defect in a 40-year-old male. In the first stage we applied reverse ulnar perforator flap for the hand defect, and ulnar artery and vein repair in the second stage. In conclusion, this two-staged procedure is a non-primary but useful option for hand and finger defects and prevents major vascular structure damage of the forearm. [Hand Microsurg 2016; 5(1.000: 40-43
Chicarilli, Z.N.; Ariyan, S.; Cuono, C.B.
Microsurgical techniques have developed numerous territories suitable for free tissue transfer. However, the demand for thin cutaneous resurfacing limits the choice of flaps available to the reconstructive microsurgeon. The radial forearm flap is a thin, axial, fasciocutaneous flap, offering pliable cutaneous resurfacing, with or without sensation. We have used 15 flaps to reconstruct defects in the head and neck and lower extremity resulting from burns, blunt and avulsive trauma, radiation necrosis, and tumor ablation. Two flaps (15 percent) developed venous congestion and were salvaged by reoperation. One retrograde flap (7.5 percent) developed partial necrosis from arterial insufficiency. Neural re-innervation was successful in two out of three patients in whom it was attempted. Two patients (15%) sustained minor donor site skin graft loss that healed secondarily. In our series of predominantly older patients the donor sites have been relatively inconspicuous at one year follow-up. A functional restoration was achieved in all patients
Transversus Abdominis Plane Blocks with Single-Dose Liposomal Bupivacaine in Conjunction with a Nonnarcotic Pain Regimen Help Reduce Length of Stay following Abdominally Based Microsurgical Breast Reconstruction.
Jablonka, Eric M; Lamelas, Andreas M; Kim, Julie N; Molina, Bianca; Molina, Nathan; Okwali, Michelle; Samson, William; Sultan, Mark R; Dayan, Joseph H; Smith, Mark L
Side effects associated with use of postoperative narcotics for pain control can delay recovery after abdominally based microsurgical breast reconstruction. The authors evaluated a nonnarcotic pain control regimen in conjunction with bilateral transversus abdominis plane blocks on facilitating early hospital discharge. A retrospective analysis was performed of consecutive patients who underwent breast reconstruction using abdominally based free flaps, with or without being included in a nonnarcotic protocol using intraoperative transversus abdominis plane blockade. During this period, the use of locoregional analgesia evolved from none (control), to continuous bupivacaine infusion transversus abdominis plane and catheters, to single-dose transversus abdominis plane blockade with liposomal bupivacaine solution. Demographic factors, length of stay, inpatient opioid consumption, and complications were reported for all three groups. One hundred twenty-eight consecutive patients (182 flaps) were identified. Forty patients (62 flaps) were in the infusion-liposomal bupivacaine group, 48 (66 flaps) were in the single-dose blockade-catheter group, and 40 (54 flaps) were in the control group. The infusion-liposomal bupivacaine patients had a significantly shorter hospital stay compared with the single-dose blockade-catheter group (2.65 ± 0.66 versus 3.52 ± 0.92 days; p plane blocks performed with single injections of liposomal bupivacaine help facilitate early hospital discharge after abdominally based microsurgical breast reconstruction. A trend toward consistent discharge by postoperative day 2 was seen. This could result in significant cost savings for health care systems. Therapeutic, III.
Alonso Vanegas, Mario A; Lew, Sean M; Morino, Michiharu; Sarmento, Stenio A
Temporal lobe resection is the most prevalent epilepsy surgery procedure. However, there is no consensus on the best surgical approach to treat temporal lobe epilepsy. Complication rates are low and efficacy is very high regarding seizures after such procedures. However, there is still ample controversy regarding the best surgical approach to warrant maximum seizure control with minimal functional deficits. We describe the most frequently used microsurgical techniques for removal of both the lateral and mesial temporal lobe structures in the treatment of medically intractable temporal lobe epilepsy (TLE) due to mesial temporal sclerosis (corticoamygdalohippocampectomy and selective amygdalohippocampectomy). The choice of surgical technique appears to remain a surgeon's preference for the near future. Meticulous surgical technique and thorough three-dimensional microsurgical knowledge are essentials for obtaining the best results. Wiley Periodicals, Inc. © 2017 International League Against Epilepsy.
Helgstrand, F; Jørgensen, L N; Rosenberg, J
The primary aim of the present study was to investigate risk factors for readmission after elective umbilical and epigastric hernia repair and secondarily to evaluate causes for readmission.......The primary aim of the present study was to investigate risk factors for readmission after elective umbilical and epigastric hernia repair and secondarily to evaluate causes for readmission....
Greger, A; Hamelmann, W; Konermann, M
A 67-year-old man suffering from epigastric pain showed a phytobezoar in the endoscopy. Therapy with Coca Cola® and enzymes was initiated. The (partial) lysis led to a migration of the bezoar into the ileum, resulting in a small bowel obstruction. After removal of the remaining bezoar via ileotomy a secondary pneumatosis intestinalis occurred. As a rare finding the (phyto-)bezoar should be considered as a differential diagnosis of abdominal pain - especially considering the rising numbers of bariatric surgery, which is a potential risk factor. Furthermore, intestinal obstruction after migration has to be considered as a relevant complication of treatment.
Andreas M Fichter
Full Text Available Extracorporeal perfusion (ECP might prolong the vital storage capabilities of composite free flaps, potentially opening a wide range of clinical applications. Aim of the study was the development a validated low-cost extracorporeal perfusion model for further research in small animal free flaps.After establishing optimal perfusion settings, a specially designed extracorporeal perfusion system was evaluated during 8-hour perfusion of rat epigastric flaps followed by microvascular free flap transfer. Controls comprised sham-operation, ischemia and in vivo perfusion. Flaps and perfusate (diluted blood were closely monitored by blood gas analysis, combined laser Doppler flowmetry and remission spectroscopy and Indocyanine-Green angiography. Evaluations were complemented by assessment of necrotic area and light microscopy at day 7.ECP was established and maintained for 8 hours with constant potassium and pH levels. Subsequent flap transfer was successful. Notably, the rate of necrosis of extracorporeally perfused flaps (27% was even lower than after in vivo perfusion (49%, although not statistically significant (P = 0,083. After sham-operation, only 6% of the total flap area became necrotic, while 8-hour ischemia led to total flap loss (98%. Angiographic and histological findings confirmed these observations.Vital storage capabilities of microvascular flaps can be prolonged by temporary ECP. Our study provides important insights on the pathophysiological processes during extracorporeal tissue perfusion and provides a validated small animal perfusion model for further studies.
Mitsunaga, Narushima; Mihara, Makoto; Koshima, Isao; Gonda, Koichi; Takuya, Iida; Kato, Harunosuke; Araki, Jun; Yamamoto, Yushuke; Yuhei, Otaki; Todokoro, Takeshi; Ishikawa, Shoichi; Eri, Uehara; Mundinger, Gerhard S
Various fingertip reconstructions have been reported for situations where microsurgical finger replantation is impossible. One method is the digital artery perforator (DAP) flap. Herein we report 13 DAP flaps for fingertip and finger stump reconstruction following traumatic finger amputations, highlighting modifications to the originally described DAP flap. From October 1998 to December 2007, a total of 13 fingers (11 patients) underwent fingertip and finger stump reconstruction with modified DAP flaps following traumatic finger amputations. We performed six adipocutaneous flaps, three adipose-only flaps, two supercharged flaps and two extended flaps. Flap size ranged from 1.44 to 8 cm(2) (average 3.25 cm(2)). All flaps survived completely with the exception of partial skin necrosis in two cases. One of these cases required debridement and skin grafting. Our initial three cases used donor-site skin grafting. The donor site was closed primarily in the 10 subsequent cases. No patients showed postoperative hypersensitivity of repaired fingertips. Semmes-Weinstein (SW) test result for flaps including a digital nerve branch did not differ from those without (average 4.07 vs. 3.92). Modified DAP flaps allow for preservation of digital length, volume and finger function. They can be raised as adiposal-only flaps or extended flaps and supercharged through perforator-to-perforator anastomoses. The donor defect on the lateral pulp can be closed primarily or by skin grafting. For traumatic fingertip and finger stump reconstructions, DAP flaps deliver consistent aesthetic and functional results. Copyright 2009 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Kansy, Katinka; Mueller, Andreas Albert; Mücke, Thomas; Koersgen, Friederike; Wolff, Klaus Dietrich; Zeilhofer, Hans-Florian; Hölzle, Frank; Pradel, Winnie; Schneider, Matthias; Kolk, Andreas; Smeets, Ralf; Acero, Julio; Haers, Piet; Ghali, G E; Hoffmann, Jürgen
Microvascular surgery following tumor resection has become an important field of oral maxillofacial surgery (OMFS). Following the surveys on current reconstructive practice in German-speaking countries and Europe, this paper presents the third phase of the project when the survey was conducted globally. The DOESAK questionnaire has been developed via a multicenter approach with maxillofacial surgeons from 19 different hospitals in Germany, Austria and Switzerland. It was distributed in three different phases to a growing number of maxillofacial units in German-speaking clinics, over Europe and then worldwide. Thirty-eight units from Germany, Austria and Switzerland, 65 remaining European OMFS-departments and 226 units worldwide responded to the survey. There is wide agreement on the most commonly used flaps, intraoperative rapid sections and a trend towards primary bony reconstruction. No uniform concepts can be identified concerning osteosynthesis of bone transplants, microsurgical techniques, administration of supportive medication and postoperative monitoring protocols. Microsurgical reconstruction is the gold standard for the majority of oncologic cases in Europe, but worldwide, only every second unit has access to this technique. The DOESAK questionnaire has proven to be a valid and well accepted tool for gathering information about current practice in reconstructive OMFS surgery. The questionnaire has been able to demonstrate similarities, differences and global inequalities. Copyright © 2015 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.
AAV vector encoding human VEGF165–transduced pectineus muscular flaps increase the formation of new tissue through induction of angiogenesis in an in vivo chamber for tissue engineering: A technique to enhance tissue and vessels in microsurgically engineered tissue
Full Text Available In regenerative medicine, new approaches are required for the creation of tissue substitutes, and the interplay between different research areas, such as tissue engineering, microsurgery and gene therapy, is mandatory. In this article, we report a modification of a published model of tissue engineering, based on an arterio-venous loop enveloped in a cross-linked collagen–glycosaminoglycan template, which acts as an isolated chamber for angiogenesis and new tissue formation. In order to foster tissue formation within the chamber, which entails on the development of new vessels, we wondered whether we might combine tissue engineering with a gene therapy approach. Based on the well-described tropism of adeno-associated viral vectors for post-mitotic tissues, a muscular flap was harvested from the pectineus muscle, inserted into the chamber and transduced by either AAV vector encoding human VEGF165 or AAV vector expressing the reporter gene β-galactosidase, as a control. Histological analysis of the specimens showed that muscle transduction by AAV vector encoding human VEGF165 resulted in enhanced tissue formation, with a significant increase in the number of arterioles within the chamber in comparison with the previously published model. Pectineus muscular flap, transduced by adeno-associated viral vectors, acted as a source of the proangiogenic factor vascular endothelial growth factor, thus inducing a consistent enhancement of vessel growth into the newly formed tissue within the chamber. In conclusion, our present findings combine three different research fields such as microsurgery, tissue engineering and gene therapy, suggesting and showing the feasibility of a mixed approach for regenerative medicine.
Frey, Jordan D; Stranix, John T; Chiodo, Michael V; Alperovich, Michael; Ahn, Christina Y; Allen, Robert J; Choi, Mihye; Karp, Nolan S; Levine, Jamie P
Free flap monitoring in autologous reconstruction after nipple-sparing mastectomy remains controversial. The authors therefore examined outcomes in nipple-sparing mastectomy with buried free flap reconstruction versus free flap reconstruction incorporating a monitoring skin paddle. Autologous free flap reconstructions with nipple-sparing mastectomy performed from 2006 to 2015 were identified. Demographics and operative results were analyzed and compared between buried flaps and those with a skin paddle for monitoring. Two hundred twenty-one free flaps for nipple-sparing mastectomy reconstruction were identified: 50 buried flaps and 171 flaps incorporating a skin paddle. The most common flaps used were deep inferior epigastric perforator (64 percent), profunda artery perforator (12.1 percent), and muscle-sparing transverse rectus abdominis myocutaneous flaps (10.4 percent). Patients undergoing autologous reconstructions with a skin paddle had a significantly greater body mass index (p = 0.006). Mastectomy weight (p = 0.017) and flap weight (p < 0.0001) were significantly greater in flaps incorporating a skin paddle. Comparing outcomes, there were no significant differences in flap failure (2.0 percent versus 2.3 percent; p = 1.000) or percentage of flaps requiring return to the operating room (6.0 percent versus 4.7 percent; p = 0.715) between groups. Buried flaps had an absolute greater mean number of revision procedures per nipple-sparing mastectomy (0.82) compared with the skin paddle group (0.44); however, rates of revision procedures per nipple-sparing mastectomy were statistically equivalent between the groups (p = 0.296). Although buried free flap reconstruction in nipple-sparing mastectomy has been shown to be safe and effective, the authors' technique has evolved to favor incorporating a skin paddle, which allows for clinical monitoring and can be removed at the time of secondary revision. Therapeutic, III.
Reid, A W N; Szpalski, C; Sheppard, N N; Morrison, C M; Blondeel, P N
The deep inferior epigastric artery perforator (DIEAP) flap is currently considered the gold standard for autologous breast reconstruction. With the current economic climate and health cutbacks, we decided to survey reimbursement for DIEAP flaps performed at the main international centres in order to assess whether they are funded consistently. Data were collected confidentially from the main international centres by an anonymous questionnaire. Our results illustrate the wide disparity in international DIEAP flap breast reconstruction reimbursement: a unilateral DIEAP flap performed in New York, USA, attracts €20,759, whereas the same operation in Madrid, Spain, will only be reimbursed for €300. Only 35.7% of the surgeons can set up their own fee. Moreover, 85.7% of the participants estimated that the current fees are insufficient, and most of them feel that we are evolving towards an even lower reimbursement rate. In 55.8% of the countries represented, there is no DIEAP-specific coding; in comparison, 74.4% of the represented countries have a specific coding for transverse rectus abdominis (TRAM) flaps. Finally, despite the fact that DIEAP flaps have become the gold standard for breast reconstruction, they comprise only a small percentage of all the total number of breast reconstruction procedures performed (7-15%), with the only exception being Belgium (40%). Our results demonstrate that DIEAP flap breast reconstruction is inconsistently funded. Unfortunately though, it appears that the current reimbursement offered by many countries may dissuade institutions and surgeons from offering this procedure. However, substantial evidence exists supporting the cost-effectiveness of perforator flaps for breast reconstruction, and, in our opinion, the long-term clinical benefits for our patients are so important that this investment of time and money is absolutely essential. Copyright © 2015 British Association of Plastic, Reconstructive and Aesthetic Surgeons
Sijo J Parekattil
Full Text Available This article presents a review of the history and evolution of robotic instrumentation and its applications in urology. A timeline for the evolution of robotic instrumentation is presented to better facilitate an understanding of our current-day applications. Some new directions including robotic microsurgical applications (robotic assisted denervation of the spermatic cord for chronic orchialgia and robotic assisted vasectomy reversal are presented. There is a paucity of prospective comparative effectiveness studies for a number of robotic applications. However, right or wrong, human nature has always led to our infatuation with the concept of using tools to meet our needs. This chapter is a brief tribute to where we have come from and where we may be potentially heading in the field of robotic assisted urologic surgery.
Full Text Available Objective: To analyse the various factors affecting pregnancy rate after microsurgical tubal recanalisation. Design: Prospective study, follow-up of 5 years in patients treated with tubal microsurgery. Setting: Referral Tertiary Care Hospital. Patients: Fifty women underwent microsurgical tubal recanalisation procedure. Principles of microsurgery were followed throughout the procedure meticulously. Interventions: Microsurgical tubal recanalisation. Main outcome measure: Pregnancy rate. Results: With microsurgery, an overall 60% pregnancy rate was achieved. In these patients, pregnancy outcome was in form of intrauterine pregnancy (96.66%, ectopic pregnancy (3.33%, term viable pregnancy (96.55% and spontaneous abortion (3.45%. Conclusions: The important factors for determining the success of operation were age of the patient, time interval between sterilization and reversal, site of ligation, method used for previous ligation & the remaining length of the tube after recanalisation. The microsurgical technique should be available at specialized centres to improve the success of family planning services.
Azaripour, Adriano; Kissinger, Maren; Farina, Vittorio Siro Leone; van Noorden, Cornelis J. F.; Gerhold-Ay, Aslihan; Willershausen, Brita; Cortellini, Pierpaolo
Aim: The aim of this randomized clinical trial was to compare the coronally advanced flap (CAF) with the modified microsurgical tunnel technique (MMTT) for treatment of Miller class I and II recessions. Material and Methods: Forty patients with 71 gingival recessions were recruited and randomly
Full Text Available Traumatic finger amputations are common, causing significant functional and cosmetic deficits. Microsurgical replantation techniques are the mainstay of treatment for most such injuries although they require adequate conservation of the amputated segment for a successful result. In distal finger amputations, replantation is the procedure of choice, as long as the amputated fragment is viable. If replantation is not an option, reposition + flap using a neurovascular flap can be an efficient option, as this offers improved skin coverage. To the best of our knowledge, this case illustrates the longest cold ischaemic time with a successful outcome.
Moriwaki, Yoshihiro; Otani, Jun; Okuda, Junzo; Maemoto, Ryo
Both laparoscopic and endoscopic robotic surgery are widely accepted for many abdominal surgeries. However, the port site for the laparoscope cannot be easily sutured without defect, particularly in the cranial end; this can result in a port-site incisional hernia and trigger the progressive thinning and stretching of the linea alba, leading to epigastric hernia. In the present case, we encountered an epigastric hernia contiguous with an incisional scar at the port site from a previous endoscopic robotic total prostatectomy. Abdominal ultrasound and CT revealed that the width of the linea alba was 30-48 mm. Previous CT images prepared before endoscopic robotic prostatectomy had shown a thinning of the linea alba. We should be aware of the possibility of epigastric hernia after laparoscopic and endoscopic robotic surgery. In laparoscopic and endoscopic robotic surgery for a high-risk patient for epigastric hernia, we should consider additional sutures cranial to the port-site incision to prevent of an epigastric hernia. © 2018 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and John Wiley & Sons Australia, Ltd.
Ni, Song; Zhu, Yiming; Li, Dezhi; Liu, Jie; An, Changming; Zhang, Bin; Liu, Shaoyan
To discuss the management of vascular crisis of free flaps after reconstruction of head and neck defects caused by tumor resection. A total of 259 cases of free flap reconstruction performed in the Cancer Hospital of Chinese Academy of Medical Sciences from 2010 to 2013 were retrospectively analyzed, including 89 cases of anterolateral thigh flaps, 48 cases of radial forearm flaps, 46 free fibula flaps, 5 cases of inferior epigastric artery perforator flaps, 5 cases of free latissimus dorsi flaps, one case of lateral arm flap, and one case of medial femoral flap. The surveillance frequency of free flaps was q1h on post-operative day (POD) 1, q2h on POD 2 and 3, and q4h after POD 3. Vascular crises were reviewed for analysis. The incidence rate of vascular crisis was 8.1% (21/259), with 15 males and 6 females. The average age was 54.8 years old (17-68), and the average time of vascular crisis was 100.8 h post-operation (3-432). There were 7 cases of free jejunum flaps and 14 dermal free flaps. Seven of these 21 cases with vascular crisis were rescued by surgery. The success rate of salvage surgery within 72 hours from the primary operation was 54.5% (6/11), significantly higher than that of salvage surgery performed later than 72 hours from primary operation (10.0%, 1/10, P=0.043). There were 14 cases of flap necrosis, two of which died of local infection. Early detection of vascular crisis can effectively improve the success rate of salvage, so as to avoid the serious consequences caused by free flap necrosis.
Sinha, Shiba; Ruskin, Olivia; McCombe, David; Morrison, Wayne; Webb, Angela
Bilateral breast reconstructions are being increasingly performed. Autologous free-flap reconstructions represent the gold standard for post-mastectomy breast reconstruction but are resource intensive. This study aims to investigate the difference between hospital reimbursement and true cost of bilateral autologous free-flap reconstructions. Retrospective analysis of patients who underwent bilateral autologous free-flap reconstructions at a single Australian tertiary referral centre was performed. Hospital reimbursement was determined from coding analysis. A true cost analysis was also performed. Comparisons were made considering the effect of timing, indication and complications of the procedure. Forty-six bilateral autologous free-flap procedures were performed (87 deep inferior epigastric perforators (DIEPs), four superficial inferior epigastric artery perforator flaps (SIEAs) and one muscle-sparing free transverse rectus abdominis myocutaneous flap (MS-TRAM)). The mean funding discrepancy between hospital reimbursement and actual cost was $12,137 ± $8539 (mean ± standard deviation (SD)) (n = 46). Twenty-four per cent (n = 11) of the cases had been coded inaccurately. If these cases were excluded from analysis, the mean funding discrepancy per case was $9168 ± $7453 (n = 35). Minor and major complications significantly increased the true cost and funding discrepancy (p = 0.02). Bilateral free-flap breast reconstructions performed in Australian public hospitals result in a funding discrepancy. Failure to be economically viable threatens the provision of this procedure in the public system. Plastic surgeons and hospital managers need to adopt measures in order to make these gold-standard procedures cost neutral. Copyright © 2015 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Joo, Wonil; Yoshioka, Fumitaka; Funaki, Takeshi; Rhoton, Albert L
The aim of this study is to demonstrate and review the detailed microsurgical anatomy of the abducens nerve and surrounding structures along its entire course and to provide its topographic measurements. Ten cadaveric heads were examined using ×3 to ×40 magnification after the arteries and veins were injected with colored silicone. Both sides of each cadaveric head were dissected using different skull base approaches to demonstrate the entire course of the abducens nerve from the pontomedullary sulcus to the lateral rectus muscle. The anatomy of the petroclival area and the cavernous sinus through which the abducens nerve passes are complex due to the high density of critically important neural and vascular structures. The abducens nerve has angulations and fixation points along its course that put the nerve at risk in many clinical situations. From a surgical viewpoint, the petrous tubercle of the petrous apex is an intraoperative landmark to avoid damage to the abducens nerve. The abducens nerve is quite different from the other nerves. No other cranial nerve has a long intradural path with angulations and fixations such as the abducens nerve in petroclival venous confluence. A precise knowledge of the relationship between the abducens nerve and surrounding structures has allowed neurosurgeon to approach the clivus, petroclival area, cavernous sinus, and superior orbital fissure without surgical complications. Copyright © 2012 Wiley Periodicals, Inc.
Demirtas, Yener; Ozturk, Nuray; Kelahmetoglu, Osman
Described in this study is a surgical concept that supports the "consider and use a pedicled perforator flap whenever possible and indicated" approach to reconstruct a particular skin defect. The operation is entirely free-style; the only principle is to obtain a pedicled perforator flap...... to reconstruct the defect. The perforators are marked with a hand-held Doppler probe and multiple flaps are designed. The appropriate flap is elevated after identifying the perforator(s). Dissection of the perforator(s) or complete incision of the flap margins are not mandatory if the flap is mobilized...... adequately to cover the defect. Defects measuring 3 x 3 cm up to 20 x 20 cm at diverse locations were successfully reconstructed in 20 of 21 patients with 26 flaps. Pedicled perforator flaps offer us reliable and satisfactory results of reconstruction at different anatomic territories of the body. It sounds...
Michael A. Fallucco
Full Text Available The Fluobeam® is a portable, near-infrared camera that is held and controlled by the surgeon to visualize tissue perfusion using indocyanine green (ICG fluorescence imaging. This case report describes how data obtained from ICG imaging allows intraoperative customization in a previously surgically scarred abdomen during autologous Deep Inferior Epigastric Artery Perforator (DIEP flap bilateral breast reconstruction. The outcome was successful breast mound recreation without fat necrosis.
Liang, Ri-Sheng; Zhou, Liang-Fu; Mao, Ying; Zhang, Rong; Yang, Wei-Zhong
To explore an effective method for further improving the surgical results of treatment of olfactory groove meningiomas. Sixty seven cases of olfactory groove meningiomas were treated by microneurosurgery, among which fifty seven were de novo cases, eight were recurrent tumors and the other two re-recurrent cases. Modified Derome approach was used in 12 cases, bilateral subfrontal approach in 28 cases, modified pterional approach in 21 cases and unilateral subfrontal approach in six cases. Tumors were resected microsurgically with radical removal of invaded dura, bone, and paranasal sinus mucosa. Reconstruction was performed in patients with skull base defect. Simpson grade I removal was accomplished in 59 cases, grade II in seven cases and grade IV in one case. Among 57 patients with de novo tumor, Simpson I resection was accomplished in 54 cases. Postoperative rhinorrhea and intracranial infection occurred in one case and was cured after temporal lumbar CSF drainage and antibiotic therapy. Two patients (2.9%) died within one month after operation, i.e.one aged patient of heart failure and the other of severe hypothalamus complication. Forty seven patients (72.3%) were followed up from one to ten years with an average of five years and four months. With the exception of two cases died, among the alive 45 patients, there were only three patients with tumor recurrence, which had undergone Simpson II or IV tumor resection. No recurrence was found in cases with Simpson I tumor removal. Previous blurred vision was not improved in three patients, hemiparalysis in two patients, and the other patients recovered well, resuming previous jobs or being able to take care themselves. Total tumor removal (Simpson I) should be the surgical goal for treatment of olfactory groove meningiomas, especially for de novo cases. An appropriate approach is fundamental in the effort to remove an OGM totally. Appropriate anterior skull base reconstruction with vascularized material is
Frigeri, Thomas; Paglioli, Eliseu; de Oliveira, Evandro; Rhoton, Albert L
The central lobe consists of the pre- and postcentral gyri on the lateral surface and the paracentral lobule on the medial surface and corresponds to the sensorimotor cortex. The objective of the present study was to define the neural features, craniometric relationships, arterial supply, and venous drainage of the central lobe. Cadaveric hemispheres dissected using microsurgical techniques provided the material for this study. The coronal suture is closer to the precentral gyrus and central sulcus at its lower rather than at its upper end, but they are closest at a point near where the superior temporal line crosses the coronal suture. The arterial supply of the lower two-thirds of the lateral surface of the central lobe was from the central, precentral, and anterior parietal branches that arose predominantly from the superior trunk of the middle cerebral artery. The medial surface and the superior third of the lateral surface were supplied by the posterior interior frontal, paracentral, and superior parietal branches of the pericallosal and callosomarginal arteries. The venous drainage of the superior two-thirds of the lateral surface and the central lobe on the medial surface was predominantly through the superior sagittal sinus, and the inferior third of the lateral surface was predominantly through the superficial sylvian veins to the sphenoparietal sinus or the vein of Labbé to the transverse sinus. The pre- and postcentral gyri and paracentral lobule have a morphological and functional anatomy that differentiates them from the remainder of their respective lobes and are considered by many as a single lobe. An understanding of the anatomical relationships of the central lobe can be useful in preoperative planning and in establishing reliable intraoperative landmarks.
Yin, Lu; Gong, Ketong; Yin, Zhonggang; Zhang, Bo; Xu, Jianhua
To evaluate the clinical outcomes of free perforator flaps combined with skin graft for reconstruction of ankle and foot soft tissue defects. Between June 2014 and October 2015, 20 cases of ankle and foot soft tissue defects were treated. There were 16 males and 4 females, aged from 19 to 61 years (mean, 43.3 years). Injury was caused by traffic accident in 7 cases, by crashing in 9 cases, and machine twist in 4 cases. The locations were the ankle in 6 cases, the heel in 3 cases, the dorsum pedis in 4 cases, and the plantar forefoot in 7 cases of avulsion injury after toes amputation. The size of wound ranged from 15 cm×10 cm to 27 cm×18 cm. The time from injury to treatment was from 11 to 52 days (mean, 27 days). The anterolateral thigh perforator flap was used in 11 cases, thoracodorsal antery perforator flap in 3 cases, medial sural artery perforator flap in 4 cases, deep inferior epigastric perforator flap in 1 case, and anteromedial thigh perforator flap in 1 case, including 5 chimeric perforator flaps, 5 polyfoliate perforator flaps, 3 flow-through perforator flaps, and 3 conjoined perforator flaps. The size of the perforator flap ranged from 10.0 cm×6.5 cm to 36.0 cm×8.0 cm, the size of skin graft from 5 cm×3 cm to 18 cm×12 cm. Venous crisis occurred in 2 flaps which survived after symptomatic treatment; 18 flaps survived successfully and skin grafting healed well. The follow-up time ranged 4-18 months (mean, 8.3 months). The flaps had good appearance, texture and color, without infection. The patients could walk normally and do daily activities. Only linear scars were observed at the donor sites. Free perforator flap can be used to reconstruct defects in the ankle and foot, especially in the weight-bearing area of the plantar forefoot. A combination of free perforator flap and skin graft is ideal in reconstruction of great soft tissue defects in the ankle and foot.
William HC Tiong
Full Text Available Reverse abdominoplasty was originally described for epigastric lift. Since the work by Baroudi and Huger in the 1970s, it has become clear that reverse abdominoplasty application can be extended beyond just aesthetic procedure. Through the knowledge of anterior abdominal wall vascularity, its application had included reconstructive prospect in the coverage of various chest wall defects. To date, reverse abdominoplasty flap has been used to reconstruct unilateral anterior chest wall defect or for larger defect but only in combination with other reconstructive techniques. Here, we presented a case where it is used as a standalone flap to reconstruct bilateral anterior chest wall soft tissue defect post-bilateral mastectomies in oncological resection. In conclusion, reverse abdominoplasty flap provided us with a simple, faster, and satisfactory reconstructive outcome.
Talley, N J; Vakil, N; Lauritsen, K
BACKGROUND: Early identification of true responders to acid suppression in functional dyspepsia patients with symptoms of epigastric pain or burning may enable clinicians to optimally tailor treatment. AIM: To evaluate whether a 1-w acid suppression trial is useful for identifying true responders...
Full Text Available Epigastric pain is a condition in which the increase of airway pressure to deal with partial or complete obstruction of airway during mechanical ventilation of lungs occurs or caused by the entrance of too much air to the stomach. This ventilation condition occurs with all methods of airway. In cases where laryngeal mask has not suitable placement can cause partial obstruction of airway and causes increased pressure of airway and the air entrance to the stomach. This research is a gradual randomized study was performed on 600 patients referred for cataract surgery. Data collection included questionnaire containing demographic information and questions about the epigastric pain. The data were analyzed by Chi-square, Kolmogorov-Smirnov, Mann-Witheny tests and SPSS software. There is a significant relationship between epigastric disease history and epigastric pain in recovery, and between heartburn and the diameter of laryngeal mask (p-value < 0.05. There is a significant relationship between epigastric disease history and duration of the use of masks, air volume delivered to the patient, age and body weight of the patients (p-value < 0.05. There is a significant relationship between epigastric disease history and epigastric pain in recovery and history of heartburn.
Kaartinen, Ilkka S; Vuento, Maarit H; Hyöty, Marja K; Kallio, Jukka; Kuokkanen, Hannu O
Total pelvic exenteration (TPE) is a rare operation in which the pelvic contents are removed entirely. Several options for pelvic floor and vaginal reconstruction have been described including transverse rectus abdominis musculocutaneous (TRAM) or deep inferior epigastric perforator (DIEP) flaps. The transverse musculocutaneous gracilis (TMG) flap has been introduced for breast reconstruction as a free flap. We adopted the pedicled TMG flap for reconstructions after TPE. To the best of our knowledge, this is the first report of this method in the literature. Between November 2011 and February 2014, 12 patients underwent TPE and reconstruction with unilateral (six patients) or bilateral (six patients) pedicled TMG flaps. Five patients underwent vaginal reconstruction with bilateral TMG flaps. We describe the operative procedure and the outcome of the operation in these patients. The total mean operative times for TPE with or without vaginal reconstruction were 467 ± 12 and 386 ± 59 min, respectively. The TMG flaps had enough vascular tissue and mobility for reconstructing the TPE defects. There was distal edge necrosis in one out of 18 flaps, while the rest survived completely. During the follow-up, complete wound healing with no signs of weakening of the pelvic floor was observed in all cases. Soft-tissue reconstructions are needed to reduce complications associated with TPE, to secure the pelvic floor and to reconstruct the vagina in select patients. The TMG flap is a logical flap choice that does not lead to functional deficits, complicate the abdominal ostomies or weaken the abdominal wall. It reduces the length of operation compared to that of abdominal flaps. IV, therapeutic. Copyright © 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
76 cases in which in the time between 1969 and 1974 coeliacographies were carried out and the diagnoses are clinically manifested were retrospectively analysed. The angiographic symptoms and the diagnostic results are compared to the literature. Following this, the diagnostic and therapeutic value in liver processes, paucreas processes, stomach tumours, gastrointestinal bleedings, traumas of the epigastric organs, catheter embolisation and stopping of acute, severe gastrointestinal bleedings are discussed. The value of angiography in comparison to laparoscopy, ERCP, sonography, and computerized tomography is discussed. At the end, the indication of angiography in diseases of the epigastric organs is summarized in two tables, distinguishing between absolute, relative, strongly restricted indications and no indication at all. (orig./MG) [de
Tran, Bao Ngoc N; Fadayomi, Ayotunde; Lin, Samuel J; Singhal, Dhruv; Lee, Bernard T
Two staged tissue expander-implant with acellular dermal matrix (TE/I + ADM) and deep inferior epigastric perforator (DIEP) flap are the most common implant and autologous methods of reconstruction in the U.S. Implant-based techniques are disproportionally more popular, partially due to its presumed cost effectiveness. We performed a comprehensive cost analysis to compare TE/I + ADM and DIEP flap. A comparative cost analysis of TE/I + ADM and DIEP flap was performed. Medicare reimbursement costs for each procedure and their associated complications were calculated. Pooled probabilities of complications including cellulitis, seroma, skin necrosis, implant removal, flap loss, partial flap loss, and fat necrosis, were calculated using published studies from 2010 to 2016. Average actual cost for successful TE/I + ADM and DIEP flap were $13 304.55 and $10 237.13, respectively. Incorporating pooled complication data from published literature resulted in an increase in cost to $13 963.46 for TE/I + ADM and $12 624.29 for DIEP flap. The expected costs for successful TE/I + ADM and DIEP flap were $9700.35 and $8644.23, which are lower than the actual costs. DIEP flap breast reconstruction incurs lower costs compared to TE/I + ADM. These costs are lower at baseline and when additional costs from pooled complications are incorporated. © 2017 Wiley Periodicals, Inc.
Full Text Available Catheter insertion for intravenous hyperalimentation is a commonly and widely used clinical technique. When compared with the incidence of complications associated with insertions into the internal jugular vein or the subclavian vein, complications associated with insertions into the femoral vein are less frequent. In this paper, we describe a very rare complication of femoral vein catheter insertion—namely, catheter displacement into the inferior epigastric vein.
Thomsen, Jørn Bo; Bille, Camilla; Wamberg, Peter
major complications needing additional surgery. One flap was lost due to a vascular problem. Breast reconstruction can be performed by a propeller TAP flap without cutting the descending branch of the thoracodorsal vessels. However, the authors would recommend that a small cuff of muscle is left around...
Kim, Sung Young; Rah, Dong Kyun; Chong, Yosep; Lee, Song Hyun; Park, Tae Hwan
The use of bilirubin, a well-known and powerful antioxidant, has gained popularity in recent years because of its role in the prevention of ischaemic heart disease in patients with Gilbert's syndrome. We investigate the effects of bilirubin on ischaemia-reperfusion (I/R) injury using a rat perforator flap model. Forty-eight rats were randomly divided into two groups: experimental (bilirubin) group (n = 24) and control group (n = 24). In each group, elevated bilateral deep inferior epigastric perforator (DIEP) flaps were created. The right (no ischaemia side) and left (ischaemia side) DIEP flaps were separated according to the presence of ischaemia induction. Ischaemia was induced in anaesthetised rats by perforator clamping for 15 or 30 minutes. After surgery, the flap survival was assessed daily on postoperative days 0 to 5, and overall histological changes of DIEP flaps above the perforator were analysed at postoperative day 5. The flap survival rate in the bilirubin group was significantly higher than that in the control group at the ischaemia side following perforator clamping for 15 or 30 minutes (93·42 ± 4·48% versus 89·63 ± 3·98%, P = 0·002; and 83·96 ± 4·23% versus 36·46 ± 6·38%, P bilirubin was found to alleviate perforator flap necrosis caused by I/R injury in this experimental rat model. © 2015 Medicalhelplines.com Inc and John Wiley & Sons Ltd.
Tuncer, Serhan; Ayhan, Suhan; Findikcioglu, Kemal; Ergun, Hakan; Tuncer, Ilhan
The effects of piracetam on flap survival, ischemia-reperfusion (I/R) injury, and vascular endothelial growth factor (VEGF) expression were evaluated in this study. Unipedicled epigastric flap model was used in 36 rats and was evaluated within 4 groups. The flap was elevated and untreated in Group 1. Postoperative piracetam treatment was given for 7 days in Group 2. In Group 3, 4 hours of ischemia and 2 hours of reperfusion were applied. I/R was applied to Group 4 and piracetam was given 30 minutes before reperfusion and postoperatively for 7 days. Laser Doppler flowmetry was used to measure blood flow changes. VEGF expression was determined using immunohistochemical methods on tissue samples taken after the completion of 2 hours reperfusion in groups 3 and 4. Flap necrosis was measured on the day 7 in all groups. Blood flow rates did not show significant difference between piracetam treated and untreated I/R groups. Piracetam significantly reduced necrosis area both in ischemic and nonischemic flaps ( P piracetam-treated Group 4 compared with Group 3 ( P = 0.005). This experimental study demonstrates that systemic piracetam treatment improves survival of pedicled flaps, reduces necrosis amounts, and increases VEGF expression in I/R induced flaps. © Thieme Medical Publishers.
MATSUSHIMA, Toshio; KAWASHIMA, Masatou; MATSUSHIMA, Ken; WANIBUCHI, Masahiko
Research in microneurosurgical anatomy has contributed to great advances in neurosurgery in the last 40 years. Many Japanese neurosurgeons have traveled abroad to study microsurgical anatomy and played major roles in advancing and spreading the knowledge of anatomy, overcoming their disadvantage that the cadaver study has been strictly limited inside Japan. In Japan, they initiated an educational system for surgical anatomy that has contributed to the development and standardization of Japanese neurosurgery. For example, the Japanese Society for Microsurgical Anatomy started an annual educational meeting in the middle of 1980s and published its proceedings in Japanese every year for approximately 20 years. These are some of the achievements that bring worldwide credit to Japanese neurosurgeons. Not only should Japanese neurosurgeons improve their educational system but they should also contribute to the international education in this field, particularly in Asia. PMID:25797782
Olabe, Jon; Olabe, Javier
Microneurovascular anastomosis and aneurysm clipping require extensive training before mastering the technique and are a surgical challenge. We developed the "infused chicken wing method" to provide a simple but realistic training method minimizing animal use and need for special facilities for animal care and anesthesia. Fresh chicken wings were used in this model. The main brachial artery was cannulated, and water was infused at 140 mm Hg followed by anatomical neurovascular dissection. Multiple microsurgical training exercises were performed under microscope vision including terminoterminal, lateroterminal, laterolateral vascular anastomosis, and nerve anastomosis. Different complexity aneurysms were created using venous patches, clipping, rupture, and vascular reconstruction techniques were performed. This novel training model is inexpensive, easily obtainable, and no live animals are required. The diameter and characteristics of arteries and veins used are similar to those of the human brain. Great microsurgical technique progress may be obtained. The infused chicken wing artery model presents a realistic microvascular training method. It is inexpensive and easy to set up. Such simplicity provides the adequate environment for developing microsurgical technique. Copyright 2009 Elsevier Inc. All rights reserved.
Akyürek, Mustafa; Safak, Tunç
This report presents a case of microsurgical replantation of a volar skin segment of the thumb. In a 24-year-old patient, a heavy object falling over the dominant thumb resulted in a crush-avulsion injury of a pure skin segment measuring 4 x 2 cm. Examination revealed that the distal fingertip as well as the bone-tendon structures remained intact. Exploration demonstrated that both neurovascular bundles were included in the avulsed skin segment. Microsurgical replantation was achieved successfully, repairing the radial digital artery at both ends with vein grafts as well as anastomosing a palmar vein. Both digital nerves were coapted proximally and distally. An excellent functional and cosmetic result was accomplished with a good sensory recovery. The authors conclude that microsurgical replantation should be attempted in cases of more proximal pure skin avulsions, even if the injury spares distal fingertip tissue or bone-tendon units. In such cases, replantation is superior to any other method of reconstruction. Liberal use of vein grafts is crucial to achieve success.
Jordan D. Frey, MD
Conclusions:. Multiple patient-specific, intra-operative, and post-operative outcomes factors are associated with increased length of stay with immediate and delayed microsurgical breast reconstruction.
Jeong, Woo Shik; Oh, Tae Suk
Extensive surgical resection of the aerodigestive track can result in a large and complex defect of the oropharynx, which represents a significant reconstructive challenge for the plastic surgery. Development of microsurgical techniques has allowed for free flap reconstruction of oropharyngeal defects, with superior outcomes as well as decreases in postoperative complications. The reconstructive goals for oral and oropharyngeal defects are to restore the anatomy, to maintain continuity of the intraoral surface and oropharynx, to protect vital structures such as carotid arteries, to cover exposed portions of internal organs in preparation for adjuvant radiation, and to preserve complex functions of the oral cavity and oropharynx. Oral and oropharyngeal cancers should be treated with consideration of functional recovery. Multidisciplinary treatment strategies are necessary for maximizing disease control and preserving the natural form and function of the oropharynx.
Winkel, R; Tajsic, N; Husum, H; Schlageter, M; Hanebuth, G; Hoffmann, R
Replacement of full thickness soft tissue defects in the lower leg and ankle, appropriate to the defect and following the course of blood vessels feeding the skin of a distally hinged fasciocutaneous flap most reliably based on the individual anatomy of distal perforators of the posterior tibial artery. Full thickness soft tissue defects, up to 12 cm in length and up to 8 cm in width. Sufficient vascularization of the foot required, in osteomyelitis, and when joints, fractures, implants and tendons are exposed and when a split skin graft, a local flap, a suralis perforator flap or a free flap is not indicated. For patients, in whom a 1-2 h operation is not possible; necessity of angioplasty; decollement or scars around the distal perforators of the posterior tibial artery; local infection or necrosis of soft tissues and/or bone, which cannot be totally excised. Radical debridement; flap dissection without tourniquet; microdissection; design of the flap on the skin: pivot point ~ 10 cm (6-14 cm) proximal of the tip of the medial malleolus; base ~ 5 cm in width, between the course of the saphenous nerve and of the great saphenous vein and the Achilles tendon; adipofascial pedicle up to 15 cm in length sited over the septum between soleus and flexor digitorum muscles, following the course of the saphenous nerve, with a central skin stripe, which expands into a proximal skin island; skin island is outlined similar to the defect, but larger by 1 to 2 cm, surrounded by an adipofascial border: adjustment of the planning as well as of the elevation of these flaps according to the individual position and the caliber of perforators requires in each case the search for a perforator at the estimated pivot point. Delay of transposition, if the division of more than one perforator proximal to the pivot point obviously diminishes circulation. No "tunnelling "of the pedicle; defects of skin due to the elevation of the flap are replaced by split and meshed skin grafts or temporary
Zhang, Dong-Yi; Kang, Shen-Song; Zhang, Zheng-Wen; Wu, Rui
The purpose of the experiment was to study the efficacy of edaravone in enhancing flap viability after ischemia/reperfusion (IR) and its mechanism. Forty-eight adult male SD rats were randomly divided into 3 groups: control group (n=16), IR group (n=16), and edaravone-treated IR group (n=16). An island flap at left lower abdomen (6.0 cm×3.0 cm in size), fed by the superficial epigastric artery and vein, was created in each rat of all the three groups. The arterial blood flow of flaps in IR group and edaravone-treated IR group was blocked for 10 h, and then the blood perfusion was restored. From 15 min before reperfusion, rats in the edaravone-treated IR group were intraperitoneally injected with edaravone (10 mg/kg), once every 12 h, for 3 days. Rats in the IR group and control group were intraperitoneally injected with saline, with the same method and frequency as the rats in the edaravone-treated IR group. In IR group and edaravone-treated IR group, samples of flaps were harvested after reperfusion of the flaps for 24 h. In the control group, samples of flaps were harvested 34 h after creation of the flaps. The content of malondialdehyde (MDA) and activity of superoxide dismutase (SOD) were determined, and changes in organizational structure and infiltration of inflammatory cells were observed by hematoxylin-eosin (HE) staining, apoptotic cells of vascular wall were marked by terminal deoxynucleotidyl transferase-mediated dUTP nick-end labeling (TUNEL) assay, and the apoptotic rate of cells in vascular wall was calculated. The ultrastructural changes of vascular endothelial cells were observed by transmission electron microscopy (TEM). Seven days after the operation, we calculated the flap viability of each group, and marked vessels of flaps by immunohistochemical staining for calculating the average number of subcutaneous vessels. The results showed that the content of MDA, the number of multicore inflammatory cells and apoptotic rate of cells in vascular wall
Hultman, Charles Scott; Kim, Sendia; Lee, Clara N; Wu, Cindy; Dodge, Becky; Hultman, Chloe Elizabeth; Roach, S Tanner; Halvorson, Eric G
Perforator flaps have become a preferred method of breast reconstruction but can consume considerable resources. We examined the impact of a Six Sigma program on microsurgical breast reconstruction at an academic medical center. Using methods developed by Motorola and General Electric, we applied critical pathway planning, workflow analysis, lean manufacturing, continuous quality improvement, and defect reduction to microsurgical breast reconstruction. Primary goals were to decrease preoperative-to-cut time and total operative time, through reduced variability and improved efficiency. Secondary goals were to reduce length of stay, complications, and reoperation. The project was divided into 3 phases: (1) Pre-Six Sigma (24 months), (2) Six Sigma (10 months), (3) and Post-Six Sigma (24 months). These periods (baseline, intervention, control) were compared by Student t test and χ analysis. Over a 5-year period, 112 patients underwent 168 perforator flaps for breast reconstructions, by experienced microsurgeons. Total operative time decreased from 714 to 607 minutes (P Six Sigma program in microsurgical breast reconstruction was associated with better operational and financial outcomes. These incremental gains were maintained over the course of the study, suggesting that these benefits were due, in part, to process improvements. However, continued reductions in total operative time and length of stay, well after the intervention period, support the possibility that "learning curve" phenomenon may have contributed to the improvement in these outcomes.
This report is to present the treatment procedure and clinical considerations of prosthodontic management of a patient who had undergone a partial mandibulectomy and fibular free flap surgery. A 59-year-old man with a squamous cell carcinoma received a partial mandibular resection. Microsurgical reconstruction with a fibular free flap surgery and implant-supported zirconia-fixed prosthesis produced by computer-aided manufacturing led to successful results for the oral rehabilitation of mandibular defects. The implant-supported zirconia-fixed prosthesis can be recommended for use in patients with mandibulectomy and fibular free flaps. Close cooperation between the surgeon and the prosthodontist is mandatory for the satisfaction of the patient.
Bisgaard, T; Kehlet, H; Bay-Nielsen, M
stay, risk of readmission, complications, and mortality 1 day. Readmissions occurred in 5.3% of cases (open 4.9%; laparoscopic 10.5%). In the majority of patients readmissions were due to wound-related problems (haematoma, bleeding and/or infection) (46%), seroma (19%), or pain (7%). At 30 days......, complications and mortality occurred in 4.1% (open 3.7%; laparoscopic 8.2%) and 0.1% (open 0.1%; laparoscopic 0.4%), respectively. CONCLUSION: This first prospective nationwide study on elective umbilical and epigastric hernia repair found low morbidity and mortality but a high readmission rate mostly because...
A. D. Kaprin
Full Text Available Objective. To minimize surgical trauma in patients with head and neck tumors during microsurgical plasty with visceral autografts.Subjects and methods. Clinical experience has been gained in the treatment of 53 patients with locally advanced craniofascial (n = 27 and oropharyngeal (n = 36 cancers. Abdominal organs were used for plastic closure of extensive defects after surgical resection. Paraumbilical incision allowing for an adequate approach into the abdominal cavity with minimal external trauma in the anterior abdominal wall was chosen as an access procedure. Video-assisted techniques were used to excise the midline aponeurosis. Donor organs, such as the omentum, greater curvature of the stomach, transverse colon, small intestine were taken through a mini-laparotomic incision to the anterior abdominal wall, then the vascular pedicle was exposed and a visceral autograft was made. After forming and cutting off the autograft, organ anastomoses were created extracorporeally.Results. Mini-access surgery could be completed in 50 of the 53 cases (4 patients had previously undergone abdominal interventions. Omental (n = 26, colo-omental (n = 15, gastro-omental (n = 7, and entero-omental (n = 5 flaps were made and prepared for autografting. No intra- or postoperative abdominal complications were found.Conclusion. Minimally invasive technologies used to create visceral authografts for head and neck tissue repair can minimize surgical trauma and reduce treatment duration. The indications for this access are the debilitating state of a cancer patient or the young age of a patient who does not wish to have an additional scar in the donor region.
Charles M Malata
Full Text Available Introduction: The deep inferior epigastric artery perforator (DIEP free flap is the gold standard for autologous breast reconstruction. However, using a single vascular pedicle may not yield sufficient tissue in patients with midline scars or insufficient lower abdominal pannus. Double-pedicled free flaps overcome this problem using different vascular arrangements to harvest the entire lower abdominal flap. The literature is, however, sparse regarding technique selection. We therefore reviewed our experience in order to formulate an algorithm and comprehensive classification for this purpose. Methods: All patients undergoing unilateral double-pedicled abdominal perforator free flap breast reconstruction (AFFBR by a single surgeon (CMM over 40 months were reviewed from a prospectively collected database. Results: Of the 112 consecutive breast free flaps performed, 25 (22% utilised two vascular pedicles. The mean patient age was 45 years (range=27-54. All flaps but one (which used the thoracodorsal system were anastomosed to the internal mammary vessels using the rib-preservation technique. The surgical duration was 656 minutes (range=468-690 mins. The median flap weight was 618g (range=432-1275g and the mastectomy weight was 445g (range=220-896g. All flaps were successful and only three patients requested minor liposuction to reduce and reshape their reconstructed breasts.Conclusion: Bipedicled free abdominal perforator flaps, employed in a fifth of all our AFFBRs, are a reliable and safe option for unilateral breast reconstruction. They, however, necessitate clear indications to justify the additional technical complexity and surgical duration. Our algorithm and comprehensive classification facilitate technique selection for the anastomotic permutations and successful execution of these operations.
... laser. 874.4500 Section 874.4500 Food and Drugs FOOD AND DRUG ADMINISTRATION, DEPARTMENT OF HEALTH AND..., nose, and throat microsurgical carbon dioxide laser. (a) Identification. An ear, nose, and throat microsurgical carbon dioxide laser is a device intended for the surgical excision of tissue from the ear, nose...
A. D. Kaprin
Full Text Available After surgical treatment for locally advanced oral tumors with resection of soft tissues, mucosal membrane, and facial skeletal structures, there are penetration combined defects, removal of which is a challenge for reconstructive surgeons. Mandibular repair is one of the problems in the correction of combined oral defects. Surgeons use different grafts to remove mandibular defects. One-flap transplantation does not always solve all reconstruction problems and ensure the repair of the mucosal membrane, a soft-tissue component, skin integuments, and facial skeleton.The authors describe a clinical case of successful single-stage correction of penetration combined orofacial defect after resection of the tongue, mouth floor, en bloc resection of the lower jaw and mental soft tissues, bilateral cervical supramyochoroidal lymphadenectomy, stage LCL CM mandibular defect formation after J. Boyd, by using two microsurgical autografts (a peroneal skin-muscle-skin autograft and a radial skin-fascia one in a 39-year-old female patient clinically diagnosed with carcinoma of the left mandibular alveolar ridge mucosa, Stage IVA (T4аN0M0.The Department of Microsurgery, P.A. Herzen Moscow Oncology Research Institute, Ministry of Health of Russia, has gained experience in comprehensively correcting extensive combined maxillofacial defects with two or more grafts in 27 patients who underwent autografting with a total of 73 flaps. The most functionally incapacitating and life-incompatible defect was removed at Stage 1 of reconstructive treatment. Delayed reconstruction was made after a complex of specialized antitumor therapy and assessment of treatment results in the absence of progressive growth. A great problem during multi-stage defect correction is presented by the lack of recipient vessels after cervical lymphadenectomy, the presence of soft tissue scar changes, trismus, temporomandibular joint ankylosis, contractures and displacement of the edges of the
Enajat, Morteza; Smit, Jeroen M; Rozen, Warren M; Hartman, Ed H M; Liss, Anders; Kildal, Morten; Audolfsson, Thorir; Acosta, Rafael
Breast reconstruction often requires multiple operations. In addition to potential complications requiring reoperation, additional procedures are frequently essential in order to complete the reconstructive process, with aesthetic outcome and breast symmetry shown to be the most important factors in patient satisfaction. Despite the importance of these reoperations in decision-making and the consent process, a thorough review of the need for such operations has not been definitively explored. A review of 370 consecutive autologous breast reconstructions (326 patients) was undertaken, comprising 365 deep inferior epigastric artery perforator (DIEP) flaps and 5 superficial inferior epigastric artery (SIEA) flaps. The need for additional procedures for either complications or aesthetic refinement following initial breast reconstruction was assessed. Overall, there was an average of 1.06 additional interventions for every patient carried out after primary reconstructive surgery. Of 326 patients, 46 underwent early postoperative operations for surgical complications (0.17 additional operations per patient as a consequence of complications). Procedures for aesthetic refinement included those performed on the reconstructed breast, contralateral breast, or abdominal donor site. Procedures for aesthetic refinement included nipple reconstruction, nipple-areola complex tattooing, dog-ear correction, liposuction, lipofilling, scar revision, mastopexy, and reduction mammaplasty. While DIEP flap surgery for breast reconstruction provides favorable results, patients frequently require additional procedures to improve aesthetic outcomes. The need for reoperation is an important part of the consent process prior to reconstructive surgery, and patients should recognize the likelihood of at least one additional procedure following initial reconstruction.
Hayashi, Akiteru; Maruyama, Yu; Onishi, Kiyoshi; Chang, Cheng-Chung; Iwahira, Yoshiko; Ebihara, Hirofumi; Sawaizumi, Masayuki
We have performed intraarterial DSA (IADSA) for a pre-operative evaluation of vessels which supply donor or the recipient sites of flaps, and for the observation of patency of the anastomotic sites and graft vessels after a microsurgical free flap transfer. IADSA was found to offer equal and, sometimes even more valuable information than does conventional angiography. In all cases, the image quality satisfied our clinical demands. Because a diluted contrast media and a low dose injection of this contrast media was used, both the intensity of local heat sensation and pain were extremely low. Further, an IADSA can be safely performed on an outpatient basis if a 4-F high flow catheter is used. Thus, we have concluded that an IADSA has reported to be a useful and safe angiographic technic, and that it offers several advantages over conventional angiography. (author)
Sánchez-Patán, Fernando; Anchuelo, Raquel; Corcuera, María-Teresa; Casado, Isabel; Gómez-Aguado, Fernando; Aller, María-Angeles; Cruz, Arturo; Alonso, María-José; Arias, Jaime
A new model of extrahepatic cholestasis, using a microsurgical technique, is performed as an alternative to the traditional model of the bile duct ligated-rat, in order to study the stage of fibrosis in the long-term. Male Wistar rats were divided into two groups: I (Sham-operated, n = 9) and II [Microsurgical Cholestasis (MC), n = 10]. After 4 weeks, portal pressure, types of portosystemic collateral circulation, mesenteric venous vasculopathy, hepatic function test, and liver histopathology were studied by using the Knodell index and fibrosis was determined by reticulin and Sirius red stains. The animals with MC presented portal hypertension with extrahepatic portosistemic collateral circulation, associated with mesenteric venous vasculopathy and increased plasma levels of bilirubin (6.30 +/- 1.80 vs. 0.22 +/- 0.37 mg/dL; P = 0.0001), alkaline phosphatase (293.00 +/- 82.40 vs. 126.30 +/- 33.42 U/L; P = 0.001), AST (380.00 +/- 78.50 vs. 68.33 +/- 11.74 IU/L; P = 0.0001), ALT (87.60 +/- 22.32 vs. 42.22 +/- 7.89 IU/L; P = 0.0001), and LDH (697.76 +/- 75.13 vs. 384.80 +/- 100.03 IU/L; P = 0.0001). On the contrary, plasma levels of albumin decreased (2.72 +/- 0.12 mg/dl vs. 2.99 +/- 0.10; P = 0.001). The microsurgical resection of the extrahepatic biliary tract in the rat produces an experimental model of hepatic inflammation, characterized by a high Knodell hepatic activity index (4), bile proliferation, and fibrosis.
Hutcheson, Florence V.; Stead, Daniel J.; Bremmer, David M.
PIV measurements of the flow in the region of a flap side edge are presented for several flap configurations. The test model is a NACA 63(sub 2)-215 Hicks Mod-B main element airfoil with a half-span Fowler flap. Air is blown from small slots located along the flap side edge on either the top, bottom or side surfaces. The test set up is described and flow measurements for a baseline and three blowing flap configurations are presented. The effects that the flap tip jets have on the structure of the flap side edge flow are discussed for each of the flap configurations tested. The results indicate that blowing air from a slot located along the top surface of the flap greatly weakened the top vortex system and pushed it further off the top surface. Blowing from the bottom flap surface kept the strong side vortex further outboard while blowing from the side surface only strengthened the flap vortex system. It is concluded that blowing from the top or bottom surfaces of the flap may lead to a reduction of flap side edge noise.
Mohammad Ali Amirzargar
Full Text Available The most common anatomic variant seen in the donor kidneys for renal transplantation is multiple renal arteries (MRA, which can cause an increased risk of complications. We describe the long-term outcomes of 16 years of experience in 76 kidney transplantations with MRAs. In a new reconstruction technique, we remove arterial clamps after anastomosing the donor to the recipient′s main renal vessels, which cause backflow from accessory arteries to prevent thrombosis. By this technique, we reduce the ischemic times as well as the operating times. Both in live or cadaver donor kidneys, lower polar arteries were anastomosed to the inferior epigastric artery and upper polar arteries were anastomosed to the superior epigastric arteries. Injection of Papaverine and ablation of sympathic nerves of these arteries dilate and prevent them from post-operative spasm. Follow-up DTPA renal scan in all patients showed good perfusion and function of the transplanted kidney, except two cases of polar arterial thrombosis. Mean creatinine levels during at least two years of follow-up remained acceptable. Patient and graft survival were excellent. No cases of ATN, hypertension, rejection and urologic complications were found. In conclusion, this technique can be safely and successfully utilized for renal transplantation with kidneys having MRAs, and may be associated with a lower complication rate and better graft function compared with the existing techniques.
Slavik, E; Ivanović, S; Grujisić, D; Djurović, B; Nikolić, I
Advances in cancer treatment continue to lengthen survival among cancer patients. As patients live longer, the need for effective pain control has gained increased importance for improving quality of life. In patients who do not respond to all available conservative methods of therapy for cancer pain, surgical methods have been applied; one of them is the open high thoracic spinothalamic chordotomy. We present a group of 86 patients suffering from nociceptive cancer pain, caused by compression of lumbosacral plexus. All patients were treated by microsurgical open high thoracic spinothalamic chordotomy. These patients did not respond to any available conservative treatment. Immediately after surgery 68 (79%) patients had total pain relief. Of the remaining 18 (21%) patients, significant pain relief was achieved in 9 (10%), while in the remaining 9 patients this procedure had no effect. After a 6-month follow-up, total pain relief remained in 62 (72%) and significant pain relief in 10 (17%) of the patients. From 62 of patients with well-defined unilateral pain treated by "moderately deep" chordotomy, total pain relief was achieved in 53 (85%), lasting for 6 months in 49 (79%) of them. These results show that microsurgical chordotomy can achieve total control of intractable cancer pain in the majority (79%) of patients, especially in those with well-defined unilateral pain (85%), indicating the usefullness of this surgical approach in the treatment of nociceptive cancer pain.
Full Text Available Cardiac myxomas are the most common benign tumors found in the heart. They usually appear in the left atrium. Those originating from the left ventricle (LV are rare. Although clinical presentation may vary, dyspnea and embolism are the most commonly reported symptoms. In the present case study, a 27-year-old woman with a large myxoma originating from the left ventricular free wall is studied. She had atypical complaints, mainly epigastric discomfort, nausea, vomiting, and anorexia. She was hospitalized for acute abdomen, but subsequent investigations revealed a large myxoma that fully filled the LV and severely compromised the flow of the aortic and mitral valves. After successful emergency tumor resection, all symptoms disappeared. The uncommon presentation caused by these tumors is discussed in this study.
Matros, Evan; Albornoz, Claudia R; Razdan, Shantanu N; Mehrara, Babak J; Macadam, Sheina A; Ro, Teresa; McCarthy, Colleen M; Disa, Joseph J; Cordeiro, Peter G; Pusic, Andrea L
Reimbursement has been recognized as a physician barrier to autologous reconstruction. Autologous reconstructions are more expensive than prosthetic reconstructions, but provide greater health-related quality of life. The authors' hypothesis is that autologous tissue reconstructions are cost-effective compared with prosthetic techniques when considering health-related quality of life and patient satisfaction. A cost-effectiveness analysis from the payer perspective, including patient input, was performed for unilateral and bilateral reconstructions with deep inferior epigastric perforator (DIEP) flaps and implants. The effectiveness measure was derived using the BREAST-Q and interpreted as the cost for obtaining 1 year of perfect breast health-related quality-adjusted life-year. Costs were obtained from the 2010 Nationwide Inpatient Sample. The incremental cost-effectiveness ratio was generated. A sensitivity analysis for age and stage at diagnosis was performed. BREAST-Q scores from 309 patients with implants and 217 DIEP flap reconstructions were included. The additional cost for obtaining 1 year of perfect breast-related health for a unilateral DIEP flap compared with implant reconstruction was $11,941. For bilateral DIEP flaps compared with implant reconstructions, the cost for an additional breast health-related quality-adjusted life-year was $28,017. The sensitivity analysis demonstrated that the cost for an additional breast health-related quality-adjusted life-year for DIEP flaps compared with implants was less for younger patients and earlier stage breast cancer. DIEP flaps are cost-effective compared with implants, especially for unilateral reconstructions. Cost-effectiveness of autologous techniques is maximized in women with longer life expectancy. Patient-reported outcomes findings can be incorporated into cost-effectiveness analyses to demonstrate the relative value of reconstructive procedures.
Full Text Available Soft tissue reconstruction of the distal lower leg is a challenging issue for plastic surgeons. Immediate coverage of exposed anatomical structures with soft tissue after trauma prevents these structures from being infected, and this is very important for burn patients. Free flaps have recently been accepted as the gold-standard technique for ankle and foot reconstruction; however, this is changing with the increasing popularity of the perforator flaps. Today, perforator flaps are commonly performed for the reconstruction of the soft-tissue defects across the body. In this report, we want to present the reconstruction of a soft-tissue defect case using perforator-based propeller flap in a burn patient for immediate reconstruction. A 45-year-old male patient had a soft-tissue defect over the medial side of the ankle and foot due to a high-voltage electrical burn. The exposed bone tissue was covered with a propeller flap of 15×6 cm size, without any circulation problems during the postoperative period. In conclusion, we want to state that perforator-based propeller flaps are reliable, successful, and effective techniques for the immediate reconstruction of distal leg and foot. These flaps can be easily performed without requiring any microsurgical technique thus, they can be commonly performed by most of the plastic surgeons.
Gunnarsson, Gudjon Leifur; Thomsen, Jorn Bo
BACKGROUND: Perforator flaps are well established, and their usefulness as freestyle island flaps is recognized. The whereabouts of vascular perforators and classification of perforator flaps in the face are a debated subject, despite several anatomical studies showing similar consistency. In our...... experience using freestyle facial perforator flaps, we have located areas where perforators are consistently found. This study is focused on a particular perforator lateral to the angle of the mouth; the modiolus and the versatile modiolus perforator flap. METHODS: A cohort case series of 14 modiolus...... perforator flap reconstructions in 14 patients and a color Doppler ultrasonography localization of the modiolus perforator in 10 volunteers. RESULTS: All 14 flaps were successfully used to reconstruct the defects involved, and the location of the perforator was at the level of the modiolus as predicted...
Full Text Available OBJECTIVE: To define the anatomy of dentate nucleus and cerebellar peduncles, demonstrating the surgical application of anatomic landmarks in cerebellar resections. METHODS: Twenty cerebellar hemispheres were studied. RESULTS: The majority of dentate nucleus and cerebellar peduncles had demonstrated constant relationship to other cerebellar structures, which provided landmarks for surgical approaching. The lateral border is separated from the midline by 19.5 mm in both hemispheres. The posterior border of the cortex is separated 23.3 mm from the posterior segment of the dentate nucleus; the lateral one is separated 26 mm from the lateral border of the nucleus; and the posterior segment of the dentate nucleus is separated 25.4 mm from the posterolateral angle formed by the junction of lateral and posterior borders of cerebellar hemisphere. CONCLUSIONS: Microsurgical anatomy has provided important landmarks that could be applied to cerebellar surgical resections.
Full Text Available Background and Importance. Ruptured periventricular aneurysms in patients with moyamoya disease represent challenging pathologies. The most common methods of treatment include endovascular embolization and microsurgical clipping. However, rare cases arise in which the location and anatomy of the aneurysm make these treatment modalities particularly challenging. Clinical Presentation. We report a case of a 34-year-old female with moyamoya disease who presented with intraventricular hemorrhage. CT angiography and digital subtraction angiography revealed an aneurysm located in the wall of the atrium of the right lateral ventricle. Distal endovascular access was not possible, and embolization risked the sacrifice of arteries supplying critical brain parenchyma. Using the BrainPath endoport system, the aneurysm was able to be accessed. Since the fusiform architecture of the aneurysm prevented clip placement, the aneurysm was ligated with electrocautery. Conclusion. We demonstrate the feasibility of endoport-assisted approach for minimally invasive access and treatment of uncommon, distally located aneurysms.
Gunnarsson, Gudjon Leifur; Jackson, Ian T; Westvik, Tormod S
BACKGROUND: Perforating vessels are a consistent anatomical finding and well described in the current literature. Any skin flap can be raised on a subcutaneous pedicle as long as it contains at least one supplying perforator. Perforator flaps have been interlinked with microsurgery and generally...... not widely performed by the general plastic surgeons. The aim of this paper is to present the simplicity of pedicled perforator flap reconstruction of moderate-sized defects of the extremities and torso. METHODS: We retrospectively reviewed the charts of 34 patients reconstructed using 34 freestyle pedicled...... perforator flaps for moderate-sized defects of the truncus and extremities. We registered indications, flap size and localization, success rate, and complications. Most importantly, we describe a simple approach to the design of freestyle pedicled perforator flaps and elaborate on technical aspects...
Fade, Geraldine; Gobel, Fabienne; Pele, Eric; Chaput, Benoit; Garrido, Ignacio; Pinsolle, Vincent; Pelissier, Philippe; Sinna, Raphael
Deep inferior epigastric perforator (DIEP) flap is one of the gold standards in autologous breast reconstruction. When the abdominal tissue is not available, the superior gluteal artery perforator (SGAP) is often a second option with its drawback, especially the donor-site deformity. Reports have highlighted that a higher and more lateral SGAP flap can be harvested to overcome several drawbacks of the classical SGAP, allowing in the same procedure a body-contouring procedure. In order to set the anatomical basis of this flap, we proposed to study the characteristics of a reliable and easily identifiable superior and lateral perforator of the superior gluteal artery (lateral SGAP (LSGAP)) situated in the region of the lower body-lift resection allowing to perform bilateral breast reconstruction at the same time. The anatomical study of 50 scans (or 100 buttocks) allows us to set forth a diagnostic assumption on the localisation of the perforator with respect to osseous landmarks (coccyx, iliac crest and great trochanter) which will be verified during the dissection of 10 cadavers (or 20 buttocks) and during the 20 colour Doppler examination (or 40 buttocks). In our computed tomography (CT) scan study, in 96% of cases, the perforator was situated in a circle with a radius≤3 cm with a 95% confidence interval and located at the junction of the proximal third-middle third of the distance summit of the posterior iliac crest (point B), most lateral point of the greater trochanter (point C). This assumption was verified by the cadaveric dissection and in vivo studies. Our study sets the anatomical landmarks of the LSGAP flap. This option allows the raising of an SGAP flap avoiding the main drawbacks of this flap and allows harvesting a flap with the tissue that is often discarded during the body-lift procedure. Copyright © 2013 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Full Text Available Two clinical forms of functional dyspepsia (FD are listed in the Rome III criteria: postprandial distress syndrome (PDS and epigastric pain syndrome (EPS, differing in the recurrence of ailments depending on the diet. Continuous EPS (CEPS is observed in some EPS patients, also at night, but its cause is still unknown. We showed previously that melatonin (MEL homeostasis may be associated with FD. In the present work we evaluated selected components of melatonin homeostasis in patients with CEPS. The study included 30 patients with CEPS, 21 women and nine men, aged 21–49 years and 30 control subjects (EPS excluded; organic and mental diseases, as well as Helicobacter pylori infection, were excluded in both groups. The average severity of abdominal pain in the last three months was estimated in a 10-point scale (Visual Analog Scale. The levels of mRNA expression of arylalkylamine-N-acetyltransferase (AANAT and hydroxyindole-O-methyltransferase (HIOMT, the main components of MEL homeostasis, were determined in gastric mucosa with real time PCR. The fasting serum level of MEL (at 09:00 a.m. and circadian urine excretion of 6-sulfatoxymelatonin (6-HMS were determined with ELISA. AANAT expression in antral mucosa of control subjects was 1.76 ± 0.41, in the gastric body 1.35 ± 0.38, and in the dyspeptic group 1.42 ± 0.38 (p < 0.05 and 0.92 ± 0.55 (p < 0.05, respectively. HIOMT expression in the control was 2.05 ± 0.70 in the antrum and 1.57 ± 0.69 in the body and in the CEPS group, it was: 1.51 ± 0.57 (p < 0.05 and 0.74 ± 0.31 (p < 0.001, respectively. MEL concentration (pg/mL was 9.41 ± 3.09 in the control group and 5.62 ± 1.34 (p < 0.01 in the CEPS group. Urinary 6-HMS excretion (μg/24 h was 11.40 ± 4.46 in the controls and 7.68 ± 2.88 (p < 0.05 in the CEPS. Moreover, a negative correlation was found between the tested parameters and severity of epigastric pain. These results indicate that patients with CEPS may display low level of
Yang, Yun-fa; Xu, Zhong-he; Zhang, Guang-ming; Wang, Jian-wei; Hu, Si-wang; Hou, Zhi-qi; Xu, Da-chuan
Posttraumatic infected massive bone defects in lower extremities are difficult to repair because they frequently exhibit massive bone and/or soft tissue defects, serious bone infection, and excessive scar proliferation. This study aimed to determine whether these defects could be classified and repaired at a single stage. A total of 51 cases of posttraumatic infected massive bone defect in lower extremity were included in this study. They were classified into four types on the basis of the conditions of the bone defects, soft tissue defects, and injured limb length, including Type A (without soft tissue defects), Type B (with soft tissue defects of 10 × 20 cm or less), Type C (with soft tissue defects of 10 × 20 cm or more), and Type D (with the limb shortening of 3 cm or more). Four types of single-stage microsurgical repair protocols were planned accordingly and implemented respectively. These protocols included the following: Protocol A, where vascularized fibular graft was implemented for Type A; Protocol B, where vascularized fibular osteoseptocutaneous graft was implemented for Type B; Protocol C, where vascularized fibular graft and anterior lateral thigh flap were used for Type C; and Protocol D, where limb lengthening and Protocols A, B, or C were used for Type D. There were 12, 33, 4, and 2 cases of Types A, B, C, and D, respectively, according to this classification. During the surgery, three cases of planned Protocol B had to be shifted into Protocol C; however, all microsurgical repairs were completed. With reference to Johner-Wruhs evaluation method, the total percentage of excellent and good results was 82.35% after 6 to 41 months of follow-up. It was concluded that posttraumatic massive bone defects could be accurately classified into four types on the basis of the conditions of bone defects, soft tissue coverage, and injured limb length, and successfully repaired with the single-stage repair protocols after thorough debridement. Thieme Medical
Magarakis, Michael; Venkat, Raghunandan; Dellon, A Lee; Shridharani, Sachin M; Bellamy, Justin; Vaca, Elbert E; Jeter, Stacie C; Zoras, Odysseas; Manahan, Michele A; Rosson, Gedge D
Some sensation to the breast returns after breast reconstruction, but recovery is variable and unpredictable. We primarily sought to assess the impact of different types of breast reconstruction [deep inferior epigastric artery perforator (DIEP) flaps versus implants] and radiation therapy on the return of sensation. Thirty-seven patients who had unilateral or bilateral breast reconstruction via a DIEP flap or implant-based reconstruction, with or without radiation therapy (minimum follow-up, 18 months; range, 18-61 months) were studied. Of the 74 breasts, 27 had DIEP flaps, 29 had implants, and 18 were nonreconstructed. Eleven breasts with implants and 10 with DIEP flaps had had prereconstruction radiation therapy. The primary outcome was mean patient-perceived static and moving cutaneous pressure threshold in nine areas. We used univariate and multivariate analyses to assess what independent factors affected the return of sensation (significance, P sensation (P = 0.041) than did DIEP flaps. However, among irradiated breasts, skin over DIEP flaps had significantly better sensation than did that over implants (static, P = 0.019; moving, P = 0.028). Implant reconstructions with irradiated skin had significantly worse static (P = 0.002) and moving sensation (P = 0.014) than did nonirradiated implant reconstructions. Without irradiation, skin overlying implants is associated with better sensation recovery than DIEP flap skin. However, with irradiation, DIEP flap skin had better sensation recovery than did skin over implants. Neurotization trended toward improvement in sensation in DIEP flaps. Copyright © 2013 Wiley Periodicals, Inc.
Full Text Available Incomplete or asymmetrical conjoined twins are extremely rare congenital anomalies. We report a case of epigastric heteropagus associated with an omphalocele and double outlet right ventricle. The cystic legion of the epigastrium was detected in our patient by an ultrasound scan at 28 weeks' gestation. He was born at 37 weeks' gestation by scheduled caesarean section. A parasite with an incomplete head and lower limb was attached to the epigastrium of the autosite. Surgical separation of the parasite and silo placement for an omphalocele was successfully performed on the 4th day of life. He underwent secondary surgical closure of the omphalocele on the 10th day. For treatment of the cardiac anomaly, he underwent an operation of Blalock–Taussig shunt because of pulmonary artery stenosis at the age of 3 months and correction of double outlet right ventricle at the age of 10 months. At the 20-month follow-up, he was alive and showed a normal growth pattern.
Lange, Aksel; Funch-Jensen, Peter; Thommesen, Peter
time (T50) was calculated. For mature infants it was found to be 6.9 mins. For a second meal given within an hour after the first meal the half emptying time was 5.5 mins (p times were not significant different from mature infants, but the number examined was small...... Epigastric impedance was used to measure patterns of the gastric emptying of a liquid non-caloric meal (5 ml water/kg) in newborn infants. The emptying patterns consisted of two components, theemptying signal - the DC component - and a phasic 3 cycle per minutes (CPM) signal - the AC component.......A periodic change of the impedance signal, the phasic 3 CPM signal, was observed after a meal in 24 of the infants. The median frequency was 3.03 CPM in 20 mature and 2.93 CPM in 4 preterminfants. In 9 infants a phasic 3 CPM signal was observed during fasting state. The median frequency was 2.9 CPM...
Christoffersen, Mette; Olsen, B H; Rosenberg, J
PURPOSE: Application of an abdominal binder is often part of a standard postoperative regimen after ventral hernia repair to reduce pain and seroma formation. However, there is lack of evidence of the clinical effects. The aim of the present study was to investigate the pain- and seroma......-reducing effect of an abdominal binder in patients undergoing laparoscopic umbilical or epigastric hernia repair. METHODS: Based on power analysis, a minimum of 54 patients undergoing laparoscopic umbilical and epigastric hernia repair were to be included. Patients were randomized to abdominal binders vs....... no abdominal binders during the first postoperative week. Standardized surgical technique, anaesthesia, and analgesic regimens were used and study observers were blinded towards the intervention. Postoperative pain (visual analogue score) on day 1 was the primary outcome. In addition, ultrasonographic...
A. Fernández García
Full Text Available Los colgajos pediculados pueden sufrir edema y congestión debido a que su drenaje a trevés del sistema venoso superfical es imposible y el flujo hacia el sistema profundo a nivel del pedículo es precario. Esta situación suele evolucionar hacia la necrosis parcial o la pérdida total del colgajo en pocas horas. La apertura del sistema venoso superficial permite el drenaje adecuado de los tejidos transferidos y evita estas complicaciones. Este artículo analiza el papel de las anastomosis microquirúrgicas en el sistema venoso superficial de los colgajos pediculados. Esta técnica permite comunicar el sistema venoso superfical de los tejidos transferidos con el sistema venoso superficial del territorio que rodea al defecto. Presentamos los resultados obtenidos con esta técnica en colgajos de perforante en hélice, colgajos miocutáneos, colgajos neurocutáneos y colgajos fasciograsos volteados.The pedicled flaps can suffer edema and congestion due to the impossibility of drainage toward the superficial venous system and the precarious flow via the deep system at the level of the pedicle. The evolution of this situation is usually partial necrosis or total loss of the flap in a few hours. The opening of the venous superficial system achieves an appropriate drainage of the transfered tissues and avoids these complications. In this article we analyze the role of the microsurgical anastomosis at the level of the superficial venous system of pedicled flaps. This technique allows to communicate the superficial venous system of the transfered tissues with the superficial venous system of the territory around the defect. We report the results with this method in propeller perforator flaps, miocutaneous flaps, neurocutaneous flaps and adipofascial turn over flaps.
Steiert, Andreas E; Gohritz, Andreas; Schreiber, Thomas C; Krettek, Christian; Vogt, Peter M
Controversy remains regarding timing in the management of complex traumatic lower extremity defects. Many authors recommend a definitive bony and soft tissue reconstruction within a critical period of 72 h, yet in many patients this may be impossible due to concomitant injuries or delayed referral. However, little data are available on the results of delayed flap reconstruction of complex traumatic extremity defects, especially using new technologies of wound coverage such as vacuum-assisted closure (VAC((R))) therapy which may reduce the disadvantages of conventional open wound therapy prior to a subsequent flap reconstruction. We retrospectively analysed the soft tissue reconstructions in 43 open extremity fractures during a 4-year period with special regard to complications, overall flap loss and wound infection. A total of 29 male and 13 female patients with 33 open fractures of the lower and 10 of the upper extremity were included. All patients had been referred from a trauma centre at a mean interval of 19 days (range 1-96 days) after the trauma event with temporary VAC((R)) of their wounds after initial fracture fixation and initial debridement of necrotic tissue. Flap reconstruction was thus only possible later than 72 h and definitive wound closure was achieved at a mean time of 28 days (range 3-106 days). Overall, three pedicled flaps were lost and one of 38 microsurgical free flaps (2.6%) underwent necrosis, the cause of which was unrelated to treatment delay. According to this study, the flap reconstructions performed beyond the frequently quoted critical interval yielded similar results to those of immediate reconstruction within the first 3 days, as reported in the literature. This strategy is in accordance with the principles of 'Damage Control Orthopaedics (DCO)' and may reduce the importance of emergency reconstructions, especially in poly-traumatised patients.
Debrah, Samuel A.; Okpala, Amalachukwu M.
Symptomatic epigastric hernia is rare in pregnant women. A case history, management of which prompted a systematic review of the literature and proposed plan for treatment of such cases, is hereby presented. There is paucity of information on management of this condition in the standard literature as searches in Pubmed, Science Direct, Hinari, Medline, African Journal Online, Bioone as well as Cochrane library revealed. There are two schools of thought for the management of hernias in pregnan...
Kulkarni, Anita R; Sears, Erika Davis; Atisha, Dunya M; Alderman, Amy K
Concern exists that plastic surgeons are performing fewer autologous and microsurgical breast reconstructions, despite superior long-term outcomes. The authors describe the proportion of U.S. plastic surgeons performing these procedures and evaluate motivating factors and perceived barriers. A random national sample of American Society of Plastic Surgeons members was surveyed (n = 325; response rate, 76 percent). Surgeon and practice characteristics were assessed, and two multiple logistic regression models were created to evaluate factors associated with (1) high-volume autologous providers and (2) microsurgical providers. Qualitative assessments of motivating factors and barriers to microsurgery were also performed. Fewer than one-fifth of plastic surgeons perform autologous procedures for more than 50 percent of their breast cancer patients, and only one-quarter perform any microsurgical breast reconstruction. Independent predictors of a high-volume autologous practice include involvement with resident education (odds ratio, 2.57; 95 percent CI, 1.26 to 5.24) and a microsurgical fellowship (odds ratio, 2.09; 95 percent CI, 1.04 to 4.27). Predictors of microsurgical breast reconstruction include involvement with resident education (odds ratio, 6.8; 95 percent CI, 3.32 to 13.91), microsurgical fellowship (odds ratio, 2.4; 95 percent CI, 1.16 to 4.95), and high breast reconstruction volume (odds ratio, 6.68; 95 percent CI, 1.76 to 25.27). The primary motivator for microsurgery is superior outcomes, and the primary deterrents are time and reimbursement. The proportion of U.S. plastic surgeons with a high-volume autologous or microsurgical breast reconstruction practice is low. Involvement with resident education appears to facilitate both, whereas time constraints and reimbursement are primary deterrents. Future efforts should focus on improving the feasibility and accessibility of all types of breast reconstruction.
Reddy, Chaitan; Pennington, David; Stern, Harvey
The achievement of patency of the microvascular anastomosis in free flap surgery is dependent on a number of factors, central to which is atraumatic handling of the vessel lumen, and intimal apposition. Initial laboratory studies demonstrating the superiority of the non-penetrating vascular closure staple (VCS - Anastoclip ®) were followed by our report in 1999 on a series of free flaps. There is still a paucity of data in the literature on the use of non-penetrating devices for microvascular anastomosis, and our review gives evidence to support the routine use of the VCS in microsurgical free flap surgery. We now report on its successful use over a thirteen year period in 819 free flap reconstructions. Our data indicates the VCS device to be as effective as sutured anastomoses in free tissue transfer surgery. There is also statistically significant data (Barnard's Exact Test) to demonstrate a higher vascular patency rate of the VCS device over sutured anastomoses when sub group analysis is performed. 'Take-back' revision rates were lower amongst flaps that employed VCS use. For arterial anastomoses, this equated to 3/654(0.05%) vs 4/170(2.4%) with hand-sewn anastomoses (p = 0.02). Similarly, for venous anastomoses the 'take-back' revision rate was 7/661(1.1%) vs 8/165(4.8%) with hand-sewn anastomoses (p = 0.003). Furthermore, the major advantage of the VCS is reduction in anastomosis time, from approximately 25 min per anastomosis for sutures to between five and 10 min for staples. Copyright © 2011 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Full Text Available Several andrological diseases require surgical repair or reconstruction of tunica albuginea, which envelops the corpora cavernosa penis. Despite intense research efforts involving a variety of biological materials, such as skin, muscle aponeurosis, human dura mater, tunica vaginalis, and pericardium, engineered tunica albuginea suitable for graft use is yet to be obtained. The study investigates microsurgical tunica albuginea allotransplantation in an animal model with the purpose of creation of an organ-specific tissue bank to store penile tissue, from cadaveric donors and male-to-female trans-sexual surgery, for allogeneic transplantation. Materials were tunica albuginea tissue explanted from 15 donor rats, cryopreserved at −80°C, gamma-irradiated, and implanted in 15 recipient rats, of which three rats were used as controls. Penile grafts were explanted at different time intervals; after macroscopic evaluation of the organ, the grafts were processed to morphological, histochemical, and immunohistochemical examinations by light microscopy. Detection of pro-inflammatory cytokines was also performed. Examination of the tunica albuginea allografts collected 1, 3, or 6 months after surgery and of control tunica albuginea fragments showed that tunica albuginea implants achieved biointegration with adjacent tissue at all-time points. The integration of cryopreserved rat tunica albuginea allografts, documented by our study, encourages the exploration of tunica albuginea allotransplantation in humans. In conclusion, the effectiveness and reliability of the tunica albuginea conditioning protocol described here suggest the feasibility of setting up a tunica albuginea bank as a further tissue bank.
Corradino, Bartolo; Di Lorenzo, Sara; Mossuto, Carmela; Costa, Renato Patrizio; Moschella, Francesco
Infiltration of botulinum toxin in the major salivary glands allows a temporary reduction of salivation that begins 8 days afterwards and returns to normal within 2 months. The inhibition of salivary secretion, carried out before the oral cavity reconstructive surgery, could allow a reduction of the incidence of oro-cutaneous fistulas and local complications. Saliva stagnation is a risk factor for patients who have to undergo reconstructive microsurgery of the oral cavity, because of fistula formation and local complications in the oral cavity. The authors suggest infiltration of botulinum toxin in the major salivary glands to reduce salivation temporarily during the healing stage. During the preoperative stage, 20 patients with oral cavity carcinoma who were candidates for microsurgical reconstruction underwent sialoscintigraphy and a quantitative measurement of the salivary secretion. Injection of botulinum toxin was carried out in the salivary glands 4 days before surgery. The saliva quantitative measurement was repeated 3 and 8 days after infiltration, sialoscintigraphy after 15 days. In all cases, the saliva quantitative measurement revealed a reduction of 50% and 70% of the salivary secretion after 72 h and 8 days, respectively. A lower rate of local complications was observed.
Sisti, Andrea; D'Aniello, Carlo; Fortezza, Leonardo; Tassinari, Juri; Cuomo, Roberto; Grimaldi, Luca; Nisi, Giuseppe
Since their introduction in 1991, propeller flaps are increasingly used as a surgical approach to loss of substance. The aim of this study was to evaluate the indications and to verify the outcomes and the complication rates using this reconstructing technique through a literature review. A search on PubMed was performed using "propeller flap", "fasciocutaneous flap", "local flap" or "pedicled flap" as key words. We selected clinical studies using propeller flaps as a reconstructing technique. We found 119 studies from 1991 to 2015. Overall, 1,315 propeller flaps were reported in 1,242 patients. Most frequent indications included loss of substance following tumor excision, repair of trauma-induced injuries, burn scar contractures, pressure sores and chronic infections. Complications were observed in 281/1242 patients (22.6%) occurring more frequently in the lower limbs (31.8%). Partial flap necrosis and venous congestion were the most frequent complications. The complications' rate was significantly higher in infants (70 years old) but there was not a significant difference between the sexes. Trend of complication rate has not improved during the last years. Propeller flaps showed a great success rate with low morbidity, quick recovery, good aesthetic outcomes and reduced cost. The quality and volume of the transferred soft tissue, the scar orientation and the possibility of direct donor site closure should be considered in order to avoid complications. Indications for propeller flaps are small- or medium-sized defects located in a well-vascularized area with healthy surrounding tissues. Copyright © 2016 International Institute of Anticancer Research (Dr. John G. Delinassios), All rights reserved.
Roorda, Andrew K; Marcus, Samuel N; Triadafilopoulos, George
Reflux-like dyspepsia (RLD), where predominant epigastric pain is associated with heartburn and/or regurgitation, is a common clinical syndrome in both primary and specialty care. Because symptom frequency and severity vary, overlap among gastroesophageal reflux disease (GERD), non-erosive reflux disease (NERD), and RLD, is quite common. The chronic and recurrent nature of RLD and its variable response to proton pump inhibitor (PPI) therapy remain problematic. To examine the prevalence of GERD, NERD, and RLD in a community setting using an algorithmic approach and to assess the potential, reproducibility, and validity of a multi-factorial scoring system in discriminating patients with RLD from those with GERD or NERD. Using a novel algorithmic approach, we evaluated an outpatient, community-based cohort referred to a gastroenterologist because of epigastric pain and heartburn that were only partially relieved by PPI. After an initial symptom evaluation (for epigastric pain, heartburn, regurgitation, dysphagia), an endoscopy and distal esophageal biopsies were performed, followed by esophageal motility and 24-h ambulatory pH monitoring to assess esophageal function and pathological acid exposure. A scoring system based on presence of symptoms and severity of findings was devised. Data was collected in two stages: subjects in the first stage were designated as the derivation cohort; subjects in the second stage were labeled the validation cohort. The total cohort comprised 159 patients (59 males, 100 females; mean age 52). On endoscopy, 30 patients (19%) had complicated esophagitis (CE) and 11 (7%) had Barrett's esophagus (BE) and were classified collectively as patients with GERD. One-hundred and eighteen (74%) patients had normal esophagus. Of these, 94 (59%) had one or more of the following: hiatal hernia, positive biopsy, abnormal pH, and/or abnormal motility studies and were classified as patients with NERD. The remaining 24 patients (15%) had normal functional
Full Text Available Primary epididymal obstructive azoospermia (OA is the most prevalent form of OA in nonvasectomized patients and has been less studied. We aim to assess the results with microsurgical vasoepididymostomy used in the treatment of men diagnosed with primary epididymal obstructive azoospermia and to identify the factors associated with natural pregnancy occurring after microsurgical reconstruction. This prospective study included consecutive patients with epididymal OA who underwent microsurgical reconstruction in our center. Clinical and biological data were obtained every three months during follow-up. Occurrence of natural pregnancy was the primary study outcome. In total, 36 patients underwent microsurgical reconstruction. The mean age was 34±4.5 years (range 24–46 years. Median follow-up time was 15 [IQR 12–21] months. The total patency rate was 77.7% (n=28. During follow-up, 8 (22.2% natural pregnancies occurred. The overall live birth rate was 100%. Low FSH levels (HR: 0.22; 95% CI: 0.052–0.88; P=0.032 and higher total motile sperm count (TMSC (HR: 1.001; 95% CI 1–1.001; P=0.012 were associated with a higher rate of natural pregnancy. Our data suggest that microsurgical vasoepididymostomy is an effective therapy of primary epididymal OA. Baseline lower FSH and higher TMSC were independent predictors for natural pregnancy occurrence.
Harza, Mihai; Voinea, Sebastian; Ismail, Gener; Gagiu, Cristian; Baston, Catalin; Preda, Adrian; Manea, Ioan; Priporeanu, Tiberiu; Sinescu, Ioanel
Primary epididymal obstructive azoospermia (OA) is the most prevalent form of OA in nonvasectomized patients and has been less studied. We aim to assess the results with microsurgical vasoepididymostomy used in the treatment of men diagnosed with primary epididymal obstructive azoospermia and to identify the factors associated with natural pregnancy occurring after microsurgical reconstruction. This prospective study included consecutive patients with epididymal OA who underwent microsurgical reconstruction in our center. Clinical and biological data were obtained every three months during follow-up. Occurrence of natural pregnancy was the primary study outcome. In total, 36 patients underwent microsurgical reconstruction. The mean age was 34 ± 4.5 years (range 24-46 years). Median follow-up time was 15 [IQR 12-21] months. The total patency rate was 77.7% (n = 28). During follow-up, 8 (22.2%) natural pregnancies occurred. The overall live birth rate was 100%. Low FSH levels (HR: 0.22; 95% CI: 0.052-0.88; P = 0.032) and higher total motile sperm count (TMSC) (HR: 1.001; 95% CI 1-1.001; P = 0.012) were associated with a higher rate of natural pregnancy. Our data suggest that microsurgical vasoepididymostomy is an effective therapy of primary epididymal OA. Baseline lower FSH and higher TMSC were independent predictors for natural pregnancy occurrence.
Patel, Sameer A; Keller, Alex
The deep inferior epigastric perforator flap is rapidly becoming a more widely employed method of autologous breast reconstruction. The technical considerations involved in the execution of the flap are many and include the selection of perforators to be incorporated in the flap. We attempt to give a mathematical explanation, based on the physics of flow through vessels and the properties of circuits with multiple resistances in parallel, for the clinical observations which have been arrived at through clinical experience. We compare the system of perforators to a circuit with multiple resistances in parallel. Each of these resistances represents a perforator vessel. In the event that there is only one perforator vessel, this simplifies to a single resistance in series with the capillary bed perfusing the flap. The flow through the flap is optimized by incorporation of the largest diameter perforator. Inclusion of other smaller perforators in addition to the largest diameter perforator will reduce the overall resistance, but this reduction in resistance is dependent on the diameter of the additional perforator and may not be worth the additional trauma of dissection and increased operative time. Incorporating several smaller perforators at the expense of excluding the largest diameter perforator appears to increase the overall resistance, unless the smaller perforators are only slightly smaller. We conclude that the best perfused flap involves use of the largest diameter vessel, that although adding additional perforators will decrease the resistance and increase flow, the magnitude of the benefit depends largely on the calibre of the additional perforator, and that this benefit needs to be weighed against the downside of increased muscle and facial trauma.
ElSheikh, M; Zeitoun, I; ElMassry, M A K
The temporalis muscle flap is a very versatile and valuable axial flap, which could be used in various reconstructive procedures in and around the oro-maxillofacial region. The surgical anatomy, vascular pattern and technique of elevation of the flap are described, together with our experience in different reconstructive situations. The advantages and disadvantages of the use of this flap are thoroughly discussed taking into consideration the potentiality of cancer recurrence under cover of the flap. (author)
Thomas Sjøberg, MD
Conclusion:. In selected patients with insufficient abdominal flap tissue, a combination of a free abdominal flap and a pedicled LICAP flap is a valuable option to increase breast size and cosmetic outcome. Additional symmetrizing surgery might still be necessary.
Nanda, Anil; Narayan, Vinayak; Mohammed, Nasser; Savardekar, Amey R; Patra, Devi Prasad
Objectives Complete surgical resection is an important prognostic factor for recurrence and is the best management for craniopharyngioma. This operative video demonstrates the technical nuances in achieving complete resection of a suprasellar craniopharyngioma. Design and Setting The surgery was performed in a middle-aged lady who presented with the history of progressive bitemporal hemianopia and excessive sleepiness over 8 months. On imaging, suprasellar craniopharyngioma was identified. The tumor was approached through opticocarotid cistern and lamina terminalis. Exposure of bilateral optic nerves, right internal carotid artery, anterior cerebral artery, and its perforator branches was then afforded and the tumor was gross totally resected. Results The author demonstrates step-by-step technique of microsurgical resection of suprasellar craniopharyngioma. The narrow corridor to deeper structures, intricacies of multiple perforator vessels, and the technique of arachnoid and capsule dissection are the main challenging factors for the gross total resection of craniopharyngioma. The tumor portion which lies under the ipsilateral optic nerve is a blind spot region with a high chance of leaving residual tumor. Mobilization of optic nerve may endanger visual function too. The use of handheld mirror ['mirror-technique'] helps in better visualization of this blind spot and achieve complete excision. Conclusions The technical pearls of craniopharyngioma surgery include the optimum utilization of translamina terminalis route, wide opening of the cisterns, meticulous separation of deep perforator vessels, capsular mobilization/traction avoidance, and the use of "mirror-technique" for blind-spot visualization. These surgical strategies help to achieve complete resection without causing neurological deficit. The link to the video can be found at: https://youtu.be/9wHJ4AUpG50 .
Meij, B. P. [Utrecht University, Utrecht (Netherlands); Voorhout, G.; Ingh, T.S.G.A.M. van den; Hazewinkel, H. A.W.; Verlaat, J.W. van ' t
Objective-Assessment of a microsurgical technique for transsphenoidalhypophysectomy in dogs. Study Design-Prospective study using physicalexamination, pituitary function testing, computed tomography (CT), and histological examination at autopsy. Animals or Sample Population-Eight laboratory beagle dogs. Methods-Pituitary function was assessed before and at 10 weeks after hypophysectomy by combined administration of four releasing hormones (anterior pituitary), administration of haloperidol (pars intermedia), and infusion of hypertonic saline (posterior pituitary). Results-CT imaging enabled accurate preoperative localization of the pituitary. Appropriate positioning and surgical technique facilitated exposure of the pituitary and its extraction without hemorrhage. Postoperative recovery was generally uncomplicated. None of the eight dogs had somatotropic. gonadotropic, lactotropic, melanotropic, or posterior pituitary responses to stimulation at 10 weeks after hypophysectomy. Four dogs (ACTH nonresponders) also had no corticotropicresponse and four (ACTH responders) bad small but significant responses in the combined anterior pituitary function test. Adrenocortical atrophy was more pronounced in the ACTH nonresponders than in the responders. No residual pituitary tissue was found along the ventral hypothalamic diencephalon but nests of pituitary cells were found embedded infibrous tissue in the sella turcica. Conclusions-The surgical technique proved to be safe and effective. Microscopic nests of pituitary cells in the sella turcica may be responsible for residual corticotropic response to hypophysiotropic stimulation after hypophysectomy. Clinical Relevance-The surgical technique may be used in the treatment of dogs with pituitary-dependent hyperadrenocorticism. The corticotropic response is the most sensitive criterion in assessing completeness of hypophysectomy in dogs. (C) Copyright 1997 by The American College of Veterinary Surgeons.
Meij, B.P.; Voorhout, G.; Ingh, T.S.G.A.M. van den; Hazewinkel, H.A.W.; Verlaat, J.W. van 't
Objective-Assessment of a microsurgical technique for transsphenoidalhypophysectomy in dogs. Study Design-Prospective study using physicalexamination, pituitary function testing, computed tomography (CT), and histological examination at autopsy. Animals or Sample Population-Eight laboratory beagle dogs. Methods-Pituitary function was assessed before and at 10 weeks after hypophysectomy by combined administration of four releasing hormones (anterior pituitary), administration of haloperidol (pars intermedia), and infusion of hypertonic saline (posterior pituitary). Results-CT imaging enabled accurate preoperative localization of the pituitary. Appropriate positioning and surgical technique facilitated exposure of the pituitary and its extraction without hemorrhage. Postoperative recovery was generally uncomplicated. None of the eight dogs had somatotropic. gonadotropic, lactotropic, melanotropic, or posterior pituitary responses to stimulation at 10 weeks after hypophysectomy. Four dogs (ACTH nonresponders) also had no corticotropicresponse and four (ACTH responders) bad small but significant responses in the combined anterior pituitary function test. Adrenocortical atrophy was more pronounced in the ACTH nonresponders than in the responders. No residual pituitary tissue was found along the ventral hypothalamic diencephalon but nests of pituitary cells were found embedded infibrous tissue in the sella turcica. Conclusions-The surgical technique proved to be safe and effective. Microscopic nests of pituitary cells in the sella turcica may be responsible for residual corticotropic response to hypophysiotropic stimulation after hypophysectomy. Clinical Relevance-The surgical technique may be used in the treatment of dogs with pituitary-dependent hyperadrenocorticism. The corticotropic response is the most sensitive criterion in assessing completeness of hypophysectomy in dogs. (C) Copyright 1997 by The American College of Veterinary Surgeons
Tayebi Meybodi, Ali; Lawton, Michael T; Yousef, Sonia; Mokhtari, Pooneh; Gandhi, Sirin; Benet, Arnau
Mastery of microsurgical anastomosis is key to achieving good outcomes in cerebrovascular bypass procedures. Animal models (especially rodents) provide an optimal preclinical bypass training platform. However, the existing models for practicing different anastomosis configurations have several limitations. We sought to optimize the use of the rat's abdominal aorta and common iliac arteries (CIA) for practicing the 3 main anastomosis configurations commonly used in cerebrovascular surgery. Thirteen male Sprague-Dawley rats underwent inhalant anesthesia. The abdominal aorta and the CIAs were exposed. The distances between the major branches of the aorta were measured to find the optimal location for an end-to-end anastomosis. Also, the feasibility of performing side-to-side and end-to-side anastomoses between the CIAs was assessed. All bypass configurations could be performed between the left renal artery and the CIA bifurcation. The longest segments of the aorta without major branches were 1) between the left renal and left iliolumbar arteries (16.9 mm ± 4.6), and 2) between the right iliolumbar artery and the aortic bifurcation (9.7 mm ± 4.7). The CIAs could be juxtaposed for an average length of 7.6 mm ± 1.3, for a side-to-side anastomosis. The left CIA could be successfully reimplanted on to the right CIA at an average distance of 9.1 mm ± 1.6 from the aortic bifurcation. Our results show that rat's abdominal aorta and CIAs may be effectively used for all the anastomosis configurations used in cerebral revascularization procedures. We also provide technical nuances and anatomic descriptions to plan for practicing each bypass configuration. Copyright © 2017 Elsevier Inc. All rights reserved.
Monroy-Sosa, Alejandro; Pérez-Cruz, Julio César; Reyes-Soto, Gervith; Delgado-Hernández, Carlos; Macías-Duvignau, Mario Alberto; Delgado-Reyes, Luis
The anterior cerebral artery originates from the bifurcation of the internal carotid artery lateral to the optic chiasm, then joins with its contralateral counterpart via the anterior communicating artery. A1-anterior communicating artery complex is the most frequent anatomical variants and is the major site of aneurysms between 30 to 37%. Know the anatomy microsurgical, variants anatomical and importance of complex precommunicating segment-artery anterior communicating in surgery neurological of the pathology vascular, mainly aneurysms, in Mexican population. The study was performed in 30 brains injected. Microanatomy was studied (length and diameter) of A1-anterior communicating artery complex and its variants. 60 segments A1, the average length of left side was 11.35 mm and 11.84 mm was right. The average diameter of left was 1.67 mm and the right was 1.64 mm. The average number of perforators on the left side was 7.9 and the right side was 7.5. Anterior communicating artery was found in 29 brains of the optic chiasm, its course depended on the length of the A1 segment. The average length of the segment was 2.84 mm, the average diameter was 1.41 mm and the average number of perforators was 3.27. A1-anterior communicating artery complex variants were found in 18 (60%) and the presence of two blister-like aneurysms. It is necessary to understand the A1-anterior communicating artery complex microanatomy of its variants to have a three-dimensional vision during aneurysm surgery.
Gomel, Victor; Koninckx, Philippe R
"Microsurgery" is a set of principles developed to improve fertility surgery outcomes. These principles were developed progressively based on common sense and available evidence, under control of clinical feedback obtained with the use of second-look laparoscopy. Fertility outcome was the end point; significant improvement in fertility rates validated the concept clinically. Postoperative adhesion formation being a major cause of failure in fertility surgery, the concept of microsurgery predominantly addresses prevention of postoperative adhesions. In this concept, magnification with a microscope or laparoscope plays a minor role as technical facilitator. Not surprisingly, the principles to prevent adhesion formation are strikingly similar to our actual understanding: gentle tissue handling, avoiding desiccation, irrigation at room temperature, shielding abdominal contents from ambient air, meticulous hemostasis and lavage, avoiding foreign body contamination and infection, administration of dexamethasone postoperatively, and even the concept of keeping denuded areas separated by temporary adnexal or ovarian suspension. The actual concepts of peritoneal conditioning during surgery and use of dexamethasone and a barrier at the end of surgery thus confirm without exception the tenets of microsurgery. Although recent research helped to clarify the pathophysiology of adhesion formation, refined its prevention and the relative importance of each factor, the clinical end point of improvement of fertility rates remains demonstrated for only the microsurgical tenets as a whole. In conclusion, the principles of microsurgery remain fully valid as the cornerstones of reproductive microsurgery, whether performed by means of open access or laparoscopy. Copyright © 2016 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.
Frederico Alonso Sabino de Freitas
Full Text Available INTRODUÇÃO: Múltiplos fatores têm sido implicados na patogênese da lesão de isquemia/reperfusão da pele, incluindo as espécies reativas de oxigênio. OBJETIVO: Estudar a lesão de isquemia/reperfusão em retalhos cutâneos de ratos avaliando os níveis teciduais do malonildialdeído (MDA e xantina oxidase (XO. MÉTODOS: Foram utilizados 8 ratos Wistar, com peso entre 300 - 400g, sendo confeccionados 2 retalhos epigástricos por animal (controle e experimento, um deles submetido à 16h de isquemia (RI seguida de 45 min de reperfusão (RR e o outro controle (RC. Foram colhidas 3 biópsias de pele dos retalhos (RC, RI, RR e encaminhadas para dosagem de MDA e XO. RESULTADOS: A análise bioquímica mostrou aumento significativo dos níveis teciduais de MDA e XO após a reperfusão em relação aos retalhos controles. CONCLUSÃO: Retalhos epigástricos de ratos submetidos à 16h de isquemia e 45min de reperfusão apresentam elevação dos níveis teciduais de MDA e XO, caracterizando a lipoperoxidação da membrana celular.INTRODUCTION: Multiple factors have been implicated in the pathogenesis of reperfusion injury in the skin, including the reactive oxygen species. OBJECTIVE: The aim was to evaluate the effect of reperfusion injury in the rat skin flap evaluated by tissue assay for malonyldialdehyde (MDA and xanthine oxidase (XO. METHODS: 8 Wistar rats were used, between 300-400g weight and two identical epigastric flaps were raised in each animal (control and experiment, the vasculature of one flap was left intact and in the second flap the arterial pedicle was clamped for 16 hours and reperfused for 45 minutes. Skin samples were obtained from each flap after these periods of time and submitted to MDA and XO analysis. RESULTS: Reperfused flaps had significantly increased MDA and XO values compared to the control flaps biopsies. CONCLUSION: The lipid peroxidation levels were higher in the rat epigastric skin flaps subjected to 16 hours of
Khorrami, Mehdi R. (Inventor); Choudhan, Meelan M. (Inventor)
A flap of the type that is movably connected to an aircraft wing to provide control of an aircraft in flight includes opposite ends, wherein at least a first opposite end includes a plurality of substantially rigid, laterally extending protrusions that are spaced apart to form a plurality of fluidly interconnected passageways. The passageways have openings adjacent to upper and lower sides of the flap, and the passageways include a plurality of bends such that high pressure fluid flows from a high pressure region to a low pressure region to provide a boundary condition that inhibits noise resulting from airflow around the end of the flap.
Toyota, Shingo; Kumagai, Tetsuya; Goto, Tetsu; Mori, Kanji; Taki, Takuyu
The retractor system is an important device in carotid endarterectomy (CEA). We applied the Lone Star (LS) Retractor System, which is a self-retaining retractor originally designed for improved visualization in many other surgical fields, in microsurgical CEA. The LS disposal retractor (14.1 cm × 14.1 cm) and LS elastic stays (5-mm sharp hook) were used as a retractor system in 38 consecutive CEAs. Using the LS retractor system, a shallow operative field could be obtained by lifting up the connective tissue surrounding the deep structures hooked by the LS elastic stays. The LS elastic stays were quick and easy to handle in the microsurgical operative field. There were no complications using the LS retractor system. The application of the LS retractor system in microsurgical CEA is feasible. An additional merit is that it is single use. Copyright © 2017 Elsevier Inc. All rights reserved.
Calafat, V; Strugarek, C; Montoya-Faivre, D; Dap, F; Dautel, G
Skin envelope degloving of fingers are rare injuries that require rapid care and surgical treatment. Mostly caused by ring finger injuries, these traumas include bone, tendon and neurovascular pedicle damage. The authors present an unusual case of finger degloving limited exclusively to the skin envelope, without skeletal, tendinous or vascular lesion. This rare case of skin envelope degloving rendered microsurgical revascularization impossible. The authors report the results at 12 months following salvage reconstruction combining a partial second toe pulp free flap for the volar side and a dermal substitute with a thin skin graft for the dorsum. Copyright © 2018 Elsevier Masson SAS. All rights reserved.
A dynamic FLAPS(TM) electronic scan antenna was the focus of this research. The novelty S of this SBIR resides in the use of plasma as the main component of this dynamic X-Band phased S array antenna...
Vakil, N; Vieth, M; Wernersson, B; Wissmar, J; Dent, J
The diagnosis of gastro-oesophageal reflux disease (GERD) in clinical practice is limited by the sensitivity and specificity of symptoms and diagnostic testing. To determine if adding histology as a criterion and excluding patients with epigastric pain enhances the diagnosis for GERD. Patients with frequent upper gastrointestinal symptoms who had not taken a proton pump inhibitor in the previous 2 months and who had evaluable distal oesophageal biopsies were included (Diamond study: NCT00291746). Epithelial hyperplasia was identified when total epithelial thickness was at least 430 μm. Investigation-based GERD criteria were: presence of erosive oesophagitis, pathological oesophageal acid exposure and/or positive symptom-acid association probability. Symptoms were assessed using the Reflux Disease Questionnaire and a pre-specified checklist. Overall, 127 (55%) of the 231 included patients met investigation-based GERD criteria and 195 (84%) met symptom-based criteria. Epithelial hyperplasia was present in 89 individuals, of whom 61 (69%) met investigation-based criteria and 83 (93%) met symptom-based criteria. Adding epithelial hyperplasia as a criterion increased the number of patients diagnosed with GERD on investigation by 28 [12%; number needed to diagnose (NND): 8], to 155 (67%). The proportion of patients with a symptom-based GERD diagnosis who met investigation-based criteria including epithelial hyperplasia was significantly greater when concomitant epigastric pain was absent than when it was present (P < 0.05; NND: 8). Histology increases diagnosis of GERD and should be performed when clinical suspicion is high and endoscopy is negative. Excluding patients with epigastric pain enhances sensitivity for the diagnosis of GERD. © 2017 John Wiley & Sons Ltd.
Hansen, H. I.; Thoft-Christensen, Palle
The main problem in designing ultra-long span suspension bridges is flutter. A solution to this problem might be to introduce an active flap control system to increase the flutter wind velocity. The investigated flap control system consists of flaps integrated in the bridge girder so each flap...... is the streamlined part of the edge of the girder. Additional aerodynamic derivatives are shown for the flaps and it is shown how methods already developed can be used to estimate the flutter wind velocity for a bridge section with flaps. As an example, the flutter wind velocity is calculated for different flap...... configurations for a bridge section model by using aerodynamic derivatives for a flat plate. The example shows that different flap configurations can either increase or decrease the flutter wind velocity. for optimal flap configurations flutter will not occur....
Tan, Qian; Zhou, Hong-Reng; Wang, Shu-Qin; Zheng, Dong-Feng; Xu, Peng; Wu, Jie; Ge, Hua-Qiang; Lin, Yue; Yan, Xin
To investigate the aesthetic effect of wound repair with flaps. One thousand nine hundred and ninety-six patients with 2082 wounds hospitalized from January 2004 to December 2011. These wounds included 503 deep burn wounds, 268 pressure sores, 392 soft tissue defects caused by trauma, 479 soft tissue defects due to resection of skin cancer and mole removal, 314 soft tissue defects caused by scar excision, and 126 other wounds. Wound area ranged from 1.5 cm x 1.0 cm to 30.0 cm x 22.0 cm. Sliding flaps, expanded flaps, pedicle flaps, and free flaps were used to repair the wounds in accordance with the principle and timing of wound repair with flaps. Five flaps showed venous congestion within 48 hours post-operation, 2 flaps of them improved after local massage. One flap survived after local heparin wet packing and venous bloodletting. One flap survived after emergency surgical embolectomy and bridging with saphenous vein graft. One flap showed partial necrosis and healed after skin grafting. The other flaps survived well. One thousand three hundred and twenty-one patients were followed up for 3 months to 2 years, and flaps of them were satisfactory in shape, color, and elasticity, similar to that of normal skin. Some patients underwent scar revision later with good results. Application of suitable flaps in wound repair will result in quick wound healing, good function recovery, and satisfactory aesthetic effect.
Feng, Kuan-Ming; Hsieh, Ching-Hua; Jeng, Seng-Feng
Theoretically, a flap can be supplied by any perforator based on the angiosome theory. In this study, the technique of free-style perforator flap dissection was used to harvest a pedicled or free skin flap from a previous free flap for a second difficult reconstruction. The authors call this a free-style puzzle flap. For the past 3 years, the authors treated 13 patients in whom 12 pedicled free-style puzzle flaps were harvested from previous redundant free flaps and recycled to reconstruct soft-tissue defects at various anatomical locations. One free-style free puzzle flap was harvested from a previous anterolateral thigh flap for buccal cancer to reconstruct a foot defect. Total flap survival was attained in 12 of 13 flaps. One transferred flap failed completely. This patient had received postoperative radiotherapy after the initial cancer ablation and free anterolateral thigh flap reconstruction. Another free flap was used to close and reconstruct the wound. All the donor sites could be closed primarily. The free-style puzzle flap, harvested from a previous redundant free flap and used as a perforator flap to reconstruct a new defect, has proven to be versatile and reliable. When indicated, it is an alternative donor site for further reconstruction of soft-tissue defects.
Choque-Velasquez, Joham; Colasanti, Roberto; Collan, Juhani; Kinnunen, Riina; Rezai Jahromi, Behnam; Hernesniemi, Juha
Microsurgical skills and eye-hand coordination need continuous training to be developed and refined. However, well-equipped microsurgical laboratories are not so widespread as their setup is expensive. Herein, we present a novel microsurgical training system that requires a high-resolution personal computer screen, smartphones, and virtual reality glasses. A smartphone placed on a holder at a height of about 15-20 cm from the surgical target field is used as the webcam of the computer. A specific software is used to duplicate the video camera image. The video may be transferred from the computer to another smartphone, which may be connected to virtual reality glasses. Using the previously described training model, we progressively performed more and more complex microsurgical exercises. It did not take long to set up our system, thus saving time for the training sessions. Our proposed training model may represent an affordable and efficient system to improve eye-hand coordination and dexterity in using not only the operating microscope but also endoscopes and exoscopes. Copyright © 2018 Elsevier Inc. All rights reserved.
Hutcheson, Florence V.; Stead, Daniel J.
PIV measurements of the flow in the region of a flap side edge are presented for several blowing flap configurations. The test model is a NACA 63(sub 2)-215 Hicks Mod-B main-element airfoil with a half-span Fowler flap. Air is blown from small slots located along the flap side edge on either the top, bottom or side surfaces. The test set up is described and flow measurements for a baseline and three blowing flap configurations are presented. The effects that the flap tip jets have on the structure of the flap side edge flow are discussed for each of the flap configurations tested. The results indicate that blowing air from a slot located along the top surface of the flap greatly weakened the top vortex system and pushed it further off the top surface. Blowing from the bottom flap surface kept the strong side vortex further outboard while blowing from the side surface only strengthened the vortex system or accelerated the merging of the side vortex to the flap top surface. It is concluded that blowing from the top or bottom surfaces of the flap may lead to a reduction of flap side edge noise.
Chen, Kuo-Hsin; Weng, Meng-Tzu; Chou, Yueh-Hung; Lu, Yueh-Feng; Hsieh, Chen-Hsi
Sorafenib followed by fractionated radiotherapy (RT) has been shown to decrease the phagocytic and candidacidal activities of antifungal agents due to radiosensitization. Moreover, sorafenib has been shown to suppress the immune system, thereby increasing the risk for candida colonization and infection. In this study, we present the 2 hepatocellular carcinoma (HCC) patients suffered from epigastric distress caused by esophageal candidiasis who received sorafenib plus RT. Two patients who had received sorafenib and RT for HCC with bone metastasis presented with hiccups, gastric ulcer, epigastric distress, anorexia, heart burn, and fatigue. Empiric antiemetic agents, antacids, and pain killers were ineffective at relieving symptoms. Panendoscopy revealed diffuse white lesions in the esophagus. Candida esophagitis was suspected. Results of periodic acid-Schiff staining were diagnostic of candidiasis. Oral fluconazole (150 mg) twice daily and proton-pump inhibitors were prescribed. At 2-weak follow-up, esophagitis had resolved and both patients were free of gastrointestinal symptoms. Physicians should be aware that sorafenib combined with RT may induce an immunosuppressive state in patients with HCC, thereby increasing their risk of developing esophagitis due to candida species.
Lewis, Stephen; Stableforth, William; Awasthi, Rachana; Awasthi, Ashish; Pitts, Narrie; Ottaway, Janet; Sherwood, Anthea; Robertson, Neil; Cochrane, Sean; Wilkinson, Stephen
The endoscopic appearance of duodenitis is a common finding in patients undergoing endoscopy because of epigastric pain however, the relationship of the visual findings to histology is poorly defined. We set out to ascertain if there was a correlation between the endoscopic and histological appearances of the duodenal mucosa. Consecutive patients with epigastric pain referred for diagnostic gastroduodenoscopy were studied. The visual appearances of 'duodenitis' (erythema, erosions and sub-epithelial haemorrhage) were reported independently by two endoscopists. Duodenal biopsies were taken and assessed for: neutrophil infiltrate, mononuclear infiltrate, gastric metaplasia, villous atrophy and a breach in the mucosa. H pylori status was determined. Of the 93 patients with endoscopic features of duodenitis an increase in histological markers of inflammation was found in 75 (81%). However, histological inflammation was absent or minimal in 68 (73%). Conversely, biopsies from normal-looking mucosa revealed histological evidence of inflammation in 26 (27%). For patients with the endoscopic features of duodenitis the positive & negative predictive value for neutrophilic infiltrate was 39% and 98% respectively. Biopsies from erosions confirmed a breach in the mucosa in only 2 of 40 patients. Neutrophilic infiltrate occurred with NSAI ingestion and infection with H pylori. The endoscopic appearance of the duodenal mucosa is unreliable in determining the presence of histological inflammation. The endoscopic appearance of 'erosions' is not usually associated with a mucosal breach.
Hutcheson, Florence V.; Stead, Daniel J.; Plassman, Gerald E.
The effects of the interaction of a wake with a half-span flap on radiated noise are examined. The incident wake is generated by bars of various widths and lengths or by a simplified landing gear model. Single microphone and phased array measurements are used to isolate the effects of the wake interaction on the noise radiating from the flap side edge and flap cove regions. The effects on noise of the wake generator's geometry and relative placement with respect to the flap are assessed. Placement of the wake generators upstream of the flap side edge is shown to lead to the reduction of flap side edge noise by introducing a velocity deficit and likely altering the instabilities in the flap side edge vortex system. Significant reduction in flap side edge noise is achieved with a bar positioned directly upstream of the flap side edge. The noise reduction benefit is seen to improve with increased bar width, length and proximity to the flap edge. Positioning of the landing gear model upstream of the flap side edge also leads to decreased flap side edge noise. In addition, flap cove noise levels are significantly lower than when the landing gear is positioned upstream of the flap mid-span. The impact of the local flow velocity on the noise radiating directly from the landing gear is discussed. The effects of the landing gear side-braces on flap side edge, flap cove and landing gear noise are shown.
Sumi, Y.; Ueda, M.; Oka, T.; Torii, S.
The reaction of skin flaps to irradiation and the optimum postoperative time for irradiation was studied in the rat. Flaps showed different reactions depending on the time of irradiation. There was a correlation between the radiosensitivity and the vascularity of the flap. Those flaps in the marginal hypovascular stage of revascularization showed reactions similar to normal skin. However, severe adverse reactions were observed in the marginal hypervascular stage
For decades, osseous vascularised flaps have been used for reconstruction of the mandible with the vascularised fibula flap (VFF) remaining the commonly used osseous free flap, reasons ranging from its adequate bone and pedicle length to its receptive dental implant placement quality. This report considers a modest use ...
Strang, Karl Axel
In the late eighteenth century, humans discovered the first pterosaur fossil remains and have been fascinated by their existence ever since. Pterosaurs exploited their membrane wings in a sophisticated manner for flight control and propulsion, and were likely the most efficient and effective flyers ever to inhabit our planet. The flapping gait is a complex combination of motions that sustains and propels an animal in the air. Because pterosaurs were so large with wingspans up to eleven meters, if they could have sustained flapping flight, they would have had to achieve high propulsive efficiencies. Identifying the wing motions that contribute the most to propulsive efficiency is key to understanding pterosaur flight, and therefore to shedding light on flapping flight in general and the design of efficient ornithopters. This study is based on published results for a very well-preserved specimen of Coloborhynchus robustus, for which the joints are well-known and thoroughly described in the literature. Simplifying assumptions are made to estimate the characteristics that can not be inferred directly from the fossil remains. For a given animal, maximizing efficiency is equivalent to minimizing power at a given thrust and speed. We therefore aim at finding the flapping gait, that is the joint motions, that minimize the required flapping power. The power is computed from the aerodynamic forces created during a given wing motion. We develop an unsteady three-dimensional code based on the vortex-lattice method, which correlates well with published results for unsteady motions of rectangular wings. In the aerodynamic model, the rigid pterosaur wing is defined by the position of the bones. In the aeroelastic model, we add the flexibility of the bones and of the wing membrane. The nonlinear structural behavior of the membrane is reduced to a linear modal decomposition, assuming small deflections about the reference wing geometry. The reference wing geometry is computed for
Moret, Lionel; Thiria, Benjamin; Zhang, Jun
We study the effect of passive pitching and flexible deflection of wings on the forward flapping flight. The wings are flapped vertically in water and are allowed to move freely horizontally. The forward speed is chosen by the flapping wing itself by balance of drag and thrust. We show, that by allowing the wing to passively pitch or by adding a flexible extension at its trailing edge, the forward speed is significantly increased. Detailed measurements of wing deflection and passive pitching, together with flow visualization, are used to explain our observations. The advantage of having a wing with finite rigidity/flexibility is discussed as we compare the current results with our biological inspirations such as birds and fish.
M Emre Altunrende
Full Text Available Background: Neurosurgery and ophthalmology residents need many years to improve microsurgical skills. Laboratory training models are very important for developing surgical skills before clinical application of microsurgery. A simple simulation model is needed for residents to learn how to handle microsurgical instruments and to perform safe dissection of intracranial or intraorbital nerves, vessels, and other structures. Materials and Methods: The simulation material consists of a one-year-old fresh cadaveric sheep cranium. Two parts (Part 1 and Part 2 were designed to approach structures of the orbit. Part 1 consisted of a 2-step approach to dissect intraorbital structures, and Part 2 consisted of a 3-step approach to dissect the optic nerve intracranially. Results: The model simulates standard microsurgical techniques using a variety of approaches to structures in and around the orbit and the optic nerve. Conclusions: This laboratory training model enables trainees to gain experience with an operating microscope, microsurgical instruments and orbital structures.
Aldelaimi, Tahrir N; Khalil, Afrah A
Reconstruction of the head and neck is a challenge for otolarygology surgeons, maxillofacial surgeons as well as plastic surgeons. Defects caused by the resection and/or trauma should be closed with flaps which match in color, texture and hair bearing characteristics with the face. Deltopectoral flap is a one such flap from chest and neck skin mainly used to cover the facial defects. This study report a patient presenting with tragic Road Traffic Accident (RTA) admitted to maxillofacial surgery department at Ramadi Teaching Hospital, Anbar province, Iraq. An incision, medially based, was done and deltopectoral fascio-cutaneous flap was used for surgical exposure and closure of defects after RTA. There was no major complication. Good aesthetic and functional results were achieved. Deltopectoral flap is an excellent alternative for the reconstruction of head and neck. Harvesting and application of the flap is rapid and safe. Only a single incision is sufficient for dissection and flap elevation.
Chen, Shao-Liang; Chiou, Tai-Fung
The boomerang flap originates from the dorsolateral aspect of the proximal phalanx of an adjacent digit and is supplied by the retrograde blood flow through the vascular arcades between the dorsal and palmar digital arteries. To provide sensation of the boomerang flap for finger pulp reconstruction, the dorsal sensory branch of the proper digital nerve and the superficial sensory branch of the corresponding radial or ulnar nerve are included within the skin flap. After transfer of the flap to the injured site, epineural neurorrhaphies are done between the digital nerves of the pulp and the sensory branches of the flap. We used this sensory flap in five patients, with more than 1 year follow-up, and all patients achieved measurable two-points discrimination. The boomerang flap not only preserves the proper palmar digital artery but also provides an extended and innervated skin paddle. It seems to be an alternative choice for one-stage reconstruction of major pulp defect.
Subramaniam, Shiva; Sharp, David; Jardim, Christopher; Batstone, Martin D
Methods of free flap monitoring have become more sophisticated and expensive. This study aims to determine the cost of free flap monitoring and examine its cost effectiveness. We examined a group of patients who had had free flaps to the head and neck over a two-year period, and combined these results with costs obtained from business managers and staff. There were 132 free flaps with a success rate of 99%. The cost of monitoring was Aus $193/flap. Clinical monitoring during this time period cost Aus$25 476 and did not lead to the salvage of any free flaps. Cost equivalence is reached between monitoring and not monitoring only at a failure rate of 15.8%. This is to our knowledge the first study to calculate the cost of clinical monitoring of free flaps, and to examine its cost-effectiveness. Copyright © 2016 The British Association of Oral and Maxillofacial Surgeons. All rights reserved.
Huotarinen, Antti; Niemelä, Mika; Jahromi, Behnam Rezai
Residents' lives are hectic-it is hard to find a place and time for training basic and advanced microsurgical skills. Surgical instruments and sutures can be purchased (or loaned from another department), but the most expensive and space-occupying device is the microscope. In developing countries, microscopes are used where they are needed most, in operating rooms. Furthermore, a conventional microscope is not portable. For all of these reasons, the availability of microscopes for training microsurgery is limited. We used a coffee cup and smartphone (CCS) as a training device instead of a microscope. The coffee cup was the base, and the smartphone functioned to magnify, illuminate, and visualize objects. We measured 2 residents' performance on end-to-end artificial bypass before and after 5 days of CCS-based training. We were able to quickly set up the environment for practicing microsurgical skills in any surrounding. After 5 days of training with CCS we could see significant development of microsurgical performance with a conventional microscope as well. The learning curve was dependent on baseline performance. CCS is efficient, mobile, and easy to set up. Even though our smartphone-based training was in 2 dimensions, we could improve our microsurgical performance with conventional microscopes, which have 3-dimensional capability. CCS also provides an easy method to record one's microsurgical training. CCS improved both of the subjects' microsurgical performance, making it a good alternative for a traditional microscope. Copyright © 2017 Elsevier Inc. All rights reserved.
Munk, Estrid Muff; Drewes, Asbjørn Mohr; Gorst-Rasmussen, Anders
Unexplained chest/epigastric pain is a common symptom in the general population. However, it has not previously been studied whether such pain could be a marker of subsequent gastrointestinal cancer. We aimed to estimate the risk of gastrointestinal cancers in a Danish 10-year follow-up study amo...
Jalikop, Shreyas; Sreenivas, K. R.
At present, there is a strong interest in developing Micro Air Vehicles (MAV) for applications like disaster management and aerial surveys. At these small length scales, the flight of insects and small birds suggests that unsteady aerodynamics of flapping wings can offer many advantages over fixed wing flight, such as hovering-flight, high maneuverability and high lift at large angles of attack. Various lift generating mechanims such as delayed stall, wake capture and wing rotation contribute towards our understanding of insect flight. We address the effect of asymmetric flapping of wings on lift production. By visualising the flow around a pair of rectangular wings flapping in a water tank and numerically computing the flow using a discrete vortex method, we demonstrate that net lift can be produced by introducing an asymmetry in the upstroke-to-downstroke velocity profile of the flapping wings. The competition between generation of upstroke and downstroke tip vortices appears to hold the key to understanding this lift generation mechanism.
Yabe, Tetsuji; Tsuda, Tomoyuki; Hirose, Shunsuke; Ozawa, Toshiyuki
In this article, a comparison of replantation using microsurgical replantation (replantation) and the Brent method and its modification (pocket principle) in the treatment of fingertip amputation is reported. As a classification of amputation level, we used Ishikawa's subzone classification of fingertip amputation, and the cases of amputations only in subzone 2 were included in this study. Between these two groups, there was no statistical difference in survival rate, postoperative atrophy, or postoperative range of motion. In terms of sensory recovery, some records were lost and exact study was difficult. But there was no obvious difference between these cases. In our comparison of microsurgical replantation versus the pocket principle in treatment of subzone 2 fingertip amputation, there was no difference in postoperative results. Each method has pros and cons, and the surgeon should choose which technique to use based on his or her understanding of the characteristics of both methods. Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.
Lopez Flores, Gerardo; Guerra Figueredo, Eritk; Ochoa Zaldivar, Luis
It is reported that spatial guidance during microsurgery is an essential element. This application of stereotaxic surgery is shown at the International Center of Neurological Restoration (Cirene) from May, 1994, to February, 1998, on describing the performance of 65 microsurgical procedures under stereotaxic conditions among 62 patients with cerebral intracranial tumors. The procedure was divided into 3 stages: image acquisition, Cat, surgical planning , with Stasis planning system, and microsurgical procedures that included the Leksell, Micromar and Esteroflex stereotaxic systems. 27 of the total of patients presented glial tumors; 33, non-glial; and only 2 non-neoplastic lesions of diverse localization and size. 30 total resections We're made. Surgical morbidity was minimum and there was no surgical mortality. The main advantages of this method are: exact localization of the craniotomy, easy spatial guidance, and the opportunity to distinguish the limits between the tumor and the sound tissue. The possibility to apply Esteroflex to cerebral microsurgery was demonstrated
Sitbon, Y; Attathom, T
Different aspects of treatment for periodontal diseases or gingival problems require rigorous diagnostics. Magnification tools and microsurgical instruments, combined with minimally invasive techniques can provide the best solutions in such cases. Relevance of treatments, duration of healing, reduction of pain and post-operative scarring have the potential to be improved for patients through such techniques. This article presents an overview of the use of microscopy in periodontics, still in the early stages of development.
Grant, Aaron L; Temple-Oberle, Claire
The purpose of this study is to determine the utility of self-assessment in microsurgical training using a previously validated rating scale. A prospective study of surgical residents taking a hands-on 5-day microsurgical training course. Learners completed multiple self-assessments of their technical skills using the University of Western Ontario Microsurgical Acquisition/Assessment instrument. Simultaneously, preceptors assessed the learners using the same scale. Self-assessment and preceptor scores were compared using the Pearson correlation coefficient (PCC). There was a significant agreement noted between the 32 preceptor assessments and 36 self-assessments that were completed. Correlation between scores for the knot-tying (PCC = 0.62) and anastomosis modules (PCC = 0.77) was good and excellent, respectively. Preceptor scores and self-scores improved over the duration of the course: for preceptors, knot-tying scores increased from 58% on day 1 to 78% on day 5 (p = 0.02) and anastomosis scores improved from 56% to 82% (p = 0.004); for self-scores, knot-tying scores increased from 44% to 81% (p = 0.001) and anastomosis scores from 49% to 84% (p = 0.001). Learners with greater experience (higher postgraduate year level) tended to have higher self as well as preceptor ratings, albeit not statistically significant. Self-assessment using the University of Western Ontario Microsurgical Acquisition/Assessment instrument has good to excellent agreement with preceptor-assessment scores suggesting good interrater reliability. Self-assessment using such tools may, therefore, be used along with preceptor supervision and assessment to potentially improve self-directed learning during these courses. Copyright © 2017 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.
Lee, Ka-Wo; Chiang, Feng-Yu
Since the introduction of endolaryngeal microsurgery, several basic microsurgical techniques have been described for the removal of benign vocal fold lesions. These techniques include conventional incision or dissection, bimanual retraction and cutting, microflap technique and the CO2 laser. Until recently, only a few microsurgical methods have emerged as new choices for the treatment of benign vocal fold lesions. This article introduces an innovative method that can precisely remove benign sessile vocal fold lesions with epithelial keratosis or hyperplasia without jeopardizing the intermediate or deep layer of the lamina propria. Instead of using conventional vertically opening microinstruments, this microsurgical pressing excision technique (MPET) utilized two pairs of custom-made horizontally left-opening or right-opening, curved microscissors/curved cupped microforceps to remove right or left vocal fold lesions accordingly. Using one instrument at a time, the lesion was subsequently removed with the microscissors and microforceps in a press-evert-cut manner. Among a total of 553 cases, the treatment results were satisfactory, with 520 (94%) patients retaining a satisfactory/normal (G0) voice 2 months postoperatively. More importantly, no patient's voice was worse postoperatively. This technique has several advantages: utilizing one instrument at a time can maximize exposure of the narrow endoscopic view, adjusting the pressing force makes precise excision easy in a well controlled horizontal plane. The MPET is particularly useful for removing sessile vocal nodules (especially those with epithelial keratosis), epithelial hyperplasia and leukoplakia in patients with difficult endolaryngeal exposure. This could be a well tolerated and precise microsurgical technique.
Elkheshin, Sherif; Soliman, Ahmed
To investigate the impact of endoscope-assisted microsurgical fenestration on temporal arachnoid cysts, and to determine the advantages and limitations of the technique. Twenty-five children with symptomatic temporal arachnoid cysts were operated via eyebrow supraorbital keyhole microsurgical fenestration targeting the medial cyst wall. Preoperative magnetic resonance imaging (MRI) of the brain was done for all patients. Preoperative clinical presentation of the patients included headache (80%), nausea & vomiting (64%), drug resistant epilepsy (52%), macrocephaly (12%) papilledema (28%), motor weakness in the form of right-sided hemiparesis (12%) and cranial nerve palsy. Postoperative complete subsidence of headache was noted in 50%, while 20% remained unchanged. Drug resistant epilepsy improved in 69% of the patients. Postoperative MRI showed initial decrease in cyst volume as early as 3 months, only in a range of 5-12% volume reduction, and the late follow-up done at 6 and 18 months continued to show further reduction reported to be significant (p CSF) collection was the most common complication (20%). Only 1 patient experienced CSF leak mandating cysto-peritoneal shunting. Conclusıon: Eyebrow supraorbital keyhole microsurgical fenestration for temporal arachnoid cysts can be performed with a fairly low risk of complications and yields a favorable improvement in clinical and neuroimaging outcomes.
Belykh, Evgenii; Byvaltsev, Vadim
Microsurgical training has become an obligatory part of many neurosurgical training programs. To assess the cost and effectiveness of acquiring and maintaining microneurosurgical skills by training on an off-the-job basis using dry models. A dry off-the-job microneurosurgical training module was set up. Training exercises involved microdissection in a deep operation field, suturing and tying on gauze, untying, pushing of thread end, and microanastomosis. The time to complete the task and success rate were evaluated. The total cost of all necessary equipment and expendables for the training module was US$910. Fifteen residents participated in the continuous off-the-job training. The average time taken to perform the anastomosis decreased after the month of training from 90 to 20 minutes. Authors revealed that at 2 months, the total time and time to complete anastomosis increased significantly for the participants who discontinued practice after the first month, compared with those who just practiced suturing on gauze after the first month (P job training showed to be readily available and can be helpful for microsurgical training in the low-income regions of the world. Our data suggest that microsurgical training should be continuous and repetitive. Simulation training may benefit from models for repetitive training of relevant technical part-skills. Copyright © 2014 Elsevier Inc. All rights reserved.
Conclusion: Data from this study suggest that NL flap is a reliable option for reconstruction of the oral floor, in form as well as function, without esthetic compromise and has a major role even in this era of free flaps. Keywords: Floor of mouth defects, local flaps, nasolabail flap, oral cavity defects, reconstruction, regional flaps ...
Yasuda, Atsushi; Yasuda, Takushi; Kato, Hiroaki; Iwama, Mitsuru; Shiraishi, Osamu; Hiraki, Yoko; Tanaka, Yumiko; Shinkai, Masayuki; Imano, Motohiro; Kimura, Yutaka; Imamoto, Haruhiko
An incisional hernia in a case of antethoracic pedicled jejunal flap esophageal reconstruction after esophagectomy is a very rare occurrence, and this hernia was distinctive in that the reconstructed jejunum had passed through the hernial orifice; a standard surgical treatment for such a presentation has not been established. Herein, we describe a case of repair using mesh prosthesis for an atypical and distinctive incisional hernia after antethoracic pedicled jejunal flap esophageal reconstruction. A 77-year-old woman with a history of subtotal esophagectomy who had undergone antethoracic pedicled jejunal flap reconstruction complained of epigastric prominence and discomfort without pain. On examination, she had an abdominal protrusion between the xiphoid process and the umbilicus that contained the small bowel. Computed tomography showed that the fenestration of the abdominal wall that was intentionally created for jejunum pull-up was dehisced in a region measuring 9 × 15 cm and the small intestine protruded through it into the subcutaneous space without strangulation. Because the hernial orifice was too large and the reconstructed jejunum was passing through the hernial orifice in this case, we applied a parastomal hernia repair method that was modified from the inguinal hernia repair using the Lichtenstein technique. After 3 years and 5 months following surgery, the patient has recovered without hernia recurrence or other complications. We consider this to be the first case of repair using Composix mesh prosthesis for repair of an atypical and distinctive incisional hernia after an antethoracic pedicled jejunal flap reconstruction. This method seems to be useful and could potentially be widely adopted as the surgical treatment for this condition.
Mahieu, R; Colletti, G; Bonomo, P; Parrinello, G; Iavarone, A; Dolivet, G; Livi, L; Deganello, A
Nowadays, the transposition of microvascular free flaps is the most popular method for management of head and neck defects. However, not all patients are suitable candidates for free flap reconstruction. In addition, not every defect requires a free flap transfer to achieve good functional results. The aim of this study was to assess whether pedicled flap reconstruction of head and neck defects is inferior to microvascular free flap reconstruction in terms of complications, functionality and prognosis. The records of consecutive patients who underwent free flap or pedicled flap reconstruction after head and neck cancer ablation from 2006 to 2015, from a single surgeon, in the AOUC Hospital, Florence Italy were analysed. A total of 93 patients, the majority with oral cancer (n = 59), were included, of which 64 were pedicled flap reconstructions (69%). The results showed no significant differences in terms of functional outcome, flap necrosis and complications in each type of reconstruction. Multivariate regression analysis of flap necrosis and functional impairments showed no associated factors. Multivariate regression analysis of complicated flap healing showed that only comorbidities remained an explaining factor (p = 0.019). Survival analysis and proportional hazard regression analysis regarding cancer relapse or distant metastasis, showed no significant differences in prognosis of patients concerning both types of reconstruction. In this retrospective, non-randomised study cohort, pedicled flaps were not significantly inferior to free flaps for reconstruction of head and neck defects, considering functionality, complications and prognosis. © Copyright by Società Italiana di Otorinolaringologia e Chirurgia Cervico-Facciale, Rome, Italy.
Shakir, Afaaf; Chattopadhyay, Arhana; Paek, Laurence S; McGoldrick, Rory B; Chetta, Matthew D; Hui, Kenneth; Lee, Gordon K
Music is commonly played in operating rooms (ORs) throughout the country. If a preferred genre of music is played, surgeons have been shown to perform surgical tasks quicker and with greater accuracy. However, there are currently no studies investigating the effects of music on microsurgical technique. Motion analysis technology has recently been validated in the objective assessment of plastic surgery trainees' performance of microanastomoses. Here, we aimed to examine the effects of music on microsurgical skills using motion analysis technology as a primary objective assessment tool. Residents and fellows in the Plastic and Reconstructive Surgery program were recruited to complete a demographic survey and participate in microsurgical tasks. Each participant completed 2 arterial microanastomoses on a chicken foot model, one with music playing, and the other without music playing. Participants were blinded to the study objectives and encouraged to perform their best. The order of music and no music was randomized. Microanastomoses were video recorded using a digitalized S-video system and deidentified. Video segments were analyzed using ProAnalyst motion analysis software for automatic noncontact markerless video tracking of the needle driver tip. Nine residents and 3 plastic surgery fellows were tested. Reported microsurgical experience ranged from 1 to 10 arterial anastomoses performed (n = 2), 11 to 100 anastomoses (n = 9), and 101 to 500 anastomoses (n = 1). Mean age was 33 years (range, 29-36 years), with 11 participants right-handed and 1 ambidextrous. Of the 12 subjects tested, 11 (92%) preferred music in the OR. Composite instrument motion analysis scores significantly improved with playing preferred music during testing versus no music (paired t test, P music was significant even after stratifying scores by order in which variables were tested (music first vs no music first), postgraduate year, and number of anastomoses (analysis of variance, P music in
Full Text Available The main objective in dermatologic surgery is complete excision of the tumour while achieving the best possible functional and cosmetic outcome. Also we must take into account age, sex, and tumour size and site. We should also consider the patient's expectations, the preservation of the different cosmetic units, and the final cosmetic outcome. Various reconstructive methods ranging from secondary healing to free flap applications are usedfor the reconstruction of perinasal or facial defects caused by trauma or tumour surgery. Herein, we describe the nasal infraorbital island skin flap for the reconstruction in a patient with basal cell carcinoma. No complications were observed in operation field. The infraorbital island skin flap which we describe for the perinasal area reconstruction is a safe, easily performed and versatile flap. The multidimensional use of this flap together with a relatively easy reconstruction plan and surgical procedure would be effective in flap choice.
Pushpendra Kumar Verma
Full Text Available Gingival recession in anterior teeth is a common concern due to esthetic reasons or root sensitivity. Gingival recession, especially in multiple anterior teeth, is of huge concern due to esthetic reasons. Various mucogingival surgeries are available for root coverage. This case report presents a new bridge flap technique, which allows the dentist not only to cover the previously denuded root surfaces but also to increase the zone of attached gingiva at a single step. In this case, a coronally advanced flap along with vestibular deepening technique was used as root coverage procedure for the treatment of multiple recession-type defect. Here, vestibular deepening technique is used to increase the width of the attached gingiva. The predictability of this procedure results in an esthetically healthy periodontium, along with gain in keratinized tissue and good patient′s acceptance.
We present, in 8 chapters, experiments on and numerical simulations of bodies flapping in a fluid. Focus is predominantly on a rigid foil, a model fish, that performs prescribed pitching oscillations where the foil rotates around its leading edge. In a flowing soap film is measured, with unpreced......We present, in 8 chapters, experiments on and numerical simulations of bodies flapping in a fluid. Focus is predominantly on a rigid foil, a model fish, that performs prescribed pitching oscillations where the foil rotates around its leading edge. In a flowing soap film is measured......-speed and the strength ratio of the vortices formed at the foil’s leading and trailing edge. The simulated vortex particles and measured thickness variations in the soap film show similar behaviour which indicates that the soap film provides a good approximation the flow of a two-dimensional incompressible and Newtonian...
Conclusion: This method is somewhat complicated compared to reconstruction with a single flap, but it is a combination of standard local flaps and is a simple reconstructive procedure. By adding additional resection, the suture line is consistent with the border of the facial unit, so postoperative scarring is inconspicuous. This technique is aesthetically useful because of the continuity of colour and texture resulting from the use of adjacent flaps.
Spanio di Spilimbergo, Stefano; Nordera, Paolo; Mardini, Samir; Castiglione, Giusy; Chim, Harvey; Pinna, Vittore; Brunello, Massimo; Cusino, Claudio; Roberto, Squaquara; Baciliero, Ugo
In the past 130 years, the temporalis muscle flap has been used for a variety of different indications. In this age of microsurgery and perforator flaps, the temporalis muscle flap still has many useful applications for craniofacial reconstruction. Three hundred sixty-six temporalis muscle flaps were performed in a single center between 1978 and 2012. The authors divided the cases into two series-before and after 1994-because, after 1994, they started to perform free flap reconstructions, and indications for reconstruction with a temporalis muscle flap were changed RESULTS:: In the series after 1994, flaps were most commonly used for reconstruction of defects in the maxilla, mandible, and oropharynx, in addition to facial reanimation and filling of orbital defects. Complications included total flap necrosis (1.6 percent) and partial flap necrosis (10.7 percent). The rate of material extrusion at the donor site decreased after porous polyethylene was uniformly used for reconstruction from 17.1 to 7.9 percent. The pedicled temporalis muscle flap continues to have many applications in craniofacial reconstruction. With increasing use of free flaps, the authors' indications for the pedicled temporalis muscle flap are now restricted to (1) orbital filling for congenital or acquired anophthalmia; (2) filling of unilateral maxillectomy defects; and (3) facial reanimation in selected cases of facial nerve palsy. Therapeutic, IV.
Mahieu, R.; Colletti, G.; Bonomo, P.; Parrinello, G.; Iavarone, A.; Dolivet, G.; Livi, L.; Deganello, A.
Nowadays, the transposition of microvascular free flaps is the most popular method for management of head and neck defects. However, not all patients are suitable candidates for free flap reconstruction. In addition, not every defect requires a free flap transfer to achieve good functional results.
Agarwal, Jayant P; Agarwal, Shailesh; Adler, Neta; Gottlieb, Lawrence J
Reconstruction of complex tissue deficiencies in which each missing component is in a different spatial relationship to each other can be particularly challenging, especially in patients with limited recipient vessels. The chimera flap design is uniquely suited to reconstruct these deformities. Chimera flaps have been previously defined in many ways with 2 main categories: prefabricated or intrinsic. Herein we attempt to clarify the definition of a true intrinsic chimeric flap and provide examples of how these constructs provide a method for reconstruction of complex defects. The versatility of the intrinsic chimera flap and its procurement from 7 different vascular systems is described. A clarification of the definition of a true intrinsic chimera flap is described. In addition, construction of flaps from the lateral femoral circumflex, deep circumflex iliac, inferior gluteal, peroneal, subscapular, thoracodorsal, and radial arterial systems is described to showcase the versatility of these chimera flaps. A true intrinsic chimera flap must consist of more than a single tissue type. Each of the tissue components receives its blood flow from separate vascular branches or perforators that are connected to a single vascular source. These vascular branches must be of appropriate length to allow for insetting with 3-dimensional spatial freedom. There are a multitude of sites from which true intrinsic chimera flaps may be harvested.
Was, Loïc; Lauga, Eric
Swimming fish and flying insects use the flapping of fins and wings to generate thrust. In contrast, microscopic organisms typically deform their appendages in a wavelike fashion. Since a flapping motion with two degrees of freedom is able, in theory, to produce net forces from a time-periodic actuation at all Reynolds numbers, we compute in this paper the optimal flapping kinematics of a rigid spheroid in a Stokes flow. The hydrodynamics for the force generation and energetics of the flapping motion is solved exactly. We then compute analytically the gradient of a flapping efficiency in the space of all flapping gaits and employ it to derive numerically the optimal flapping kinematics as a function of the shape of the flapper and the amplitude of the motion. The kinematics of optimal flapping are observed to depend weakly on the flapper shape and are very similar to the figure-eight motion observed in the motion of insect wings. Our results suggest that flapping could be a exploited experimentally as a propulsion mechanism valid across the whole range of Reynolds numbers.
Was, Loïc; Lauga, Eric
Swimming fish and flying insects use the flapping of fins and wings to generate thrust. In contrast, microscopic organisms typically deform their appendages in a wavelike fashion. Since a flapping motion with two degrees of freedom is able, in theory, to produce net forces from a time-periodic actuation at all Reynolds numbers, we compute in this paper the optimal flapping kinematics of a rigid spheroid in a Stokes flow. The hydrodynamics for the force generation and energetics of the flapping motion is solved exactly. We then compute analytically the gradient of a flapping efficiency in the space of all flapping gaits and employ it to derive numerically the optimal flapping kinematics as a function of the shape of the flapper and the amplitude of the motion. The kinematics of optimal flapping are observed to depend weakly on the flapper shape and are very similar to the figure-eight motion observed in the motion of insect wings. Our results suggest that flapping could be a exploited experimentally as a propulsion mechanism valid across the whole range of Reynolds numbers. (paper)
Shinozaki, Satoshi; Osawa, Hiroyuki; Sakamoto, Hirotsugu; Hayashi, Yoshikazu; Kawarai Lefor, Alan; Yamamoto, Hironori
The effect of acotiamide on gastrointestinal symptoms is undefined. The aim of this study is to evaluate the effect of acotiamide on abdominal symptoms in patients with functional dyspepsia. We retrospectively reviewed 51 patients treated with acotiamide. We evaluated patient quality of life using the Izumo scale that detects changes in quality of life caused by abdominal symptoms. Acotiamide ameliorated the symptoms of functional dyspepsia at one and three months (improved: 61% vs 80%, p=0.029 and resolved: 17% vs 33%, p=0.069). We then evaluated the effect of acotiamide on epigastric pain syndrome (EPS) (n=33) and postprandial distress syndrome (PDS) (n=41). Acotiamide treatment showed an early effect on rates of improvement (63%) and resolution (42%) of EPS symptoms at one month, maintained up to three months (69% and 39%, respectively). Both rates of improvement and resolution of PDS symptoms showed a significant increase from one month to three months (56% vs 78%, p=0.021 and 17% vs 46%, p=0.004, respectively). The severity of functional dyspepsia symptoms before treatment was significantly associated with failed resolution of functional dyspepsia symptoms (p=0.013). Acotiamide improves and resolves EPS symptoms as well as PDS symptoms. PDS symptoms take longer to resolve than EPS symptoms. J. Med. Invest. 63: 230-235, August, 2016.
Niumsawatt, Vachara; Debrotwir, Andrew N; Rozen, Warren Matthew
Computed tomographic angiography (CTA) has become a mainstay in preoperative perforator flap planning in the modern era of reconstructive surgery. However, the increased use of CTA does raise the concern of radiation exposure to patients. Several techniques have been developed to decrease radiation dosage without compromising image quality, with varying results. The most recent advance is in the improvement of image reconstruction using an adaptive statistical iterative reconstruction (ASIR) algorithm. We sought to evaluate the image quality of ASIR in preoperative deep inferior epigastric perforator (DIEP) flap surgery, through a direct comparison with conventional filtered back projection (FBP) images. A prospective review of 60 consecutive ASIR and 60 consecutive FBP CTA images using similar protocol (except for radiation dosage) was undertaken, analyzed by 2 independent reviewers. In both groups, we were able to accurately identify axial arteries and their perforators. Subjective analysis of image quality demonstrated no statistically significant difference between techniques. ASIR can thus be used for preoperative imaging with similar image quality to FBP, but with a 60% reduction in radiation delivery to patients.
van Zanten, S V; Flook, N; Talley, N J
BACKGROUND: While empiric acid-suppressive therapy for uninvestigated dyspepsia patients with symptoms of epigastric pain or burning is standard practice, it is unknown whether an early response to therapy predicts outcome. AIM: To evaluate whether a 1-w acid suppression trial is effective...... for predicting 8-w response in such patients. METHODS: Helicobacter pylori-negative patients (aged 18-50 years) in primary care with uninvestigated epigastric pain or burning were randomized to esomeprazole 40 mg q.d.s. or b.d. for 1w, followed by esomeprazole 40 mg q.d.s. or placebo for 7w. Each day, patients......, respectively, and 47% (339 of 716) and 34% (124 of 368), respectively, at 8w (both P treatment were 58% and 70%, respectively, at 8w. CONCLUSION: A 1-w acid suppression trial is of limited clinical value for predicting 8-w response...
Utku Can Dölen
Full Text Available Local flaps exhibit excellent color matching that no other type of flap can compete with. Moreover, surgery using a local flap is easier and faster than surgery using a distant or free flap. However, local flaps can be much more difficult to design. We designed 2 templates to plan a V-Y rotation advancement flap. The template for a unilateral V-Y rotation advancement flap was used on the face (n=5, anterior tibia (n=1, posterior axilla (n=1, ischium (n=1, and trochanter (n=2. The template for a bilateral flap was used on the sacrum (n=8, arm (n=1, and anterior tibia (n=1. The causes of the defects were meningocele (n=3, a decubitus ulcer (n=5, pilonidal sinus (n=3, and skin tumor excision (n=10. The meningocele patients were younger than 8 days. The mean age of the adult patients was 50.4 years (range, 19–80 years. All the donor areas of the flaps were closed primarily. None of the patients experienced wound dehiscence or partial/total flap necrosis. The templates guided surgeons regarding the length and the placement of the incision for a V-Y rotation advancement flap according to the size of the wound. In addition, they could be used for the training of residents.
Full Text Available IntroductionSymptomatic umbilical and/or epigastric hernias are often seen concomitantly with rectus abdominis diastasis (RAD, and suture repair of such defects has a high recurrence rate. In the literature there are reports of both endoscopic and open techniques for repair of symptomatic umbilical and/or epigastric hernias in association with RAD. This paper now reports on the early results of a hybrid technique used for reconstruction of the linea alba and mesh augmentation (ELAR plus.Material and methodsBetween 15 June 2015 and 31 January 2016, 40 patients with symptomatic umbilical and /or epigastric hernia and concomitant RAD underwent reconstruction of the linea alba using a hybrid technique involving a small umbilical incision and the use of video endoscopic equipment. The patients comprised 29 men and 11 women with a mean age of 53.6 years and mean BMI of 32.6. The mean operating time was 120 minutes. The mesh had a mean longitudinal extension of 18.6 cm and transverse extension of 9.1 cm. ResultsThirty-day follow-up results are available for all patients. Thirty-seven out of 40 patients (92.5 % experienced no postoperative complication. Two cases of discrete impaired umbilical wound healing and one seroma were successfully managed with conservative treatment. On 30-day follow-up, three out of 40 patients (7.5 % complained of intermittent pain on exertion, and two out of 40 patients (5 % still took painkillers when required.ConclusionEndoscopic-assisted linea alba reconstruction plus mesh augmentation (ELAR plus is a novel minimally invasive procedure for repair of symptomatic umbilical and/or epigastric hernias with concomitant RAD. Reconstruction of the linea alba via a minimally invasive access route is able to restore the normal anatomy of the abdominal wall.
Stemann Andersen, Peter; Elberg, Jens Jørgen
The survival of a microsurgically replanted segment of nose in a 41-year-old woman was facilitated by the assistance of the medicinal leech Hirudo medicinalis. An arterial microanastomosis was made to a severed partial segment of nose with no possibility of recreating a venous anastomosis. The re....... The resulting venous congestion was treated with nine days of treatment with a medical leech until venous neovascularisation had been achieved. At follow-up six months after discharge there was a well-heeled nasal segment and a satisfying functional - as well as cosmetic - result....
Mertens, P; Sindou, M
Ablative functional neurosurgery can be useful in some selected patients for the treatment of harmful spasticity in the lower limbs. Microsurgical drezotomy was introduced in 1972, on the basis of anatomical studies of the human dorsal root entry zone (DREZ) showing a topographical segregation of the afferent fibers according to their size and thus functional destinations. It consists of a 3 mm deep microsurgical lesion directed at a 45 degree angle in the postero-lateral sulcus, penetrating the DREZ in its ventro-lateral aspect, at the level of all the rootlets considered as involved in spasticity (and pain). It destroys mainly the lateral (nociceptive) and central (myotatic) afferent fibers as well as the facilitatory medial part of the Lissauer tract, whilst sparing most of the medial (lemniscal) fibers and the inhibitor lateral part of the Lissauer tract. We report a series of 121 bedridden patients suffering from harmful spasticity in one (15) or both (106) lower limbs and treated with microsurgical drezotomy. Surgery was decided on because of abnormal postures in flexion in two-thirds of the patients and in hyperextension in one-third, additional pain in 75 of them, and hyperactive bladder in 38 cases. The post-operative results were evaluated after a mean follow-up time of 5 years and 6 months. Both spasticity and spasms were significantly decreased or suppressed respectively in 78% and 88% of the patients. When present, pain was relieved without abolition of sensation in 82%. These benefits resulted in either disappearance or marked reduction of the abnormal postures and articular limitation in 90% of the patients. When present preoperatively, urinary leakage disappeared in 85% of the cases. Mild to severe complications occurred in 32 patients and precipitated or were responsible for death in 6 cases (5%). This is explained by the fact that most of the patients, especially those affected by multiple sclerosis, were in very precarious general and
Cislo, M.; Murawski, M.; Palczynski, B.
40 women were operated on infertility due to oviductal factor. This kind of infertility has been previously diagnosed by hysterosalpingography examination and then verified in 22 cases (55%) by laparoscopy combined with chromotubation. The operations were carried out with use of microsurgical technique and instruments. At the same time the prophylactics of postoperative intraperitoneal adhesions was applied. Seven pregnancies were obtained, that makes 17.5% of success. It is an outcome comparable with results presented by many other world centers of gynecological microsurgery. (author)
Cristian R. Jecan
Full Text Available Introduction. The paramedian forehead flap is one of the best options for reconstruction of the median upper two-thirds of the face due to its vascularity, color, texture match and ability to resurface all or part of the reconstructed area. The forehead flap is the gold standard for nasal soft tissue reconstruction and the flap of choice for larger cutaneous nasal defects having a robust pedicle and large amount of tissue. Materials and Methods. We are reporting a clinical series of cutaneous tumors involving the nose, medial canthus, upper and lower eyelid through a retrospective review of 6 patients who underwent surgical excision of the lesion and primary reconstruction using a paramedian forehead flap. Results. The forehead flap was used for total nose reconstruction, eyelids and medial canthal reconstruction. All flaps survived completely and no tumor recurrence was seen in any of the patients. Cosmetic and functional results were favorable. Conclusions. The forehead flap continues to be one of the best options for nose reconstruction and for closure of surgical defects of the nose larger than 2 cm. Even though is not a gold standard, median forehead flap can be an advantageous technique in periorbital defects reconstruction.
Materials and Methods: A total of 10 patients were selected based on the size of surgical defect. Nasolabial flap was used to reconstruct defects of small to moderate size in the oro-facial region and post-operative follow up was done. Results: All of the patients underwent inferiorly based Transposition Island flap for reconstruction of different oro-facial defects. Few complications like bulky size of the flap, slight donor site distortion (scar formation and intra-oral hair growth were seen in six patients. Two incidences of infection in the transferred flap were seen. Conclusion: It is a safe minor procedure done under general anesthesia with good reconstructive results over small or moderately sized maxillofacial defects. Proper attention to flap design, operative technique and post - operative management are useful in reducing the incidence of complications.
Bull, J. S.
Flight test evaluation of a Delayed Flap approach procedure intended to provide reductions in noise and fuel consumption is underway using the NASA CV-990 test aircraft. Approach is initiated at a high airspeed (240 kt) and in a drag configuration that allows for low thrust. The aircraft is flown along the conventional ILS glide slope. A Fast/Slow message display signals the pilot when to extend approach flaps, landing gear, and land flaps. Implementation of the procedure in commercial service may require the addition of a DME navigation aid co-located with the ILS glide slope transmitter. The Delayed Flap approach saves 250 lb of fuel over the Reduced Flap approach, with a 95 EPNdB noise contour only 43% as large.
Bast, John; Pitcher, Austin A; Small, Kevin; Otterburn, David M
Abdominal wall flaps are routinely used in reconstructive procedures. In some patients inadequate venous drainage from the deep vein may cause fat necrosis or flap failure. Occasionally the superficial inferior epigastric vessels (SIEV) are of sufficient size to allow for microvascular revascularization. This study looked at the ratio of the sub- and suprascarpal fat layers, the number of deep system perforators, and SIEV diameter to determine any correlation of the fat topography and SIEV. 50 abdominal/pelvic CT angiograms (100 hemiabdomens) were examined in women aged 34-70 years for number of perforators, SIEV diameter, and fat pad thickness above and below Scarpa's fascia. Data was analyzed using multivariate model. The average suprascarpal and subscarpal layers were 18.6 ± 11.5 mm and 6.2 ± 7.2 mm thick, respectively. The average SIEV diameter was 2.06 ± 0.81 mm and the average number of perforators was 2.09 ± 1.03 per hemiabdomen. Hemiabdomens with suprascarpal thickness>23 mm had greater SIEV diameter [2.69 mm vs. 1.8 mm (P fat layer thickness did not correlate with the number of perforators. Neither subscarpal fat thickness nor suprascarpal-to-subscarpal fat layer thickness correlated significantly with SIEV caliber or number of perforators in multivariate model. Suprascarpal fat pad thicker than 23 mm had larger SIEVs irrespective of the number of deep system perforators. This may indicate a cohort of patients at risk of venous congestion from poor venous drainage if only the deep system is revascularized. We recommend harvesting the SIEV in patients with suprascarpal fat pad >23 mm to aid in superficial drainage. © 2015 Wiley Periodicals, Inc.
Full Text Available Objective. The influence of Coherent Ultrapulse, TruPulse and Erbium: YAG laser skin resurfacing on survival of the skin flaps when performed simultaneously was evaluated. Material and methods. We used twelve female Yucatan minipigs in the study. Skin flaps including paniculus carnosus were raised on the animals’ back. The flaps were sutured into the defect under tension. We designed 4 experimental groups: Control-Flaps only, Group 2-Flaps + 4 immediate TruPulse laser passes, Group 3-Flaps + 2 immediate Coherent UltraPulse laser passes, Group 4-Flaps – immediate 50J/cm2 total fluence with Erbium: YAG laser. Results. Flap survival in Control group was 98.8%. There was no flap in Group 2 with complete survival. Survival of the flaps in Group 2 (Tru-Pulse ranged from 75-90%, with average flap survival area of 85.2%. In Group 3 (UltraPulse all 24 flaps had some area of necrosis. Flap survival in Group 3 ranged from 75-95%, with an average of 85.6%. In Group 4 (Erbium: YAG flap survival area ranged from 70-95%, with all 24 flaps with some area of necrosis, with average flap survival area of 87.3%. There is a significant statistical difference in flap survival area between groups 2, 3 and 4 versus Control (p<0.001. Conclusion. The results of our study suggest that laser resurfacing of skin flaps sutured under tension in the same operative session is detrimental for skin flap survival. We also found no significant difference in flap survival area between TruPulse, Coherent UltraPulse and Erbium: YAG laser treated flaps.
Al Saady, Rana L.; van der Meulen, Ivanka J.; Nieuwendaal, Carla P.; Engelbrecht, Leonore A.; Mourits, Maarten P.; Lapid-Gortzak, Ruth
Laser in situ keratomileusis flap amputation was performed in 3 eyes of 2 patients because of flap melt and surface irregularity. In the first patient, a 34-year-old man, flaps were excised after a photorefractive keratectomy retreatment procedure on a previous LASIK flap had been done, secondary to
Jacobs, Jordan; Børsen-Koch, Mikkel; Gunnarsson, Gudjon L.
complications occurred in 10 of 106 (10%) cases and included hematoma (1/108), venous congestion (2/108), and partial flap necrosis (7/108). The reconstructive goal was achieved in 103 of 106 (97%) flaps. CONCLUSIONS: The TAP flap is a pedicled, fasciocutaneous flap that can be used for total breast...
Fotopoulos, Peter; Holmer, Per; Leicht, Pernille
in the flap, leaving the long thoracic nerve intact on the serratus muscle. Coverage of the flap with split-thickness skin graft is done immediately. The free serratus fascia flap is an ideal flap for dorsal hand coverage when the extensor tendons are exposed, especially because of low donor-site morbidity....
Like microvascular free flaps, pectoralis major flaps can be transferred in a single stage and have largely replaced deltepectoral (Bakanjiam) flap in head and neck reconstruction. This retrospective study was carried out to highlight the usefulness of this flap in different situations. Ten patients, aged six to 55 years operated ...
Russo, Francesco; Chimienti, Guglielmina; Clemente, Caterina; Riezzo, Giuseppe; D'Attoma, Benedetta; Martulli, Manuela
The goals of the study were to investigate in both postprandial distress syndrome (PDS) and epigastric pain syndrome (EPS) the gastric electrical activity and the gastric emptying (GE) time together with the circulating concentrations of motilin, somatostatin, corticotrophin-releasing factor, and neurotensin, and to establish whether the genetic variability in the neurotensin system genes differs between these 2 categories of functional dyspepsia (FD). The current FD classification is based on symptoms and it has been proven not to be completely satisfying because of a high degree of symptom overlap between subgroups. Gastric electrical activity was evaluated by cutaneous electrogastrography: the GE time by C-octanoic acid breast test. Circulating concentrations of gut peptides were measured by a radioimmunoassay. NTS 479 A/G and NTSR1 rs6090453 SNPs were evaluated by PCR and endonuclease digestion. Fifty-four FD patients (50 female/4 male) were studied. Using a symptom questionnaire, 42 patients were classified as PDS and 12 as EPS, although an overlap between the symptom profiles of the 2 subgroups was recorded. The electrogastrographic parameters (the postprandial instability coefficient of dominant frequency, the dominant power, and the power ratio) were significantly different between the subgroups, whereas the GE time did not differ significantly. In addition, EPS was characterized by a different gut peptide profile compared with PDS. Finally, neurotensin polymorphism was shown to be associated with neurotensin levels. This evidence deserves further studies in consideration of an analgesic role of neurotensin. Analysis of gut peptide profiles could represent an interesting tool to enhance FD diagnosis and overcome limitations due to a distinction based solely on symptoms.
Full Text Available Objective To investigate surgical strategies, clinical effects and complications of microsurgical one-stage treatment of intracranial mirror aneurysms via bilateral frontolateral approaches. Methods Review clinical data of 18 cases with anterior circulation mirror aneurysms who underwent one-stage clipping via bilateral frontolateral approaches from July 2010 to July 2015 admitted to Department of Neurosurgery in Tianjin Huanhu Hospital. The operative efficacy was evaluated according to postoperative Glasgow Outcome Scale (GOS. Results The 36 aneurysms in 18 patients were successfully clipped via bilateral frontolateral approaches at one-stage, including 18 posterior communicating artery (PCoA mirror aneurysms in 9 cases and 18 middle cerebral artery (MCA mirror aneurysms in 9 cases. GOS score of 5 was discovered in 16 cases, and 4 was discovered in 2 cases after operation. One case underwent ventriculoperitoneal shunting (VPS due to communicating hydrocephalus, one case got postoperative pulmonary infection and no death occurred. Intracranial CTA at 6 months postoperatively showed aneurysms of 18 patients were clipped completely, the parent artery blood flow was smooth, and no recurrence was found. Conclusions Microsurgical one-stage clipping via bilateral frontolateral approaches for treating intracranial mirror aneurysms is a sugrical method with small incision, fitting surgical field, high safety, satisfactory effect and good prognosis, which is a new minimally invasive neurosurgical technique. DOI: 10.3969/j.issn.1672-6731.2016.08.012
Toba N. Niazi
Full Text Available Stereotactic radiosurgery to benign tumors of the spine has not been advocated as a primary treatment modality because of the favorable prognosis for these lesions after gross-total resection. There is even less evidence regarding its use as an adjuvant to neurosurgical resection of benign recurrent spinal disease. We describe the case of a 30-year-old man with a thoracic spinal schwannoma who had an interval increase of his lesion five months after thoracoscopic microsurgical resection. The patient opted for noninvasive stereotactic radiosurgery in lieu of additional surgical excision and has had stable disease 15 months after radiosurgical treatment with the linear accelerator (LINAC system. In this setting, stereotactic radiosurgery provided a useful adjunct to thoracoscopic microsurgical resection. Future Class I and II evidence should be sought to evaluate the utility of stereotactic radiosurgery as a primary treatment modality or as an adjuvant for microneurosurgical resection of benign spinal lesions in patients who want noninvasive treatment after disease recurrence or who harbor medical comorbidities that would preclude them from being safe surgical candidates.
El Ahmadieh, Tarek Y; Aoun, Salah G; El Tecle, Najib E; Nanney, Allan D; Daou, Marc R; Harrop, James; Batjer, Hunt H; Bendok, Bernard R
Simulation has been adopted as a powerful training tool in many areas of health care. However, it has not yet been systematically embraced in neurosurgery because of the absence of validated tools, assessment scales, and curricula. To use our validated microanastomosis module and scale to evaluate the effects of an educational intervention on the performance of neurosurgery residents at the 2012 Congress of Neurological Surgeons Annual Meeting. The module consisted of an end-to-end microanastomosis of a 3-mm vessel and was divided into 3 phases: (1) a cognitive and microsuture prelecture testing phase, (2) a didactic lecture, and (3) a cognitive and microsuture postlecture testing phase. We compared resident knowledge and technical proficiency from the pretesting and posttesting phases. One neurosurgeon and 7 neurosurgery residents participated in the study. None had previous experience in microsurgery. The average score on the microsuture prelecture and postlecture tests, as measured by our assessment scale, was 32.50 and 39.75, respectively (P = .001). The number of completed sutures at the end of each procedure was higher for 75% of participants in the postlecture testing phase (P = .03). The average score on the cognitive postlecture test (12.75) was significantly better than that of the cognitive prelecture test (8.38; P = .001). Simulation has the potential to enhance resident education and to elevate proficiency levels. Our data suggest that a focused microsurgical module that incorporates a didactic component and a technical component can enhance resident knowledge and technical proficiency in microsurgical anastomosis.
Budohoski, Karol P; Guilfoyle, Mathew R; Kenyon, Olivia; Barone, Damiano G; Santarius, Thomas; Trivedi, Rikin A
Peripheral nerve sheath tumors are benign entities that manifest with pain or neurological deficits from mass effect. Treatment is mostly surgical, however, the aggressiveness of treatment needs to be carefully considered with respect to preserving function. We present a case of a 62-year-old male with a 2-year history of left lower extremity pain radiating toward the dorsolateral foot. There was a tender and palpable mass in the lateral popliteal fossa with imaging consistent with Schwannoma of the common peroneal nerve. The patient was counseled for surgery and informed consent was obtained. Microsurgical resection was undertaken and gross total resection was achieved without compromise of function. We demonstrate the placement of neurophysiological monitoring electrodes in all 3 compartment of the calf as well as the use of stimulation to identify a nonfunctioning area for entering the nerve sheath. Anatomy of the popliteal fossa and microsurgical technique for resection of nerve sheath tumors are discussed. When dealing with these pathologies, it is important to use intraoperative neurophysiology as well as careful technique in order to achieve maximal resection without compromising neurological function. Copyright © 2017 by the Congress of Neurological Surgeons.
Becker, Alexander D.; Masoud, Hassan; Newbolt, Joel W.; Shelley, Michael; Ristroph, Leif
Fish schools and bird flocks are fascinating examples of collective behaviours in which many individuals generate and interact with complex flows. Motivated by animal groups on the move, here we explore how the locomotion of many bodies emerges from their flow-mediated interactions. Through experiments and simulations of arrays of flapping wings that propel within a collective wake, we discover distinct modes characterized by the group swimming speed and the spatial phase shift between trajectories of neighbouring wings. For identical flapping motions, slow and fast modes coexist and correspond to constructive and destructive wing-wake interactions. Simulations show that swimming in a group can enhance speed and save power, and we capture the key phenomena in a mathematical model based on memory or the storage and recollection of information in the flow field. Lastly, these results also show that fluid dynamic interactions alone are sufficient to generate coherent collective locomotion, and thus might suggest new ways to characterize the role of flows in animal groups
Becker, Alexander D.; Masoud, Hassan; Newbolt, Joel W.; Shelley, Michael; Ristroph, Leif
Fish schools and bird flocks are fascinating examples of collective behaviours in which many individuals generate and interact with complex flows. Motivated by animal groups on the move, here we explore how the locomotion of many bodies emerges from their flow-mediated interactions. Through experiments and simulations of arrays of flapping wings that propel within a collective wake, we discover distinct modes characterized by the group swimming speed and the spatial phase shift between trajectories of neighbouring wings. For identical flapping motions, slow and fast modes coexist and correspond to constructive and destructive wing-wake interactions. Simulations show that swimming in a group can enhance speed and save power, and we capture the key phenomena in a mathematical model based on memory or the storage and recollection of information in the flow field. These results also show that fluid dynamic interactions alone are sufficient to generate coherent collective locomotion, and thus might suggest new ways to characterize the role of flows in animal groups.
Baumholtz, Michael A; Al-Shunnar, Buthainah M; Dabb, Richard W
The boomerang-shaped latissimus dorsi musculocutaneous flap for breast reconstruction offers a stable platform for breast reconstruction. It allows for maximal aesthetic results with minimal complications. The authors describe a skin paddle to obtain a larger volume than either the traditional elliptical skin paddle or the extended latissimus flap. There are three specific advantages to the boomerang design: large volume, conical shape (often lacking in the traditional skin paddle), and an acceptable donor scar. Thirty-eight flaps were performed. No reconstruction interfered with patient's ongoing oncological regimen. The most common complication was seroma, which is consistent with other latissimus reconstructions.
Vrijhof, Eric J.; de Bruine, Adriaan; Zwinderman, Aeilko; Lycklama à Nijeholt, August A. B.; Koole, Leo
To investigate whether a newly designed nonabsorbable polymeric stent for the reconstruction of the vas deferens provided less stricturing at the site of the anastomosis in comparison with the conventional microsurgical reconstruction of the vas deferens. Prospective randomized study in 26 rabbits,
Chung, Sang-Bong; Ryu, Jiwook; Chung, Yeongu; Lee, Sung Ho; Choi, Seok Keun
To provide detailed information about how to realize a self-training laboratory with cost-effective microsurgical instruments, especially pertinent for the novice trainee. Our training model is designed to allow the practice of the microsurgery skills in an efficient and cost-effective manner. A used stereoscopic microscope is prepared for microsurgical training. A sufficient working distance for microsurgical practice is obtained by attaching an auxiliary objective lens. The minimum instrument list includes 2 jeweler's forceps, iris scissors, and alligator clips. The iris scissors and alligator clip provide good alternatives to micro-scissors and microvascular clamp. The short time needed to set up the microscope and suture the gauze with micro-forceps makes the training model suitable for daily practice. It takes about 15 minutes to suture 10 neighboring fibers of the gauze with 10-0 nylon; thus, training can be completed more quickly. We have developed an inexpensive and efficient micro-anastomosis training system using a stereoscopic microscope and minimal micro-instruments. Especially useful for novice trainees, this system provides high accessibility for microsurgical training. Copyright © 2017 Elsevier Inc. All rights reserved.
Full Text Available In this case report, we discuss the microsurgical management of a Spetzler-Martin grade 5 arteriovenous malformation (AVM in a young boy who presented with a hemorrhagic episode and had a high calculated risk of rebleeding. We also outline the rationale for choosing the management option.
Young, Ezekiel E; Friedlander, Daniel; Lue, Kathy; Anele, Uzoma A; Khurgin, Jacob L; Bivalacqua, Trinity J; Burnett, Arthur L; Redett, Richard J; Gearhart, John P
To provide sexual function and quality of life outcomes in patients with severe penile deficiency who underwent radial forearm flap phalloplasty with and without penile prosthesis implantation. Patients with history of severe penile deficiency who underwent microsurgical radial forearm flap phalloplasty with and without penile prosthesis implantation between 2007 and 2014 were identified. They completed a set of web-based validated questionnaires including the International Index of Erectile Function, the Pediatric Penile Perception Score, the Sexual Quality of Life for Men, and several items addressing general quality of life. Outcomes were compared between groups. Nine of the 12 identified patients who had prosthesis after phalloplasty and 4 out of the 7 phalloplasty-only patients completed the survey, resulting in an overall response rate of 68%. Among the phalloplasty-prosthesis patients, 66% reported current sexual activity and 78% reported regular masturbation, whereas 1 of the 4 phalloplasty-only patients reported both. Prosthesis patients scored notably higher in all domains of the International Index of Erectile Function except for sexual desire. In contrast, they demonstrated similar scores of penile perception, as well as general and sexual quality of life. Among patients who have undergone flap phalloplasty, the subsequent placement of penile prosthesis appears to effectively allow for both intercourse and masturbation, resulting in measurable improvements in orgasmic function, intercourse satisfaction, and overall sexual satisfaction. Despite these important benefits, prosthesis placement does not appear to result in improvements in penile perception scores, or general or sexual quality of life. Copyright © 2017 Elsevier Inc. All rights reserved.
Zhou, Xiao; Wang, Libo; Mi, Jingyi; Xu, Yajun; Rui, Yongjun; Xue, Mingyu; Shen, Xiaofang; Qiang, Li
The aim of treating thumb fingertip amputations with no indication for replantation is to reestablish functional and esthetic properties. From March 2005 to October 2008, we treated 14 patients with thumb fingertip amputation using palmar V-Y flaps combined with bone and nail bed grafts. There were 10 men and 4 women, whose ages at surgery ranged from 19 to 63 years (mean 35.8 years). In all, 11 of the injuries occurred in the dominant hand. According to Allen's classification, two were type II, seven were type III, and five were type IV. All patients underwent emergency surgery, with a time delay after injury of 3-12 h (mean 6.4 h). In each case, the amputation was a crush or avulsion injury, making microsurgical replantation not feasible. All of the flaps survived. At 8-17 months (average 12.8 months) of follow-up, the average subjective satisfaction score was 8.64. All patients experienced cold intolerance, and none of the patients complained of dysesthesia. Favorable results (excellent or good) were found in 78.6%. Thin primary nails appeared on the grafted nail bed about 3 weeks after surgery, following which the newly formed nail thickened and developed a more natural appearance. In one case, the new nail plate showed abnormal thickening due to hyperkeratosis. The bone graft healed at 5 weeks. The mean two-point discrimination was 7.5 mm. Grip strength was 10% less than that in the unaffected hand. Metacarpophalangeal and proximal interphalangeal joint mobility losses were less than 10°. All patients returned to their jobs. No patients had postoperative complications. We believe that the combination of palmar V-Y flap and bone and nail bed grafts provides a distinct advantage over other choices. It improves function when replantation is not an option.
Li, Qingfeng; Zan, Tao; Gu, Bin; Liu, Kai; Shen, Guoxiong; Xie, Yun; Weng, Rui
Resurfacing of facial massive soft tissue defect is a formidable challenge because of the unique character of the region and the limitation of well-matched donor site. In this report, we introduce a technique for using the prefabricated cervicothoracic skin flap for facial resurfacing, in an attempt to meet the principle of flap selection in face reconstructive surgery for matching the color and texture, large dimension, and thinner thickness (MLT) of the recipient. Eleven patients with massive facial scars underwent resurfacing procedures with prefabricated cervicothoracic flaps. The vasculature of the lateral thigh fascial flap, including the descending branch of the lateral femoral circumflex vessels and the surrounding muscle fascia, was used as the vascular carrier, and the pedicles of the fascial flap were anastomosed to either the superior thyroid or facial vessels in flap prefabrication. A tissue expander was placed beneath the fascial flap to enlarge the size and reduce the thickness of the flap. The average size of the harvested fascia flap was 6.5 x 11.7 cm. After a mean interval of 21.5 weeks, the expanders were filled to a mean volume of 1,685 ml. The sizes of the prefabricated skin flaps ranged from 12 x 15 cm to 15 x 32 cm. The prefabricated skin flaps were then transferred to the recipient site as pedicled flaps for facial resurfacing. All facial soft tissue defects were successfully covered by the flaps. The donor sites were primarily closed and healed without complications. Although varied degrees of venous congestion were developed after flap transfers, the marginal necrosis only occurred in two cases. The results in follow-up showed most resurfaced faces restored natural contour and regained emotional expression. MLT is the principle for flap selection in resurfacing of the massive facial soft tissue defect. Our experience in this series of patients demonstrated that the prefabricated cervicothoracic skin flap could be a reliable alternative
Pettas, Vasilis; Barlas, Athanasios; Gertz, Drew Patrick
the sensor inputs. The AEP is increased due to the upscaling but also further due to the flap system while the fatigue loads in components of interest (blade, tower, nacelle and main bearing) are reduced close to the level of the original turbine. The aim of this study is to demonstrate a simple....... In an industrial-oriented manner the baseline rotor is upscaled by 5% and the ATEFs are implemented in the outer 30% of the blades. The flap system is kept simple and robust with a single flap section and control with wind speed, rotor azimuth, root bending moments and angle of attack in flap's mid-section being...
Kim, Chae Min; Yun, In Sik; Lee, Dong Won; Lew, Dae Hyun; Rah, Dong Kyun; Lee, Won Jai
Reconstruction of ischial pressure sore defects is challenging due to extensive bursas and high recurrence rates. In this study, we simultaneously applied a muscle flap that covered the exposed ischium and large bursa with sufficient muscular volume and a profunda femoris artery perforator fasciocutaneous flap for the management of ischial pressure sores. We retrospectively analyzed data from 14 patients (16 ischial sores) whose ischial defects had been reconstructed using both a profunda femoris artery perforator flap and a muscle flap between January 2006 and February 2014. We compared patient characteristics, operative procedure, and clinical course. All flaps survived the entire follow-up period. Seven patients (50%) had a history of surgery at the site of the ischial pressure sore. The mean age of the patients included was 52.8 years (range, 18-85 years). The mean follow-up period was 27.9 months (range, 3-57 months). In two patients, a biceps femoris muscle flap was used, while a gracilis muscle flap was used in the remaining patients. In four cases (25%), wound dehiscence occurred, but healed without further complication after resuturing. Additionally, congestion occurred in one case (6%), but resolved with conservative treatment. Among 16 cases, there was only one (6%) recurrence at 34 months. The combination of a profunda femoris artery perforator fasciocutaneous flap and muscle flap for the treatment of ischial pressure sores provided pliability, adequate bulkiness and few long-term complications. Therefore, this may be used as an alternative treatment method for ischial pressure sores.
Manahan, Michele A; Prucz, Roni B; Shridharani, Sachin M; Baltodano, Pablo A; Rosson, Gedge D
As the science of breast reconstruction evolves, significant changes in reconstruction strategies and outcomes are expected. The purpose of this study is to determine the changes in breast reconstruction trends and outcomes that occurred at a multidisciplinary academic institution during the last decade. We compared 265 patients over two distinct 6-month intervals separated by 5 years (2002 vs. 2007) and performed long-term follow-up (4.75 ± 3.38 years 2002, 2.99 ± 2.25 years 2007). We studied patients seeking prophylactic mastectomy, patients with early breast cancer, and patients with locally advanced disease. We analyzed demographic data, breast cancer history and treatment, type and timing of reconstruction, and complications. Implant to flap reconstruction ratio was 48:49 in 2002 and 76:102 in 2007. Use of transverse rectus abdominis myocutaneous flap declined from 57 to 4%; conversely, deep inferior epigastric perforator flap increased from 27 to 91% (P < 0.001). Correspondingly, donor site chronic pain (4 vs. 0, P = 0.012) and postoperative abdominal wall bulge (9 vs. 3, P = 0.004) rates decreased. Timing of reconstruction showed increased staged cases in 2007 compared to 2002 (P = 0.045). Post-final reconstruction radiation therapy was reduced in 2007 (P = 0.016), with subsequent lower rates of implant rupture (P < 0.001). At our institution and over the last decade, increasing staged reconstructions have successfully reduced the rates of post-final reconstruction radiotherapy with optimized outcomes. Contrary to national trends, the rates of autologous flap reconstructions have increased with reduced donor site morbidity. This suggests that academic breast reconstruction trends are independent from national trends. © 2014 Wiley Periodicals, Inc.
Pelsser, Cristel; Maennel, Olaf; Mohapatra, Pradosh; Bush, Randy; Patel, Keyur
The Border Gateway Protocol (BGP), the de facto inter-domain routing protocol of the Internet, is known to be noisy. The protocol has two main mechanisms to ameliorate this, MinRouteAdvertisementInterval (MRAI), and Route Flap Damping (RFD). MRAI deals with very short bursts on the order of a few to 30 seconds. RFD deals with longer bursts, minutes to hours. Unfortunately, RFD was found to severely penalize sites for being well-connected because topological richness amplifies the number of update messages exchanged. So most operators have disabled it. Through measurement, this paper explores the avenue of absolutely minimal change to code, and shows that a few RFD algorithmic constants and limits can be trivially modified, with the result being damping a non-trivial amount of long term churn without penalizing well-behaved prefixes' normal convergence process.
Cabbabe, E.B.; Herbold, D.R.; Sunwoo, Y.C.; Baroudi, I.F.
Postirradiation alteration of oral flora is well documented in the literature. Infection as a complication leading to partial or complete loss of a flap used to reconstruct a defect in the oral cavity is a worrisome outcome. We describe how a flap that was judged clinically to be viable became overwhelmingly infected with the Klebsiella oxytoca, an oral cavity pathogen encountered in this patient following irradiation. Local and systemic changes led to detachment of the flap. This complication may be explained, in view of the absence of venous congestion or arterial ischemia both clinically and pathologically, by the proven contamination of the flap by the Klebsiella pathogen. Local factors resulted in lower resistance and subsequent overwhelming infection. Discussion of the case, review of pertinent literature, and proposed solutions are presented
Ahmad, Faisal I; Gerecci, Deniz; Gonzalez, Javier D; Peck, Jessica J; Wax, Mark K
Hematomas may develop in the postoperative setting after free tissue transfer. When hematomas occur, they can exert pressure on surrounding tissues. Their effect on the vascular pedicle of a free flap is unknown. We describe our incidence of hematoma in free flaps and outcomes when the flap is compromised. Retrospective chart review of 1,883 free flaps performed between July 1998 and June 2014 at a tertiary referral center. Patients with free flap compromise due to hematoma were identified. Etiology, demographic data, and outcomes were evaluated. Eighty-eight (4.7%) patients developed hematomas. Twenty (22.7%) of those had flap compromise. Twelve compromises (60%) showed evidence of pedicle thrombosis. The salvage rate was 75% versus 54% in 79 flaps with compromise from other causes (P = .12). Mean time to detection of the hematoma was 35.3 hours in salvaged flaps compared to 91.6 hours in unsalvageable flaps (P = .057). Time to operating room (OR) from detection was 2.8 hours in salvageable flaps compared to 12.4 hours in nonsalvageable flaps (P = .053). The salvage rate for flaps that returned to the OR in hematomas developed rarely. When they did, 23% went on to develop flap compromise. Prompt recognition and re-exploration allowed for a high salvage rate. Vessel thrombosis predicted inability to salvage the flap. 4 © 2015 The American Laryngological, Rhinological and Otological Society, Inc.
Mercut, R; Sinna, R; Vaucher, R; Giroux, P A; Assaf, N; Lari, A; Dast, S
Perineal defects are encountered ever more frequently, in the treatment of vulvar cancers or abdominoperineal resection. The surgical treatment of vulvar cancer leads to significant skin defect. The aim of the reconstruction is not to provide volume but rather to resurface perineum. We propose a new solution to cover the extensive skin defect remaining after excision. We report 3 patients who underwent large excision for vulvar cancer, with lymph node dissection. For reconstruction, we performed 3 advancement flaps. Two V-Y flaps cantered on the infra-gluteal folds and based on pudendal perforator arteries were used to cover the postero-lateral parts of the defect. The third advancement flap from the superior aspect of the defect was a Y-V Mons pubis flap. The defects were successfully covered by the 3 flap technique. The first patient suffered a non-union that slowly healed by secondary intention. For the other cases, we used the same technique, but applied negative pressure wound therapy on the sutures, with excellent results. The 3 flap technique is a simple and reliable method and the donor site morbidity is minimal. It can be realised without changing the position of the patient after tumour excision, and does not require delicate perforator dissection. This surgical option can be easily applied, allowing better management of these cases. Copyright © 2018 Elsevier Masson SAS. All rights reserved.
Full Text Available Amputation of the penis is a rare condition reported from various parts of the world as isolated cases or small series of patients; the common etiology is self-mutilating sharp amputation or an avulsion or crush injury in an industrial accident. A complete reconstruction of all penile structures should be attempted in one stage which provides the best chance for full rehabilitation of the patient. We report here a single case of total amputation of the penis in an acute paranoid schizophrenic patient .The penis was successfully reattached using a microsurgical technique. After surgery, near-normal appearance and function including a good urine flow and absence of urethral stricture, capabilities of erection and near normal sensitivity were observed.
Forhad Hossain Chowdhury
Full Text Available A 42-year-old woman presented with a 3-month history of progressive occipital headache, vomiting, walking difficulty, and repeated fall. She had no history of sudden and severe headache. She had positive cerebellar signs, predominantly on the right side. Computerized tomography (CT scan, CT angiogram, and magnetic resonance image (MRI of the brain showed suspected partially thrombosed giant 4 th ventricular posterior inferior cerebellar artery aneurysm. Patient developed severe hypersensitivity reaction during both CT scan and MRI after contrast injection. Though needed, digital subtraction angiogram (DSA of cerebral vessels was not done. The aneurysm was managed by microsurgical clipping of the aneurysm neck and partial excision of thrombosed aneurysm. Here, we report the details of management of these difficult giant aneurysm without DSA.
Chang, S.D.; Steinberg, G.K.; Levy, R.P.; Marks, M.P.; Frankel, K.A.; Shuster, D.L.; Marcellus, M.L.
Radiosurgery is effective in obliterating small arteriovenous malformations (AVMs), but less successful in thrombosing larger AVMs. This study reviewed patients who underwent surgical resection of their large AVMs following failed radiosurgical obliteration. AVMs from 36 patients (aged 7 to 64 years, mean 29.9) were surgically resected 1 to 11 years after radiosurgery. Initial AVM volumes were 0.7 to 117 cm 3 (mean 21.6 cm 3 ), and radiosurgical doses ranged from 4.6 to 45 Gray equivalent (GyE) (mean 21.1 GyE). Thirty AVMs (83%) were located in eloquent tissue. Venous drainage was deep (14), superficial (13), or both (9). Spetzler grades were II (2), III (12), IV (18), and V (4). Nine patients suffered rehemorrhage after radiosurgery but prior to surgery, while three patients developed radiation necrosis. Twenty-seven patients underwent endovascular embolization prior to surgery. During microsurgical resection, the AVMs were found to be significantly less vascular and more easily resected, compared to AVMs in patients who had not received radiosurgery. Histology showed endothelial proliferation with hyaline and mineralization in vessel walls. Partial or complete thrombosis of some AVM vessels, and evidence of vessel and brain necrosis were noted in many cases. Clinical outcome was excellent or good in 34 cases, with two patients dying of rebleeding from residual AVM. Five patients were neurologically worse following microsurgical resection. Final outcome was largely related to the pretreatment grade. Radiosurgery several years prior to surgical resection appears useful in treating unusually large and complex AVMs. (author)
Micko, Alexander; Knopp, Karoline; Knosp, Engelbert; Wolfsberger, Stefan
In times of the ubiquitous debate about doctors' working hour restrictions, it is still questionable if the physician's performance is impaired by high work load and long shifts. In this study, we evaluated the impact of sleep interruption on neurosurgical performance. Ten medical students and 10 neurosurgical residents were tested on the virtual-reality simulator NeuroTouch by performing an identical microsurgical task, well rested (baseline test), and after sleep interruption at night (stress test). Deviation of total score, timing, and excessive force on tissue were evaluated. In addition, vital parameters and self-assessment were analyzed. After sleep interruption, total performance score increased significantly (45.1 vs. 48.7, baseline vs. stress test, P = 0.048) while timing remained stable (10.1 vs. 10.4 minutes for baseline vs. stress test, P > 0.05) for both students and residents. Excessive force decreased in both groups during the stress test for the nondominant hand (P = 0.05). For the dominant hand, an increase of excessive force was encountered in the group of residents (P = 0.05). In contrast to their results, participants of both groups assessed their performance worse during the stress test. In our study, we found an increase of neurosurgical simulator performance in neurosurgical residents and medical students under simulated night shift conditions. Further, microsurgical dexterity remained unchanged. Based on our results and the data in the available literature, we cannot confirm that working hour restrictions will have a positive effect on neurosurgical performance. Copyright © 2017 Elsevier Inc. All rights reserved.
Kim, K S; Eo, S R; Kim, D Y; Lee, S Y; Cho, B H
Many methods have been used to reattach amputated fingertips. Of these methods, microsurgery has been accepted as the procedure of choice because the defining characteristic of a microsurgically replanted finger is that its surival in the recipient bed is predicated on functioning intravascular circulation. Although considerable progress has been made in the techniques for microvascular replantation of amputated fingers, the replantation of an amputated fingertip is difficult because digital arteries branch into small arteries. This is in addition to digital veins that run from both sides of the nail bed to the median dorsal sides, which are difficult to separate from the immobile soft tissue. Furthermore, even with the most technically skilled microsurgeon, replantation failure often occurs, especially in severe injury cases. Therefore, the technique is not the only protection against failure, and a new strategy of fingertip reattachment is needed. From March of 1997 to December of 1999, 12 fingers of 11 patients with zone 1 or zone 2 fingertip amputations that were reattached microsurgically but were compromised were deepithelialized, reattached, and then inserted into the abdominal pocket. All had been complete amputations with crushing injuries. Approximately 3 weeks later, the fingers were depocketed and covered with a skin graft. Of the 12 fingers, 7 survived completely and 3 had partial necrosis on less than one-third the volume of the amputated part. The complete survival rate was approximately 58 percent. The results of the above 10 fingers were satisfactory from both functional and cosmetic aspects. The authors believe that this high success rate was achieved because the deepithelialized finger pulp was placed in direct contact with the deep abdominal fascia, which was equipped with plentiful vascularity, not subcutaneous fat. In addition, the pocketing was performed promptly before necrosis of the compromised fingertip occurred. From the results of this
Kamide, Tomoya; Tabani, Halima; Safaee, Michael M; Burkhardt, Jan-Karl; Lawton, Michael T
OBJECTIVE While most paraclinoid aneurysms can be clipped with excellent results, new postoperative visual deficits are a concern. New technology, including flow diverters, has increased the popularity of endovascular therapy. However, endovascular treatment of paraclinoid aneurysms is not without procedural risks, is associated with higher rates of incomplete aneurysm occlusion and recurrence, and may not address optic nerve compression symptoms that surgical debulking can. The increasing endovascular management of paraclinoid aneurysms should be justified by comparisons to surgical benchmarks. The authors, therefore, undertook this study to define patient, visual, and aneurysm outcomes in the most common type of paraclinoid aneurysm: ophthalmic artery (OphA) aneurysms. METHODS Results from microsurgical clipping of 208 OphA aneurysms in 198 patients were retrospectively reviewed. Patient demographics, aneurysm morphology (size, calcification, etc.), clinical characteristics, and patient outcomes were recorded and analyzed. RESULTS Despite 20% of these aneurysms being large or giant in size, complete aneurysm occlusion was accomplished in 91% of 208 cases, with OphA patency preserved in 99.5%. The aneurysm recurrence rate was 3.1% and the retreatment rate was 0%. Good outcomes (modified Rankin Scale score 0-2) were observed in 96.2% of patients overall and in all 156 patients with unruptured aneurysms. New visual field defects (hemianopsia or quadrantanopsia) were observed in 8 patients (3.8%), decreased visual acuity in 5 (2.4%), and monocular blindness in 9 (4.3%). Vision improved in 9 (52.9%) of the 17 patients with preoperative visual deficits. CONCLUSIONS The most important risk associated with clipping OphA aneurysms is a new visual deficit. Meticulous microsurgical technique is necessary during anterior clinoidectomy, aneurysm dissection, and clip application to optimize visual outcomes, and aggressive medical management postoperatively might potentially
Quillot, M; Lodde, J P; Pegorier, O; Reynaud, J P; Cormerais, A
The authors propose a modification of the classical design of island flaps for cover of pressure sores, applied to gluteus maximus and tensor fascia lata muscles: the hatchet flap. 31 flaps have been used including 13 gluteus maximus superior flaps for sacral pressure sores, 9 gluteal inferior flaps for ischial pressure sores and 9 tensor fascia lata flaps for trochanteric pressure sores. A small partial necrosis and two cases of sepsis were observed in this series, but did not require surgical revision. The authors emphasize the value of this modification of the classical flap design, which preserves an even better musculocutaneous capital in these patients, who are often already multi-operated. The very rapid recovery of patients supports the authors' application of hatchet flaps to the surgery of pressure sores, and suggests the extension to other musculocutaneous flaps in the future.
Razak, N. A.; Dimitriadis, G.; Razaami, A. F.
Lately, due to the growing interest in Micro Aerial Vehicles (MAV), interest in flapping flight has been rekindled. The reason lies in the improved performance of flapping wing flight at low Reynolds number regime. Many studies involving flapping wing flight focused on the generation of unsteady aerodynamic forces such as lift and thrust. There is one aspect of flapping wing flight that received less attention. The aspect is aerodynamic power consumption. Since most mechanical flapping wing aircraft ever designed are battery powered, power consumption is fundamental in improving flight endurance. This paper reports the results of experiments carried out on mechanical wings under going active root flapping and pitching in the wind tunnel. The objective of the work is to investigate the effect of the pitch angle oscillations and wing profile on the power consumption of flapping wings via generation of unsteady aerodynamic forces. The experiments were repeated for different airspeeds, flapping and pitching kinematics, geometric angle of attack and wing sections with symmetric and cambered airfoils. A specially designed mechanical flapper modelled on large migrating birds was used. It will be shown that, under pitch leading conditions, less power is required to overcome the unsteady aerodnamics forces. The study finds less power requirement for downstroke compared to upstroke motion. Overall results demonstrate power consumption depends directly on the unsteady lift force.
E. A. Razgulyaeva
Full Text Available For laser-assisted in situ keratomileusis (LASIK retreatments with a previous unsuccessful mechanical microkeratome-assisted surgery, some surgical protocols have been described as feasible, such as relifting of the flap or the creation of a new flap and even the change to a surface ablation procedure (photorefractive keratectomy (PRK. This case shows the use of femtosecond technology for the creation of a secondary flap to perform LASIK in a cornea with a primary incomplete flap obtained with a mechanical microkeratome. As we were unable to characterize the interface of the first partial lamellar cut, a thick flap was planned and created using a femtosecond laser platform. As the primary cut was very thick in the nasal quadrant, a piece of loose corneal tissue appeared during flap lifting which was fitted in its position and not removed. Despite this condition and considering the regularity of the new femtosecond laser cut, the treatment was uneventful. This case report shows the relevance of a detailed corneal analysis with an advanced imaging technique before performing a secondary flap in a cornea with a primary incomplete flap. The femtosecond laser technology seems to be an excellent tool to manage such cases successfully.
Ichiro Hashimoto, MD
Conclusions: The perforator vessels of the internal pudendal artery are very close to the ischial tuberosity. Blood flow to the flap is reliable when careful debridement of the pressure sore is performed. The iPap thigh flap is a new option for soft-tissue defects in the ischial region, including ischial pressure sores.
Werker, Paul M N
The prepuce free flap was used in 10 oral and oropharyngeal reconstructions. During the course of this study, various modifications took place. Residual penile skin necrosis and skin island necrosis early in the series led to modification of flap design. This solved the donor-site problem by placing
Sato, Tomoya; Yana, Yuichiro; Ichioka, Shigeru
Although free flap is gaining popularity for the reconstruction of diabetic foot ulcers, it is unclear whether free flap reconstruction increases the chances of postoperative independent ambulation. The aim of this study is to evaluate the relationship between free flap success and postoperative ambulation. This study reviewed 23 cases of free flap reconstruction for diabetic foot ulcers between January 2007 and March 2014. Free rectus abdominis, latissimus dorsi, and anterolateral thigh flaps were used in ten, eight, and five patients, respectively. A comparison was made between free flap success and postoperative independent ambulation using Fisher's exact test. Two patients developed congestive heart failure with fatal consequences within 14 days postoperatively, resulting in an in-hospital mortality rate of 8.7%. Five patients lost their flaps (21.7%). Of the 16 patients who had flap success, 12 achieved independent ambulation. Five patients with flap loss did not achieve independent ambulation, except one patient who underwent secondary flap reconstruction using a distally based sural flap. Fisher's exact test revealed that independent ambulation was associated with free flap success (p = 0.047). The present study indicates that free flap reconstruction may increase the possibility of independent ambulation for patients with extensive tissue defects due to diabetic ulcers. Intermediate limb salvage rates and independent ambulation rates were favourable in patients with successful reconstruction. The use of foot orthoses and a team approach with pedorthists were effective to prevent recurrence.
Full Text Available Flaps from temporal region have been used for mid face, orbital and peri-orbital reconstruction. The knowledge of the vascular anatomy of the region helps to dissect and harvest the muscle/fascia/skin/combined tissue flaps from that region depending upon the requirement. Suprastructure maxillectomy defects are usually covered with free flaps to fill the cavity. Here we report an innovative idea in which a patient with a supra structure maxillectomy with external skin defect was covered with chimeric flap based on the parietal and frontal branches of superficial temporal artery and the temporalis muscle flap based on deep temporal artery.
Full Text Available The present study was achieved to clarify the venous drainage of the udder in twelve healthy Egyptian Baladi goats. Gum-milk latex injection (nine specimens and radiographic imaging technique (three specimens were used to demonstrate the course and tributaries of the main veins draining the udder. The obtained results revealed that the udder of goat was drained through three venous circles, one at its base, while the other two were present in the form of one circle at the base of each teat. The basal venous circle was formed by the external pudendal and cranial superficial epigastric veins, as well as the dorsal labial and mammary branch of the ventral perineal vein. While the papillary venous circle was formed mainly by the cranial and caudal lateral sinus branches of the cranial mammary vein of the external pudendal vein. Also, the origin, course, distribution and termination of the cranial superficial epigastric vein were described. The venous architecture reported in this study could serve as a guide for the further surgical interference within the udder of goat.
Tenekeci, Goktekin; Basterzi, Yavuz; Unal, Sakir; Sari, Alper; Demir, Yavuz; Bagdatoglu, Celal; Tasdelen, Bahar
Bilateral rotation flaps are considered the workhorse flaps in reconstruction of myelomeningocele defects. Since the introduction of perforator flaps in the field of reconstructive surgery, perforator flaps have been used increasingly in the reconstruction of various soft tissue defects all over the body because of their appreciated advantages. The aim of this study was to compare the complications and surgical outcomes between bilateral rotation flaps and dorsal intercostal artery perforator (DICAP) flaps in the soft tissue reconstruction of myelomeningocele defects. Between January 2005-February 2017, we studied 47 patients who underwent reconstruction of myelomeningocele defects. Patient demographics, operative data, and postoperative data were reviewed retrospectively and are included in the study. We found no statistically significant differences in patient demographics and surgical complications between these two groups; this may be due to small sample size. With regard to complications-partial flap necrosis, cerebrospinal fluid (CSF) leakage, necessity for reoperation, and wound infection-DICAP propeller flaps were clinically superior to rotation flaps. Partial flap necrosis was associated with CSF leakage and wound infection, and CSF leakage was associated with wound dehiscence. Although surgical outcomes obtained with DICAP propeller flaps were clinically superior to those obtained with rotation flaps, there was no statistically significant difference between the two patient groups. A well-designed comparative study with adequate sample size is needed. Nonetheless, we suggest using DICAP propeller flaps for reconstruction of large myelomeningocele defects.
Full Text Available We describe a modified volar “V-Y cup” flap for volar fingertip defects that do not exceed more than half of the distal phalanx for better aesthetic and functional outcome. In seven cases out of eight, the flap was elevated with a subdermal pedicle, whereas in one case, the flap was elevated as an island on the bilateral neurovascular bundle. The fingertips have been evaluated for sensibility using standard tests, hook nail deformity and patient satisfaction. Seven flaps have survived completely. The flap with skeletonized bilateral digital neurovascular bundle has shown signs of venous insufficiency on the 5 postoperative day with consecutive necrosis. Suturing the distal edges of the flap in a “cupping” fashion provided a normal pulp contour. The modified flap can be used for defects as mentioned above. Subdermally dissected pedicle-based flap is safe and easy to elevate. The aesthetic and functional outcomes have been reported to be satisfactory.
equipment, cost, steep learning curve, and prolonged operating ... A Versatile Alternative when Reverse Sural Artery Flap is .... He had wound debridement, fracture reduction, and .... flaps that were raised in the patient and the logistics of limb.
The agility and maneuverability of natural fliers would be desirable to incorporate into engineered micro air vehicles (MAVs). However, there is still much for engineers to learn about flapping flight in order to understand how such vehicles can be built for efficient flying. The goal of this study is to develop a methodology for capturing high quality flow field data around flexible flapping wings in a hover environment and to interpret it to gain a better understanding of how aerodynamic forces are generated. The flow field data was captured using particle image velocimetry (PIV) and required that measurements be taken around a repeatable flapping motion to obtain phase-averaged data that could be studied throughout the flapping cycle. Therefore, the study includes the development of flapping devices with a simple repeatable single degree of freedom flapping motion. The acquired flow field data has been examined qualitatively and quantitatively to investigate the mechanisms behind force production in hovering flight and to relate it to observations in previous research. Specifically, the flow fields have been investigated around a rigid wing and several carbon fiber reinforced flexible membrane wings. Throughout the whole study the wings were actuated with either a sinusoidal or a semi-linear flapping motion. The semi-linear flapping motion holds the commanded angular velocity nearly constant through half of each half-stroke while the sinusoidal motion is always either accelerating or decelerating. The flow fields were investigated by examining vorticity and vortex structures, using the Q criterion as the definition for the latter, in two and three dimensions. The measurements were combined with wing deflection measurements to demonstrate some of the key links in how the fluid-structure interactions generated aerodynamic forces. The flow fields were also used to calculate the forces generated by the flapping wings using momentum balance methods which yielded
DANIEL FRANCISCO MELLO
Full Text Available ABSTRACT Objective: to describe the use of a superomedial fasciocutaneous thigh flap for scrotal reconstruction in open areas secondary to the surgical treatment of perineal necrotizing fasciitis (Fournier’s gangrene. Methods: retrospective analysis of cases treated at the Plastic Surgery Service of Santa Casa de Misericórdia, São Paulo, from 2009 to 2015. Results: fifteen patients underwent scrotal reconstruction using the proposed flap. The mean age was 48.9 years (28 to 66. Skin loss estimates in the scrotal region ranged from 60 to 100%. Definitive reconstruction was performed on average 30.6 days (22 to 44 after the initial surgical treatment. The mean surgical time was 76 minutes (65 to 90 to obtain the flaps, bilateral in all cases. Flap size ranged from 10cm to 13cm in the longitudinal direction and 8cm to 10cm in the cross-sectional direction. The complication rate was 26.6% (four cases, related to the occurrence of segmental and partial dehiscence. Conclusion: the superomedial fasciocutaneous flap of thigh is a reliable and versatile option for the reconstruction of open areas in the scrotal region, showing adequate esthetic and functional results.
Full Text Available Context: Despite the abundance of techniques for the repair of Hypospadias, its problems still persist and a satisfactory design to correct the penile curvature with the formation of neourethra from the native urethral tissue or genital or extragenital tissues, with minimal postoperative complications has yet to evolve. Aim: Persisting with such an endeavor, a new technique for the repair of distal and midpenile hypospadias is described. Materials and Methods: The study has been done in 70 cases over the past 11 years. The "Forked-Flap" repair is a single stage method for the repair of such Hypospadias with chordee. It takes advantage of the rich vascular communication at the corona and capitalizes on the established reliability of the meatal based flip-flap. The repair achieves straightening of the curvature of the penis by complete excision of chordee tissue from the ventral surface of the penis beneath the urethral plate. The urethra is reconstructed using the native plate with forked flap extensions and genital tissue relying on the concept of meatal based flaps. Water proofing by dartos tissue and reinforcement by Nesbit′s prepucial tissue transfer completes the one stage procedure. Statistical Analysis: An analysis of 70 cases of this single stage technique of repair of penile hypospadias with chordee, operated at 3 to 5 years of age over the past 11 years is presented. Results and Conclusion: The Forked Flap gives comparable and replicable results; except for a urethrocutaneous fistula rate of 4% no other complications were observed.
Full Text Available Background: The tenuous blood supply of traditional flaps for wound cover combined with collateral damage by sacrifice of functional muscle, truncal vessels, or nerves has been the bane of reconstructive procedures. The concept of perforator plus flaps employs dual vascular supply to flaps. By safeguarding perforators along with supply from its base, robust flaps can be raised in diverse situations. This is achieved while limiting collateral damage and preserving nerves, vessels, and functioning muscle with better function and aesthesis. Materials and Methods: The perforator plus concept was applied in seven different clinical situations. Functional muscle and fasciocutaneous flaps were employed in five and adipofascial flaps in two cases, primarily involving lower extremity defects and back. Adipofascial perforator plus flaps were employed to provide cover for tibial fracture in one patients and chronic venous ulcer in another. Results: All flaps survived without any loss and provided long-term stable cover, both over soft tissue and bone. Functional preservation was achieved in all cases where muscle flaps were employed with no clinical evidence of loss of power. There was no sensory loss or significant oedema in or distal to the flap in both cases where neurovascular continuity was preserved during flap elevation. Fracture union and consolidation were satisfactory. One patient had minimal graft loss over fascia which required application of stored grafts with subsequent take. No patient required re-operation. Conclusions: Perforator plus concept is holistic and applicable to most flap types in varied situations. It permits the exercise of many locoregional flap options while limiting collateral functional damage. Aesthetic considerations are also addressed while raising adipofascial flaps because of no appreciable donor defects. With quick operating times and low failure risk, these flaps can be a better substitute to traditional flaps and at
Full Text Available AIM:To observe the clinical effect of on-flap and off-flap epipolis laser in situ keratomileusis(EPi-LASIKin ametropia.METHODS: Sixty-eight myopia patients(136 eyesreceiving surgical treatment were selected and divided into research group and control group according to different therapies. The patients in research group adopted off-flap EPi-LASIK and those in control group adopted on-flap EPi-LASIK. The index like uncorrected visual acuity, diopter and Haze of two groups before surgery, 1wk, 1 and 4mo after surgery was observed. RESULTS: One month after surgery, the uncorrected visual acuity of research group was 1.33±0.22 while that of control group was 1.22±0.19(PPPCONCLUSION:On-flap and off-flap EPi-LASIK are safe and effective surgery approaches in the clinical treatment of ametropia. The presence of corneal epithelial flap has a certain effect in the postoperative clinical outcome at early stage. The impact will be gradually reduced over time.
Nguyen, Vincent; Basma, Jaafar; Klimo, Paul; Sorenson, Jeffrey; Michael, L Madison
Objectives To describe the orbitopterional approach for the resection of a suprasellar craniopharyngioma with emphasis on the microsurgical and pathological anatomy of such lesions. Design After completing the orbitopterional craniotomy in one piece including a supraorbital ridge osteotomy, the Sylvian fissure was split in a distal to proximal direction. The ipsilateral optic nerve and internal carotid artery were identified. Establishing a corridor to the tumor through both the opticocarotid and optic cisterns allowed for a wide angle of attack. Using both corridors, a microsurgical gross total resection was achieved. A radical resection required transection of the stalk at the level of the hypothalamus. Photographs of the region are borrowed from Dr Rhoton's laboratory to illustrate the microsurgical anatomy. Understanding the cisternal and topographic relationships of the optic nerve, optic chiasm, and internal carotid artery is critical to achieving gross total resection while preserving normal anatomy. Participants The surgery was performed by the senior author assisted by Dr. Jaafar Basma. The video was edited by Dr. Vincent Nguyen. Outcome Measures Outcome was assessed with extent of resection and postoperative visual function. Results A gross total resection of the tumor was achieved. The patient had resolution of her bitemporal hemianopsia. She had diabetes insipidus with normal anterior pituitary function. Conclusions Understanding the microsurgical anatomy of the suprasellar region and the pathological anatomy of craniopharyngiomas is necessary to achieve a good resection of these tumors. The orbitopterional approach provides the appropriate access for such endeavor. The link to the video can be found at: https://youtu.be/Be6dtYIGqfs .
Chae Min Kim
Full Text Available Background Reconstruction of ischial pressure sore defects is challenging due to extensive bursas and high recurrence rates. In this study, we simultaneously applied a muscle flap that covered the exposed ischium and large bursa with sufficient muscular volume and a profunda femoris artery perforator fasciocutaneous flap for the management of ischial pressure sores. Methods We retrospectively analyzed data from 14 patients (16 ischial sores whose ischial defects had been reconstructed using both a profunda femoris artery perforator flap and a muscle flap between January 2006 and February 2014. We compared patient characteristics, operative procedure, and clinical course. Results All flaps survived the entire follow-up period. Seven patients (50% had a history of surgery at the site of the ischial pressure sore. The mean age of the patients included was 52.8 years (range, 18-85 years. The mean follow-up period was 27.9 months (range, 3-57 months. In two patients, a biceps femoris muscle flap was used, while a gracilis muscle flap was used in the remaining patients. In four cases (25%, wound dehiscence occurred, but healed without further complication after resuturing. Additionally, congestion occurred in one case (6%, but resolved with conservative treatment. Among 16 cases, there was only one (6% recurrence at 34 months. Conclusions The combination of a profunda femoris artery perforator fasciocutaneous flap and muscle flap for the treatment of ischial pressure sores provided pliability, adequate bulkiness and few long-term complications. Therefore, this may be used as an alternative treatment method for ischial pressure sores.
Tvrdek, M; Kozák, J
The authors present a case report of a patient with anophthalmia in whom retroauriculo-temporal flap (Washio flap) was used for reconstruction of eyelids. This flap, which is mostly used for reconstructions of nasal defects, was not used in this way according to available literature.
Kelly, John L
Free-flap failure is usually caused by venous or arterial thrombosis. In many cases, lack of experience and surgical delay also contribute to flap loss. The authors prospectively analyzed the outcome of 57 free flaps over a 28-month period (January, 1999 to April, 2001). The setting was a university hospital tertiary referral center. Anastomotic technique, ischemia time, choice of anticoagulant, and the grade of surgeon were recorded. The type of flap, medications, and co-morbidities, including preoperative radiotherapy, were also documented. Ten flaps were re-explored (17 percent). There were four cases of complete flap failure (6.7 percent) and five cases of partial failure (8.5 percent). In patients who received perioperative systemic heparin or dextran, there was no evidence of flap failure (p = .08). The mean ischemia time was similar in flaps that failed (95 +\\/- 29 min) and in those that survived (92 +\\/- 34 min). Also, the number of anastomoses performed by trainees in flaps that failed (22 percent), was similar to the number in flaps that survived (28 percent). Nine patients received preoperative radiotherapy, and there was complete flap survival in each case. This study reveals that closely supervised anastomoses performed by trainees may have a similar outcome to those performed by more senior surgeons. There was no adverse effect from radiotherapy or increased ischemia time on flap survival.
Background: Post-pneumonectomy bronchopleural fistulae is associated with high mortality and morbidity. The omental flap has been widely used to manage this condition either through laparoscopic or open surgery with varied degrees of success. We present a modification of the omental flap by using two flaps of the ...
Kamide, Tomoya; Burkhardt, Jan-Karl; Tabani, Halima; Safaee, Michael M; Lawton, Michael T
Although most posterior communicating artery (PCoA) aneurysms can be clipped easily with excellent results, some require anterior clinoidectomy for safe and complete clipping. To review our microsurgical series of ruptured PCoA aneurysms and identify the preoperative predictors for anterior clinoidectomy during microsurgical clipping for PCoA aneurysms. Results from microsurgical clipping of 104 patients with ruptured PCoA aneurysms were reviewed retrospectively. Distances and angles were obtained from computed tomographic angiography and compared between the anterior and nonanterior clinoidectomy groups. Anterior clinoidectomy was required in 19 of the 104 cases (18%). None developed surgical complications due to anterior clinoid process (ACP) resection, including postoperative visual deficit. Univariate and multivariate analyses revealed that the distances from the ACP tip to the aneurysmal proximal neck and from the ACP line to the aneurysmal proximal neck were statistically significant predictive factors for the need of anterior clinoidectomy. Based on a receiver operating characteristic analysis, the distances from the ACP tip to the aneurysmal proximal neck PCoA aneurysm surgery, the distances from the ACP tip to the aneurysmal proximal neck and from the ACP line to the aneurysmal proximal neck were both found to be useful predictors of whether anterior clinoidectomy was required. Copyright © 2017 Elsevier Inc. All rights reserved.
Di Stadio, Arianna; Colangeli, Roberta; Dipietro, Laura; Martini, Alessandro; Parrino, Daniela; Nardello, Ennio; D'Avella, Domenico; Zanoletti, Elisabetta
The use of surgical cochlear nerve decompression is controversial. This study aimed at investigating the safety and validity of microsurgical decompression via an endoscope-assisted retrosigmoid approach to treat tinnitus in patients with neurovascular compression of the cochlear nerve. Three patients with disabling tinnitus resulting from a loop in the internal auditory canal were evaluated with magnetic resonance imaging and tests of pure tone auditory, tinnitus, and auditory brain response (ABR) to identify the features of the cochlear nerve involvement. We observed a loop with a caliber greater than 0.8 mm in all patients. Patients were treated via an endoscope-assisted retrosigmoid microsurgical decompression. After surgery, none of the patients reported short-term or long-term complications. After surgery, tinnitus resolved immediately in 2 patients, whereas in the other patient symptoms persisted although they improved; in all patients, hearing was preserved and ABR improved. Microsurgical decompression via endoscope-assisted retrosigmoid approach is a promising, safe, and valid procedure for treating tinnitus caused by cochlear nerve compression. This procedure should be considered in patients with disabling tinnitus who have altered ABR and a loop that has a caliber greater than 0.8 mm and is in contact with the cochlear nerve. Copyright © 2018 Elsevier Inc. All rights reserved.
Bonde, Christian T; Holstein-Rathlou, Niels-Henrik; Elberg, Jens J
was to evaluate if, and to what extent, a tissue flap could compensate a reduction in blood flow due to an acute constriction of the feed artery. Further, we wanted to examine the possible role of smooth muscle L-type calcium channels in the autoregulatory mechanism by pharmacological intervention with the L......, the flow in the pedicle was reduced and the flow was recorded. RESULTS: The flaps showed a strong autoregulatory response with complete compensation for flow reductions of up to 70-80%. Infusion of nimodipine caused a 28+/-10% increase in blood flow and removed the autoregulation. Papaverine caused...... a further increase in blood flow by 61+/-19%. The time control experiments proved that the experimental procedure was reproducible and stable over time. CONCLUSIONS: A tissue flap can nearly completely compensate for repeated flow reductions of up to 70-80%. This is due to a decrease in the peripheral...
P Mohan Kumar
Full Text Available Marginal tissue recession exposes the anatomic root on the teeth, which gives rise to -common patient complaints. It is associated with sensitivity, tissue irritation, cervical abrasions, and esthetic concerns. Various types of soft tissue grafts may be performed when recession is deep and marginal tissue health cannot be maintained. Double papilla flap is an alternative technique to cover isolated recessions and correct gingival defects in areas of insufficient attached gingiva, not suitable for a lateral sliding flap. This technique offers the advantages of dual blood supply and denudation of interdental bone only, which is less susceptible to permanent damage after surgical exposure. It also offers the advantage of quicker healing in the donor site and reduces the risk of facial bone height loss. This case report presents the advantages of double papilla flap in enhancing esthetic and functional outcome of the patient.
Ogino, Akihiro; Onishi, Kiyoshi; Okada, Emi; Nakamichi, Miho
Lower lip reconstruction requires consideration of esthetic and functional outcome in selecting a surgical procedure, and reconstruction with local tissue is useful. The authors reconstructed full-thickness defects with a unit advancement flap. Reconstruction was performed using this method in 4 patients with lower lip squamous cell carcinoma in whom tumor resection with preservation of the mouth angle was possible. The lower lip resection width was 30 to 45 mm, accounting for 50% to 68% of the entire width of the lower lip. The flap was prepared by lateral extension from above the mental unit and matched with the potential wrinkle line of the lower lip in order to design a unit morphology surrounded by the anterior margin of the depressor labii inferioris muscle. It was elevated as a full-thickness flap composed of the orbicularis oris muscle, skin, and mucosa of the residual lower lip from the bilateral sides, and advanced to the defect. Flap transfer was adjusted by small triangular resection of the skin on the lateral side of the mental unit. The postoperative scar was inconspicuous in all patients and there was no impairment of the mouth opening-closing or articulation functions. This was a relatively simple surgical procedure. A blood supply of the flap was stable, and continuity of the orbicularis oris muscle was reconstructed by transferred the residual lower lip advancement flap from the bilateral sides. The postoperative mouth opening-closing function was sufficient, and dentures could be placed from an early phase in elderly patients. The postoperative scar was consistent with the lip unit morphology, being esthetically superior. This procedure may be applicable for reconstruction of defects approximately 1/3 to 2/3 the width of the lower lip where the mouth angle is preserved.
Zarghooni, Kourosh; Beyer, Frank; Papadaki, Joanna; Boese, Christoph Kolja; Siewe, Jan; Schiffer, Gereon; Eysel, Peer; Bredow, Jan
Introduction Because of recent increases in life expectancy, lumbar spinal stenosis (LSS) has become one of the most common degenerative changes in the spine. In patients not responding to conservative therapy, microsurgical decompression is the gold standard of operative treatment for degenerative LSS. The goal of the current study is to evaluate quality of life after microsurgical decompression for LSS, using data from the DWG Register (previously Spine Tango). Methods 36 patients were included in this single-center, prospective, observational study from January 2013 to June 2014. Data were collected from the Spine Tango or DWG Register. The core outcome measure index (COMI), Oswestry Disability Index (ODI), and the quality of life questionnaire EuroQoL-5D were used. Data were collected prior to surgery as well as six weeks, six months, and twelve months after the operation. Results The patient cohort comprised 13 females and 23 males (36.1 and 63.9 %). Complete 12-month follow-up data on 21 patients were available for analysis. Compared to preoperative measures, the COMI score increased 8.1 ± 1.5 over the entire follow up, with 4.5 ± 3.1 at 6 weeks (p < 0.001), 4.8 ± 3.1 at 6 months, and 3.8 ± 3.2 at 12 months. ODI scores, measuring spinal function impairment, were significantly better than preoperative values overall (47.5 ± 17.3) and after 6 weeks (29.1 ± 22.4; p < 0.005), 6 months (30.0 ± 19.3), and 12 months (23.8 ± 18.2). Quality of life measures improved in a similar manner (preoperative: 0.36 ± 0.38; 6 weeks: 0.57 ± 0.34 (p < 0.019); 6 months: 0.62 ± 0.28; 12 months: 0.67 ± 0.31). Conclusion Our study shows that LSS patients without previous surgery and neurologic deficits can expect significant pain relief and improved quality of life already six weeks after undergoing stabilizing decompression. There was an increase in positive postoperative effects over 12 months. The DWG
Full Text Available Objective To explore the techniques and curative effect of microsurgical procedures assisted by minimal exposure tubular retractor system (METRx in the treatment of lumbar disc herniation (LDH. Methods A total of 51 LDH patients, including 24 patients with L4-5 herniation and 27 patients with L5-S1 herniation, underwent discectomy assisted by METRx system. The operation time, intraoperative blood loss, postoperative complications and hospital stay were recorded. Visual Analogue Scale (VAS and Oswestry Disability Index (ODI were used to evaluate the degree of low back pain before operation, one week, 3 months after operation, and in the last follow-up. Lumbar MRI was used to evaluate the decompression of spinal canal. Results The success rate of operations in 51 cases was 98.04% (50/51. The average operation time was 125 min, the average intraoperative blood loss was 50 ml, the mean hospital stay was 5 d, all patients were followed up for 6-48 months (average 24 months. Compared with preoperation, both VAS and ODI scores decreased significantly one week after operation (P = 0.036, 0.029, 3 months after operation (P = 0.018, 0.023 and in the last follow-up (P = 0.007, 0.013. The improvement rate of ODI was 35.37% in the last follow-up. No infection, postoperative cerebrospinal fluid (CSF fistula, neurological defects or incision infection was found. One patient presented acute abdominalgia on the 2nd day after operation, and was diagnosed as annexitis. One patient showed nerve root irritation symptoms after operation caused by thick nerve root during the surgery. They were cured after symptomatic treatment. Conclusions Microsurgical procedures for treating LDH assisted by METRx system can effectively relieve nerve root compression, protect the dural sac and nerve roots, and reduce surgical complications. DOI: 10.3969/j.issn.1672-6731.2016.04.008
C. Casado Sánchez
Full Text Available La reconstrucción mamaria mediante colgajo DIEP (Deep Inferior Epigastric Perforator se encuentra condicionada en muchas ocasiones por características de la paciente o del tratamiento oncológico recibido, de tal forma que diversos grupos de trabajo contraindican este método en caso de existir alguno de esos factores. Nosotros hemos realizado un estudio de los mismos, analizando su impacto sobre la viabilidad del colgajo y su correlación con las complicaciones postoperatorias, para optimizar así su indicación. Los condicionantes analizados son el tabaco, las intervenciones quirúrgicas previas que afecten en alguna medida la pared abdominal, el sobrepeso u obesidad de la paciente, el volumen de la mama contralateral, el tratamiento radioterápico anterior o posterior a la reconstrucción, y finalmente el gasto sanitario que supone. Estas controversias son a su vez las más discutidas en la literatura al respecto. Se valoran los resultados obtenidos tras 55 reconstrucciones mamarias mediante colgajo DIEP entre enero de 2000 y noviembre de 2005, así como los estudios y publicaciones más recientes existentes sobre esta materia. Hemos encontrado una pobre correlación entre los índices de fracaso del colgajo y las controversias estudiadas, determinando así dos contraindicaciones absolutas para que una paciente pudiese beneficiarse de un colgajo DIEP: abdominoplastia previa y radioterapia adyuvante tras reconstrucción inmediata. Los excelentes resultados que se obtienen globalmente, nos llevan a recomendar este colgajo por encima de otras opciones terapéuticas.The use of DIEP (Deep Inferior Epigastric Perforator flap surgery in breast reconstruction is often conditioned by the patient and the oncologic treatment characteristics to such an extent that several working groups advise against this surgical procedure when any of these factors is present. In the study of this interaction, an analysis of its impact on the flap feasibility and its
Motivated by the fluctuating plume model of turbulent mixing downstream of a point source, a flapping model is formulated for application to other configurations. For the scalar mixing layer, simple expressions for single-point scalar fluctuation statistics are obtained that agree with measurements. For a spatially homogeneous scalar mixing field, the family of probability density functions previously derived using mapping closure is reproduced. It is inferred that single-point scalar statistics may depend primarily on large-scale flapping motions in many cases of interest, and thus that multipoint statistics may be the principal indicators of finer-scale mixing effects
Pradeoth Mukundan Korambayil
Full Text Available Aim: The purpose of the study is to present a management protocol for various types of soft tissue defects of the distal third region of leg and foot treated with pedicle flaps, by including hyperbaric oxygen (HBO therapy in the treatment regimen with flap delay. Methods: We present a prospective study of 23 patients with various types of soft tissue defects of the foot, and lower third of leg managed in our institution from December 2012 to December 2013. All soft tissue defects were treated by a reverse pedicle flap. Twelve patients were managed with flap delay with HBO therapy and 11 patients with immediate flaps without HBO therapy. The postoperative period, hospital course, and follow-up were documented. Results: Of 12 patients with flap delay and HBO, 10 patients did not suffer any complications secondary to flap transfer. One patient had discoloration of the tip of the flap, which settled without the intervention, and 1 patient had recurrent abscess formation, which required debridement and closure. Of 11 patients with direct transfer, 6 patients presented with complications including flap congestion, partial flap loss, and tip necrosis, which required secondary intervention. Conclusion: HBO therapy is a useful adjunct in flap delay of the reverse pedicle flap for soft tissue reconstruction of the lower third of the leg and foot regions.
O.J.F. van Waes (Oscar); J.A. Halm (Jens); J. Vermeulen (Jefrey); S. Ashford (Sofie)
textabstractBackground: Sural artery perforator flaps have been described for use as both local flaps and in free tissue transfer. We present the use of this flap for compound soft tissue defects of the lower limb in civilian casualties of armed conflict in Afghanistan. Methods/results: Detailed
Hekner, D.D.; Roeling, TAP; van Cann, EM
The aim of this study was to investigate the vascular anatomy of the distal forearm in order to optimize the choice between the radial forearm free flap and the ulnar forearm free flap and to select the best site to harvest the flap. The radial and ulnar arteries of seven fresh cadavers were
Lin, Chin-Ta; Chen, Shih-Yi; Chen, Shyi-Gen; Tzeng, Yuan-Sheng; Chang, Shun-Cheng
Despite advances in reconstruction techniques, pressure sores continue to present a challenge to the plastic surgeon. The parasacral perforator flap is a reliable flap that preserves the entire contralateral side as a future donor site. On the ipsilateral side, the gluteal muscle itself is preserved and all flaps based on the inferior gluteal artery are still possible. We present our experience of using parasacral perforator flaps in reconstructing sacral defects. Between August 2004 and January 2013, 19 patients with sacral defects were included in this study. All the patients had undergone surgical reconstruction of sacral defects with a parasacral perforator flap. The patients' sex, age, cause of sacral defect, flap size, flap type, numbers of perforators used, rotation angle, postoperative complications, and hospital stay were recorded. There were 19 parasacral perforator flaps in this series. All flaps survived uneventfully except for 1 parasacral perforator flap, which failed because of methicillin-resistant Staphylococcus aureus infection. The overall flap survival rate was 95% (18/19). The mean follow-up period was 17.3 months (range, 2-24 months). The average length of hospital stay was 20.7 days (range, 9-48 days). No flap surgery-related mortality was found. Also, there was no recurrence of sacral pressure sores or infected pilonidal cysts during the follow-up period. Perforator-based flaps have become popular in modern reconstructive surgery because of low donor-site morbidity and good preservation of muscle. Parasacral perforator flaps are durable and reliable in reconstructing sacral defects. We recommend the parasacral perforator flap as a good choice for reconstructing sacral defects.
Huynh, T.; Thoft-Christensen, Palle
Active vibration control of long span suspension bridge flutter using separated control flaps (SFSC) has shown to increase effectively the critical wind speed of bridges. In this paper, an SFSC calculation based on modal equations of the vertical and torsional motions of the bridge girder including...... the flaps is presented. The length of the flaps attached to the girder, the flap configuration and the flap rotational angles are parameters used to increase the critical wind speed of the bridge. To illustrate the theory a numerical example is shown for a suspension bridge of 1000m+2500m+1000m span based...... on the Great Belt Bridge streamlined girder....
Wilson F. Busato Junior
Full Text Available OBJECTIVE: Microsurgical procedures are currently the gold standard for vasovasostomy with excellent results, but it takes an increased operative time demanding special training and experience in microsurgery. The objective of this study is to reach the same results with reduced operative time. MATERIALS AND METHODS: Male adults Wistar rats were divided into 3 groups: I 20 rats in control group, II 20 with conventional one-layer microsuture and III 20 with fibrin glue. After four weeks each rat was left for two weeks with two female rats. RESULTS: The fertility rates were 80% in group I, 70% in group II and 65% in group III (p > 0.05. In group II granuloma was found in 75% of the rats, while in group III in 85% (p 0.05. Overall operative time was 41.7 ± 2.49 and 28.55 ± 1.14 minutes in groups II and III (p < 0.05 and the time to anastomosis of 24.6 ± 1.8 and 9.35 ± 0.78 minutes (p < 0.05, respectively. CONCLUSIONS: We can conclude that vasovasostomy with fibrin adhesive has the same results of the conventional microsurgery technique but with a reduced operative time and a simplified procedure.
Deshpande, Nikhil; Chauhan, Manish; Pacchierotti, Claudio; Prattichizzo, Domenico; Caldwell, Darwin G; Mattos, Leonardo S
In this paper, a novel, motorized, multi-degrees-of-freedom (DoF), microsurgical forceps tool is presented, which is based on a master-slave teleoperation architecture. The slave device is a 7-DoF manipulator with: (i) 6-DoF positioning and orientation, (ii) 1 open/close gripper DoF; and (iii) an integrated force/torque sensor for tissue grip-force measurement. The master device is a 7-DoF haptic interface which teleoperates the slave device, and provides haptic feedback in its gripper interface. The combination of the device and the surgeon interface replaces the manual, hand-held device providing easy-to-use and ergonomic tissue control, simplifying the surgical tasks. This makes the system suitable to real surgical scenarios in the operating room (OR). The performance of the system was analysed through the evaluation of teleoperation control and characterization of gripping force. The new system offers an overall positioning error of less than 400 μm demonstrating its safety and accuracy. Improved system precision, usability, and ergonomics point to the potential suitability of the device for the OR and its ability to advance haptic-feedback-enhanced transoral laser microsurgeries.
Guo, Fuyou; Wang, Guoqing; Suresh, Vigneyshwar; Xu, Dingkang; Zhang, Xiaoyang; Feng, Mengzhao; Wang, Fang; Liu, Xianzhi; Song, Laijun
The optimal management of craniopharyngioma is still controversial. The aim of this study is to explore microsurgical outcomes of craniopharyngioma in 335 cases. Clinical data of 335 consecutive patients with craniopharyngioma between March 2011 and March 2017 were retrospectively analyzed. Gross total resection (GTR) was achieved in 265 cases (79.1%), subtotal resection (STR) was obtained in 70 cases (20.9%). The GTR rate was 81.93% in pediatric group and 78.17% in adult group respectively, no significant difference regarding the GTR rate was found in adult group compared with in pediatric group (p > 0.05). However, there was a noticeable difference in the elevated hypothalamic obesity in children group compared with in adult group after operation (p 0.05). Additionally, there were no statistically significant differences for recurrence-free curves between GTR and STR plus adjuvant radiotherapy (p > 0.05). Present findings demonstrated that tumor recurrence and surgical times contribute to negative total resection for craniopharyngioma. Postoperative precise adjuvant radiotherapy was considered in selected cases if pursuit of GTR was rather dangerous under disadvantageous removal factors. Copyright © 2018 Elsevier B.V. All rights reserved.
Bozkurt, Baran; Yagmurlu, Kaan; Middlebrooks, Erik H; Karadag, Ali; Ovalioglu, Talat Cem; Jagadeesan, Bharathi; Sandhu, Gauravjot; Tanriover, Necmettin; Grande, Andrew W
To evaluate the microsurgical anatomy of the fiber tract connections of the supplementary motor area (SMA) and pre-SMA, and examine its potential functional role with reference to clinical trials in the literature. Ten postmortem formalin-fixed human brains (20 sides) and 1 cadaveric head were prepared following Klingler's method. The fiber dissection was performed in a stepwise fashion, from lateral to medial and also from medial to lateral, under an operating microscope, with 3D images captured at each stage. Our findings were supported by in vivo magnetic resonance imaging tractography in 2 healthy subjects. The connections of the SMA complex, composed of the pre-SMA and the SMA proper, are composed of short "U" association fibers and the superior longitudinal fasciculus I, cingulum, claustrocortical fibers, callosal fibers, corticospinal tract, frontal aslant tract, and frontostriatal tract. The claustrocortical fibers may play an important role in the integration of motor, language, and limbic functions of the SMA complex. The frontostriatal tract connects the pre-SMA to the putamen and caudate nucleus, and also forms parts of both the internal capsule and the dorsal external capsule. The SMA complex has numerous connections throughout the cerebrum. An understanding of these connections is important for presurgical planning for lesions in the frontal lobe and helps explain symptoms related to SMA injury. Copyright © 2016 Elsevier Inc. All rights reserved.
Tayebi Meybodi, Ali; Aklinski, Joseph; Gandhi, Sirin; Lawton, Michael T; Preul, Mark C
Animal models are commonly used in training protocols for microsurgical vascular anastomosis. Rat common carotid arteries (CCAs) are frequently used for this purpose. Much attention has been paid to the technical details of various anastomosis configurations using these arteries. However, technical nuances of exposing rat CCAs have been understudied. The purpose of this study is to describe nuances of technique for safely and efficiently exposing rat CCAs in preparation for a vascular anastomosis. Bilateral CCAs were exposed and prepared for anastomosis in 10 anesthetized Sprague-Dawley rats through a midline cervical incision. The exposed length of the CCA was measured. Additionally, technical nuances of exposure and surgically relevant anatomic details were recorded. The CCAs were exposed from the sternoclavicular joint to their bifurcation (average length, 19.1 ± 2.8 mm). Tenets important for a safe and efficient exposure of the CCAs included 1) generous subcutaneous dissection to expose the external jugular veins (EJVs), 2) avoiding injury to or compression of the EJVs, 3) superior mobilization of the salivary glands, 4) division of internal jugular veins, 5) opening the carotid sheath at its midlevel and from medial to lateral, and 6) avoiding injury to the vagus nerve or sympathetic trunk. Using the principles introduced in this study, trainees may safely and efficiently expose rat CCAs in preparation for a bypass. Copyright © 2018 Elsevier Inc. All rights reserved.
Singh, Ramandeep; Suri, Ashish; Anand, Sneh; Baby, Britty
With advancements in imaging techniques, neurosurgical procedures are becoming highly precise and minimally invasive, thus demanding development of new ergonomically aesthetic instruments. Conventionally, neurosurgical instruments are manufactured using subtractive manufacturing methods. Such a process is complex, time-consuming, and impractical for prototype development and validation of new designs. Therefore, an alternative design process has been used utilizing blue light scanning, computer-aided designing, and additive manufacturing direct metal laser sintering (DMLS) for microsurgical instrument prototype development. Deviations of DMLS-fabricated instrument were studied by superimposing scan data of fabricated instrument with the computer-aided designing model. Content and concurrent validity of the fabricated prototypes was done by a group of 15 neurosurgeons by performing sciatic nerve anastomosis in small laboratory animals. Comparative scoring was obtained for the control and study instrument. T test was applied to the individual parameters and P values for force (P direct application of these additive-manufactured instruments in the operating room requires further validation. © The Author(s) 2016.
Hekner, Dominique D; Abbink, Jan H; van Es, Robert J; Rosenberg, Antoine; Koole, Ronald; Van Cann, Ellen M
Donor-site morbidity following harvest of the radial forearm free flap was compared with that following harvest of the ulnar forearm free flap. Twenty-eight radial forearm and 27 ulnar forearm flaps were harvested in 55 patients with head and neck defects. Pressure perception was measured with Semmes-Weinstein monofilaments. Cold perception was tested with chloroethyl. Donor-site healing was evaluated. Patients were interviewed about grip and pinch strength and donor-site appearance. In the radial forearm free flap group, pressure perception and cold perception were reduced in the donor hand, whereas in the ulnar group, no differences were observed between the donor and unoperated hands. In the radial forearm group, 15 percent of patients experienced reduced strength in the donor hand, whereas in the ulnar forearm group, none of the patients reported reduced strength in the donor hand. In the radial forearm group, 14 percent had partial or complete loss of the skin graft, whereas in the ulnar forearm group, 4 percent had partial loss of the skin graft. In the radial forearm group, 18 percent of patients were dissatisfied with the appearance of the donor site, and no complaints were reported in the ulnar forearm group. The authors' study shows less donor site-morbidity following harvest of the ulnar forearm free flap than following harvest of the radial forearm free flap. These results emphasize that the ulnar forearm free flap should be considered as an alternative for the radial forearm free flap for reconstruction of soft-tissue defects. Therapeutic, III.
Amir, A; Silfen, R; Hauben, D J
To the best of our knowledge, the recreation of an inframammary fold after TRAM flap breast reconstruction has not yet been described. This article offers a technique for the creation of an inframammary fold as a secondary procedure. The technique has been performed thus far in two patients with good aesthetic outcomes and no postoperative complications. It may also be suitable for adding bulk to the TRAM flap, especially in bilateral breast reconstruction, and for other minor chest deformities.
Full Text Available The reconstruction of extensive and complex wounds represents a challenging problem for reconstructive surgeon. The reconstructive options to provide cover-age following debridment of these complicated wounds are local, distant flaps, or freetissue transfer. Vertical rectus abdominis flaps have been used succes-sully to repair defects in the groin, hip, perineal, trunk, and breast regions. We encountered flap lymphedema after successful reconstruction of the chronic in-guinal wound with a vertical rectus abdominis (VRAM flap. As far as were able to ascertain, there is no report in the literature related to flap lymphedema.
Yong Jig Lee
Full Text Available This report describes the use of a tubularized random flap for the curative treatment of recurrent anterior urethral stricture. Under the condition of pendulous lithotomy and suprapubic cystostomy, the urethral stricture was removed via a midline ventral penile incision followed by elevation of the flap and insertion of an 18-Fr catheter. Subcutaneous buried interrupted sutures were used to reapproximate the waterproof tubularized neourethra and to coapt with the neourethra and each stump of the urethra, first proximally and then distally. The defect of the penile shaft was covered by advancement of the surrounding scrotal flap. The indwelling catheter was maintained for 21 days. A 9 month postoperative cystoscopy showed no flap necrosis, no mechanical stricture, and no hair growth on the lumen of the neourethra. The patient showed no voiding discomfort 6 months after the operation. The advantages of this procedure are the lack of need for microsurgery, shortening of admission, the use of only spinal anesthesia (no general anesthesia, and a relatively short operative time. The tubularized unilateral penile fasciocutaneous flap should be considered an option for initial flap urethroplasty as a curative technique.
Goedhart, Menno; van Kampen, E.; Armanini, S.F.; de Visser, C.C.; Chu, Q.
Flight control of Flapping Wing Micro Air Vehicles is challenging, because of their complex dynamics and variability due to manufacturing inconsistencies. Machine Learning algorithms can be used to tackle these challenges. A Policy Gradient algorithm is used to tune the gains of a
Mahieu, R.; Russo, S.; Gualtieri, T.; Colletti, G.; Deganello, A.
The purpose of this report is to highlight how an unusual, outdated, unpopular and overlooked reconstructive method such as the masseter flap can be a reliable, straightforward and effective solution for oral reconstruction in selected cases. We report the transposition of the masseter crossover
The omental flap should be prophylactically used in post-pneumonectomy bronchial stump reinforcement where the underlying chronic inflammatory condition poses high risk for bronchial dehiscence. We present a unique case of pulmonary tuberculosis (TB) complicated by empyema, chronic pulmonary aspergillosis and ...
Harris, G D; Nagle, D J; Lewis, V L; Bauer, B S
Free flap versatility and dependability make the final result of microvascular reconstruction highly predictable. Free tissue transplantation should be considered as a primary treatment after trauma. The early use of free tissue transfer will result in fewer operations and a shortened duration of hospitalization in the initial post-trauma period.
Germann, G; Waag, K-L; Selle, B; Jester, A
A case of complex microsurgical reconstruction of the dorsum of the foot, including tendon transfer following tumor resection, in a 15-week-old male infant is presented. After birth, a 5.5 x 4 cm large tumor was observed on the dorsum of the right foot. Biopsy showed a congenital malignant fibro sarcoma. After initial chemotherapy a radical excision of the tumor at the age of 14 weeks was followed. To cover the defect a musculocutaneous latissimus dorsi flap was taken, the cutaneous part being large enough to cover the defect. Extensor tendons were reconstructed with free tendon transplants. Amputation is usually indicated in these cases. To the best of our knowledge, microsurgical reconstruction in infants at this age with congenital malignant tumors has not yet been reported. The case shows that Plastic surgery can play an important role in pediatric oncology and should routinely be integrated into the multi-modal treatment concepts. (c) 2006 Wiley-Liss, Inc. Microsurgery, 2006.
C. Márquez Zevallos
Full Text Available Los traumatismos de miembros inferior representan un reto importante para el cirujano plástico en cuanto a su reconstrucción cuando no se dispone de técnicas microquirúrgicas. En el presente trabajo se presentan 2 casos de reconstrucción de rodilla con doble colgajo muscular de gemelo, en los que se demuestra que se pueden utilizar simultáneamente los dos gemelos sin dejar ninguna secuela estética importante ni funcional en la deambulación de los pacientes. Hasta donde podemos conocer, no existe en la literatura nacional ni internacional un reporte de casos con esta aplicación, ya que siempre se ha empelado un solo músculo precisamente por el temor a alterar la función de flexo-extensión del pie.Lower limb traumatism has always been a problem for plastic surgeon when in the moment of the surgical reconstruction we have not microsurgical techniques. In this paper, we present 2 cases of knee reconstruction using a double gemelar muscular flap, showing how is possible the simultaneous use of the two muscles without aesthetic or functional sequels. As we know, there is no national or international report of cases with this muscular reconstruction; it has been usual to use only one muscle, in order to avoid problems in the flexo-extension movements of the foot.
Gravvanis, Andreas; Smith, Roger W
The esthetic outcome is dictated essentially not only by the position, size, and shape of the reconstructed breast, but also by the extra scaring involved. In the present study, we conducted a visual analog scale survey to compare the esthetic outcome in delayed autologous breast reconstruction following two different abdominal flaps inset. Twenty-five patients had their reconstruction using the Single-esthetic Unit principle and were compared with 25 patients that their breast was reconstructed using the Two-Esthetic Unit principle. Photographic images were formulated to a PowerPoint presentation and cosmetic outcomes were assessed from 30 physicians, by means of a Questionnaire and a visual analog scale. Our data showed that the single-esthetic unit breast reconstruction presents significant advantages over the traditional two-esthetic units, due to inconspicuous flap reconstruction, better position of the inframammary fold, and more natural transition from native and reconstructed tissues. Moreover, patient self-evaluation of esthetic outcome and quality of life showed that single-esthetic unit reconstruction is associated with higher patient satisfaction, therefore should be considered the method of choice. © 2010 Wiley-Liss, Inc.
Jakubietz, Rafael G; Jakubietz, Danni F; Zahn, Robert; Schmidt, Karsten; Meffert, Rainer H; Jakubietz, Michael G
Perforator flaps have been successfully used for reconstruction of pressure sores. Although V-Y advancement flaps approximate debrided wound edges, perforator-based propeller flaps allow rotation of healthy tissue into the defect. Perforator-based propeller flaps were planned in 13 patients. Seven pressure sores were over the sacrum, five over the ischial tuberosity, and one on the tip of the scapula. Three patients were paraplegic, six were bedridden, and five were ambulatory. In three patients, no perforators were found. In 10 patients, propeller flaps were transferred. In two patients, total flap necrosis occurred, which was reconstructed with local advancement flaps. In two cases, a wound dehiscence occurred and had to be revised. One hematoma required evacuation. No further complications were noted. No recurrence at the flap site occurred. Local perforator flaps allow closure of pressure sores without harvesting muscle. The propeller version has the added benefit of transferring tissue from a distant site, avoiding reapproximation of original wound edges. Twisting of the pedicle may cause torsion and venous obstruction. This can be avoided by dissecting a pedicle of at least 3 cm. Propeller flaps are a safe option for soft tissue reconstruction of pressure sores. © Thieme Medical Publishers.
Han Gyeol Song
Full Text Available Background Robots have allowed head and neck surgeons to extirpate oropharyngealtumors safely without the need for lip-split incision or mandibulotomy. Using robots inoropharyngealreconstruction is newbut essentialfor oropharyngeal defectsthatresultfromrobotic tumor excision. We report our experience with robotic free-flap reconstruction ofhead and neck defectsto exemplify the necessity forrobotic reconstruction.Methods We investigated head and neck cancer patients who underwent ablation surgeryand free-flap reconstruction by robot. Between July 1, 2011 andMarch 31, 2012, 5 caseswereperformed and patient demographics, location of tumor, pathologic stage, reconstructionmethods, flap size, recipient vessel, necessary pedicle length, and operation time wereinvestigated.Results Among five free-flap reconstructions, four were radial forearm free flaps and onewas an anterolateral thigh free-flap. Four flaps used the superior thyroid artery and oneflap used a facial artery as the recipient vessel. The average pedicle length was 8.8 cm. Flapinsetting and microanastomosis were achieved using a specially manufactured roboticinstrument. The total operation timewas 1,041.0 minutes(range, 814 to 1,132 minutes, andcomplicationsincluding flap necrosis, hematoma, andwound dehiscence did not occur.Conclusions Thisstudy demonstratesthe clinically applicable use ofrobotsin oropharyngealreconstruction, especially using a free flap. A robot can assist the operator in insettingthe flap at a deep portion of the oropharynx without the need to perform a traditionalmandibulotomy. Robot-assisted reconstruction may substitute for existing surgical methodsand is accepted asthemost up-to-datemethod.
Smith, Mark L; Molina, Bianca J; Dayan, Erez; Jablonka, Eric M; Okwali, Michelle; Kim, Julie N; Dayan, Joseph H
Free flaps have a well-established role in breast reconstruction after mastectomy; however, their role in partial breast reconstruction remains poorly defined. We reviewed our experience with partial breast reconstruction to better understand indications for free tissue transfer. A retrospective review was performed of all patients undergoing partial breast reconstruction at our center between February 2009 and October 2015. We evaluated the characteristics of patients who underwent volume displacement procedures versus volume replacement procedures and free versus pedicled flap reconstruction. There were 78 partial breast reconstructions, with 52 reductions/tissue rearrangements (displacement group) and 26 flaps (replacement group). Bra cup size and body mass index (BMI) were significantly smaller in the replacement group. Fifteen pedicled and 11 free flaps were performed. Most pedicled flaps (80.0%) were used for lateral or upper pole defects. Most free flaps (72.7%) were used for medial and inferior defects or when there was inadequate donor tissue for a pedicled flap. Complications included hematoma, cellulitis, and one aborted pedicled flap. Free and pedicled flaps are useful for partial breast reconstruction, particularly in breast cancer patients with small breasts undergoing breast-conserving treatment (BCT). Flap selection depends on defect size, location, and donor tissue availability. Medial defects are difficult to reconstruct using pedicled flaps due to arc of rotation and intervening breast tissue. Free tissue transfer can overcome these obstacles. Confirming negative margins before flap reconstruction ensures harvest of adequate volume and avoids later re-operation. Judicious use of free flaps for oncoplastic reconstruction expands the possibility for breast conservation. Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.
Min Jo Kang
Full Text Available Background The aim of lower-extremity reconstruction has focused on wound coverage andfunctional recovery. However, there are limitations in the use of a local flap in cases of extensivedefects of the lower-extremities. Therefore, free flap is a useful option in lower-extremityreconstruction.Methods We performed a retrospective review of 49 patients (52 cases who underwentlower-extremity reconstruction at our institution during a 10-year period. In these patients,we evaluated causes and sites of defects, types of flaps, recipient vessels, types of anastomosis,survival rate, and complications.Results There were 42 men and 10 women with a mean age of 32.7 years (range, 3-72years. The sites of defects included the dorsum of the foot (19, pretibial area (17, ankle(7, heel (5 and other sites (4. The types of free flap included latissimus dorsi muscle flap(10, scapular fascial flap (6, anterolateral thigh flap (6, and other flaps (30. There werefour cases of vascular complications, out of which two flaps survived after intervention. Theoverall survival of the flaps was 96.2% (50/52. There were 19 cases of other complications atrecipient sites such as partial graft loss (8, partial flap necrosis (6 and infection (5. However,these complications were not notable and were resolved with skin grafts.Conclusions The free flap is an effective method of lower-extremity reconstruction. Goodoutcomes can be achieved with complete debridement and the selection of appropriaterecipient vessels and flaps according to the recipient site.
Min Jo Kang
Full Text Available BackgroundThe aim of lower-extremity reconstruction has focused on wound coverage and functional recovery. However, there are limitations in the use of a local flap in cases of extensive defects of the lower-extremities. Therefore, free flap is a useful option in lower-extremity reconstruction.MethodsWe performed a retrospective review of 49 patients (52 cases who underwent lower-extremity reconstruction at our institution during a 10-year period. In these patients, we evaluated causes and sites of defects, types of flaps, recipient vessels, types of anastomosis, survival rate, and complications.ResultsThere were 42 men and 10 women with a mean age of 32.7 years (range, 3-72 years. The sites of defects included the dorsum of the foot (19, pretibial area (17, ankle (7, heel (5 and other sites (4. The types of free flap included latissimus dorsi muscle flap (10, scapular fascial flap (6, anterolateral thigh flap (6, and other flaps (30. There were four cases of vascular complications, out of which two flaps survived after intervention. The overall survival of the flaps was 96.2% (50/52. There were 19 cases of other complications at recipient sites such as partial graft loss (8, partial flap necrosis (6 and infection (5. However, these complications were not notable and were resolved with skin grafts.ConclusionsThe free flap is an effective method of lower-extremity reconstruction. Good outcomes can be achieved with complete debridement and the selection of appropriate recipient vessels and flaps according to the recipient site.
Ng, Ivan; Hwang, Peter Y K; Kumar, Dinesh; Lee, Cheng Kiang; Kockro, Ralf A; Sitoh, Y Y
To evaluate the feasibility of surgical planning using a virtual reality platform workstation in the treatment of cerebral arterio-venous malformations (AVMs) Patient-specific data of multiple imaging modalities were co-registered, fused and displayed as a 3D stereoscopic object on the Dextroscope, a virtual reality surgical planning platform. This system allows for manipulation of 3D data and for the user to evaluate and appreciate the angio-architecture of the nidus with regards to position and spatial relationships of critical feeders and draining veins. We evaluated the ability of the Dextroscope to influence surgical planning by providing a better understanding of the angio-architecture as well as its impact on the surgeon's pre- and intra-operative confidence and ability to tackle these lesions. Twenty four patients were studied. The mean age was 29.65 years. Following pre-surgical planning on the Dextroscope, 23 patients underwent microsurgical resection after pre-surgical virtual reality planning, during which all had documented complete resection of the AVM. Planning on the virtual reality platform allowed for identification of critical feeders and draining vessels in all patients. The appreciation of the complex patient specific angio-architecture to establish a surgical plan was found to be invaluable in the conduct of the procedure and was found to enhance the surgeon's confidence significantly. Surgical planning of resection of an AVM with a virtual reality system allowed detailed and comprehensive analysis of 3D multi-modality imaging data and, in our experience, proved very helpful in establishing a good surgical strategy, enhancing intra-operative spatial orientation and increasing surgeon's confidence.
Full Text Available People around the world suffer chronic lower back pain. Because spine imaging often does not explain the degree of perceived pain reported by patients, the role of the processing of nociceptor signals in the brain as the basis of pain perception is gaining increased attention. Modern neuroimaging techniques (including functional and morphometric methods have produced results that suggest which brain areas may play a crucial role in the perception of acute and chronic pain. In this study, we examined twelve patients with chronic low back pain and sciatica, both resulting from lumbar disc herniation. Structural magnetic resonance imaging (MRI of the brain was performed one day prior to and about four weeks after microsurgical lumbar discectomy. The subsequent MRI revealed an increase in gray matter volume in the basal ganglia but a decrease in volume in the hippocampus, which suggests the complexity of the network that involves movement, pain processing, and aspects of memory. Interestingly, volume changes in the hippocampus were significantly correlated to preoperative pain intensity but not to the duration of chronic pain. Mapping structural changes of the brain that result from lumbar disc herniation has the potential to enhance our understanding of the neuropathology of chronic low back pain and sciatica and therefore may help to optimize the decisions we make about conservative and surgical treatments in the future. The possibility of illuminating more of the details of central pain processing in lumbar disc herniation, as well as the accompanying personal and economic impact of pain relief worldwide, calls for future large-scale clinical studies.
Aboukaïs, Rabih; Bonne, Nicolas-Xavier; Touzet, Gustavo; Vincent, Christophe; Reyns, Nicolas; Lejeune, Jean-Paul
We aimed to evaluate the outcome of patients who underwent salvage microsurgery for vestibular schwannoma (VS) that failed primary Gammaknife radiosurgery (GKS). Among the 1098 patients who received GKS for the treatment of VS in our center between January 2004 and December 2012, the follow-up was organized in our institution for 290 patients who lived in our recruitment area. Tumor progression was noted in 23 patients. A salvage microsurgical resection was performed in 11 patients, who were included in our study. Grading of facial function was done according to the House & Brackman scale. The mean age at diagnosis was 50.2 years (19-68 years) and the mean follow-up was 9.4 years (4-13 years). The mean dose was 11.8 Gy (11-12 Gy) and the mean volume was 922 mm3 (208-2500 mm3). The mean period between GKS and diagnosis of tumor progression was 32 months (18-72 months). Concerning salvage microsurgery, complete resection was obtained in 8 patients. Small residual tumor on the facial nerve was deliberately left in 3 patients and no tumor progression was noted with a mean follow-up of 26 months. At last follow-up, facial nerve function was grade 1 in 4 patients, grade 2 in 3 patients, grade 3 in 1 patient and grade 4 in 3 patients. Salvage surgery of recurrent vestibular schwannoma after failed initial GKS remains a good treatment. However, facial nerve preservation is more challenging in this case and small tumor remnant could be sometimes deliberately left. Copyright © 2018 Elsevier B.V. All rights reserved.
Lim, Jae H; Boyle, Glen M; Panizza, Benedict
To determine the feasibility of using a mouse tumor model as a microsurgical training tool for otolaryngology-head and neck surgery (OHNS) trainees. Animal study. We injected athymic nude mice with human cutaneous squamous cell carcinoma (A431 cell line) deep to the parotid region overlying the masseter muscle. We sacrificed the animals 1 to 3 weeks postinjection, once a visible tumor growth was confirmed. We then asked 10 OHNS trainees to excise the tumor with preservation of the facial nerves under a high-magnification dissecting microscope. The trainees graded the tasks in several areas of specific measures using a visual analogue scale (VAS) including 1) tumor texture, 2) surgical realism, 3) usefulness, and 4) difficulty of the task. Noticeable tumor growth occurred within 5 days following A431 cell injection and reached measureable size (0.5-1.5 cm) within 1 to 3 weeks. The tumor displaced the facial nerve laterally and medially, with few demonstrating infiltration of the nerve. VAS scores (± standard deviation) were 8.1 (± 1.7), 7.7 (± 2.5), 9.0 (± 0.9) and 6.6 (± 1.9) for tumor texture, surgical realism, usefulness, and the difficulty of the task, respectively. We demonstrate a novel, reliable and cost-effective mouse model for simulating tumor extirpation microsurgery with preservation of important neural structures. OHNS trainees have found this simulation model to be realistic, useful, and appropriately challenging. © 2015 The American Laryngological, Rhinological and Otological Society, Inc.
Full Text Available Introduction: A microsurgical anterior cervical approach with discectomy and fusion (MACDF is one of the most widely used procedures for treating radicular disorders. This approach is highly successful; however, it is not free from complications. These can be associated with soft tissue injuries. Aim of the Study: The recognition of the risks for these complications should be identified for timely prevention and safe treatment. Materials and Methods: Study Design: Retrospective case control study. This study includes a retrospective case series of 37 patients, paying special attention to immediate complications related to the use of mechanical retraction of soft tissue (dysphagia, dysphonia, esophageal lesions and local hematoma; and a comparative analysis of the outcomes after changes in the retraction method. Results: All selected cases had a positive neurological symptom response in relation to neuropathic pain. Dysphagia and dysphonia were found during the first 72 h in 94.1% of the cases in which automatic mechanical retraction was used for more than one hour during the surgical procedure. A radical change was noted in the reduction of the symptoms after the use of only manual protective blades without automatic mechanical retraction: 5.1% dysphagia and 0% dysphonia in the immediate post-operative period, P = 0.001. Conclusions: Soft tissue damage due to the use of automatic retractors in MACDF is not minor and leads to general discomfort in the patient in spite of good neurological results. These problems most often occur when automatic retractors are used continuously for more than 1 hour, as well as when they are used in multiple levels. Dysphagia, dysphonia and local pain decreased with the use of transient manual blades for retraction, and with intermittent release following minimally invasive principles.
Full Text Available Objective The dorsal root entry zone (DREZ is a hyperactive focus in neuropathic pain (NP syndromes, and DREZotomy has been used in selective cases of NP. This study aims to investigate the therapeutic effect of microsurgical DREZotomy in chronic pain due to spinal cord and cauda equina injuries. Methods Two patients suffered with chronic pain due to spinal cord and cauda equina injuries were treated with microsurgical DREZotomy, and postoperative therapeutic effect and complications were observed. Results One patient had great pain, and the pain was alleviated 2 weeks after surgery, while carbamazepine (300 mg/d was administered continously. Another patient was completely free of pain 2 weeks after surgery, and no recurrence occurred during 3-year follow up. No severe complications were found in the 2 patients. Conclusion Microsurgical DREZotomy is an effective approach in treating chronic pain due to spinal cord and cauda equina injuries.
Edwin Jonathan Aslim
Full Text Available BackgroundGroin dissections result in large wounds with exposed femoral vessels requiring soft tissue coverage, and the reconstructive options are diverse. In this study we reviewed our experience with the use of the pedicled anterolateral thigh and vertical rectus abdominis musculocutaneous flaps in the reconstruction of large groin wounds.MethodsGroin reconstructions performed over a period of 10 years were evaluated, with a mean follow up of two years. We included all cases with large or complex (involving perineum defects, which were reconstructed with the pedicled anterolateral thigh musculocutaneous or the vertical rectus abdominis musculocutaneous (VRAM flaps. Smaller wounds which were covered with skin grafts, locally based flaps and pedicled muscle flaps were excluded.ResultsTwenty-three reconstructions were performed for large or complex groin defects, utilising the anterolateral thigh (n=10 and the vertical rectus abdominis (n=13 pedicled musculocutaneous flaps. Femoral vein reconstruction with a prosthetic graft was required in one patient, and a combination flap (VRAM and gracilis muscle flap was performed in another. Satisfactory coverage was achieved in all cases without major complications. No free flaps were used in our series.ConclusionsThe anterolateral thigh and vertical rectus abdominis pedicled musculocutaneous flaps yielded consistent results with little morbidity in the reconstruction of large and complex groin defects. A combination of flaps can be used in cases requiring extensive cover.
Weigert, M; Mellerowicz, H; Werhahn, C
Isolated division of the tibial nerve in the thigh preserving the peroneal and sural nerves does not cause loss of normal position of the animal, in particular of sitting. Nor does it lead to pressure sores. The animals are fitter then after division of the sciatic nerve. Microsurgical suture of the isolated tibial nerve in the thigh of the rabbit with 1 or 2 simple sutures with 10 x 0 thread show that an average recovery can be achieved in over 80 per cent. As few sutures as possible should be used. Otherwise there with be scarring and no return of function.
Galkin, R A; Makarov, I V
Advantages of the formation of gastroduodenal anastomosis using the microsurgical precision technique as compared to the two-row interrupted Albert-Lembert suture and the one-row suture of Pirogov-Mateshuk were established in an experimental investigation in 63 dogs. The article describes the precision suture technique proposed by the authors which was used in Billroth-I resection of the stomach in 15 patients. It was shown that the use of the precision suture resulted in healing by the first intention type, without motor evacuatory disorders and with shorter time of hospital treatment.
Vadivukkarasan, M.; Kumaran, Dhivyaraja; Panchagnula, Mahesh; Multi-phase flow physics Group Team
We attempt to delineate and describe the complete evolution of a thin soap film when air is blown through a nozzle in the normal direction. The sequence of events and its intrinsic dynamics are captured using high speed imaging. By careful observation, it was observed that multiple mechanisms occur in the same system and each event is triggered by an independent mechanism. The events include (a) flapping of a liquid sheet and pinching of the bubble, (b) onset of rupture on the liquid sheet, (c) formation of ligaments and (d) ejection of drops. From this study, it is shown that these events are predominantly governed by Kelvin-Helmholtz instability, Taylor - Culick law, Rayleigh-Taylor instability and capillary instability, respectively. The present experiments can be considered as an extension to the previous studies on soap films as well as thin flapping sheets which has direct relevance to coaxial atomizers used in aircraft applications.
Vaienti, Luca; Urzola, Victor; Scotti, Andrea; Masetto, L
With the understanding of the extensive vascular supply of the subcutaneous tissue, of its efficacy in the protection of the anatomical structures and of its capability of promoting the adequate functioning of very stressed regions of the human body, the use of subcutaneous adipose flaps has become a valid and sometimes the only reasonable therapeutic weapon in the treatment of small and medium-sized tissue loss. Such a defect represents a common complication of great toe injuries and surgery. Here subcutaneous flap reconstruction is proposed for the treatment of dorsal and medial soft tissue losses of the hallux complicated with infection. Two case are reported. To the best of the authors' knowledge, this application has not been reported in this anatomical site so far. The technique might be worth knowing both for orthopedic and plastic surgeons, as it may represent a safe, less invasive solution for most tegumentary problems of the dorso-medial side of the first ray.
Gi Yeun Hur
Full Text Available BackgroundDeep burns of the elbow lead to soft tissue necrosis and infection, with exposure of deep structures. Adequate wound coverage of this area requires thin, pliable, and durable tissue, while optimal functional recovery requires early coverage and functional rehabilitation. We have found 3 types of island flaps that provide reliable coverage for the elbow.MethodsA retrospective study was performed on all patients who underwent flap coverage of an elbow defect at our hospital. The patients' data including age, sex, cause of injury, wound dimensions, timing of flap coverage, postoperative elbow motion, and complications were investigated.ResultsBetween 2001 and 2012, 16 patients were treated at our hospital. The mean age was 53.3 years. Three kinds of flaps were performed: 9 latissimus dorsi flaps, 4 lateral arm flaps, and 4 radial forearm flaps. The average defect size was 183.5 cm2 (range, 28 to 670 cm2. Wound coverage was performed at mean duration of 45.9 days (range, 14 to 91 days. The mean postoperative active elbow flexion was 98° (range, 85° to 115°. Partial flap failure occurred in 1 latissimus dorsi flap. Minor complications included partial flap loss (11.8%, hematoma (23.5%, seroma (35.3%, and wound infection (5.9%.ConclusionsFlap selection for elbow reconstruction is determined by the defect size and the extent of the adjacent tissue injury. Elbow reconstruction using an island flap is a single-staged, reliable, and relatively simple procedure that permits initiation of early rehabilitation, thereby improving a patient's functional outcome.
Tsai, Tsung-Han; Peng, Kai-Ling; Lin, Chien-Jen
Laser in situ keratomileusis (LASIK) is the most common and popular procedure performed for the correction of refractive errors in the last two decades. We report a case of traumatic flap displacement with flap folding which occurred 3 years after LASIK was performed. Previous literature suggests that vision prognosis would be closely related to proper and prompt management of traumatic flap displacement with flap folding 3 years after LASIK. A 23-year-old female presented to our hospital who had undergone uneventful LASIK in both eyes 3 years prior. Unfortunately, she had suffered a blunt trauma in her right eye in a car accident. A late onset of corneal flap displacement was found with upper and lower portion of the flap being folded inside the corneal bed. Surgical intervention for debridement with subsequent reposition of corneal flap was performed as soon as possible in the operating room. A bandage contact lens was placed, and topical antibiotic and corticosteroids were given postoperatively. Two days after the operation, the displaced corneal flap was found to be well attached smoothly on the corneal bed without folds. The best-corrected visual acuity was 6/6 with refraction of -0.75 D to 1.0 D ×175° in her right eye 1 month later. We reviewed a total of 19 published cases of late-onset traumatic flap dislocations or displacements after LASIK with complete data from 2000 to 2014. Traumatic displacement of corneal flaps after LASIK may occur after blunt injury with specific direction of force to the flap margin, especially tangential one. According to the previous literature, late-onset traumatic flap displacement may happen at any time after LASIK and be caused by various types of injuries. Fortunately, good visual function could mostly be restored with immediate and proper management.
Han Gyeol Song
Full Text Available BackgroundRobots have allowed head and neck surgeons to extirpate oropharyngeal tumors safely without the need for lip-split incision or mandibulotomy. Using robots in oropharyngeal reconstruction is new but essential for oropharyngeal defects that result from robotic tumor excision. We report our experience with robotic free-flap reconstruction of head and neck defects to exemplify the necessity for robotic reconstruction.MethodsWe investigated head and neck cancer patients who underwent ablation surgery and free-flap reconstruction by robot. Between July 1, 2011 and March 31, 2012, 5 cases were performed and patient demographics, location of tumor, pathologic stage, reconstruction methods, flap size, recipient vessel, necessary pedicle length, and operation time were investigated.ResultsAmong five free-flap reconstructions, four were radial forearm free flaps and one was an anterolateral thigh free-flap. Four flaps used the superior thyroid artery and one flap used a facial artery as the recipient vessel. The average pedicle length was 8.8 cm. Flap insetting and microanastomosis were achieved using a specially manufactured robotic instrument. The total operation time was 1,041.0 minutes (range, 814 to 1,132 minutes, and complications including flap necrosis, hematoma, and wound dehiscence did not occur.ConclusionsThis study demonstrates the clinically applicable use of robots in oropharyngeal reconstruction, especially using a free flap. A robot can assist the operator in insetting the flap at a deep portion of the oropharynx without the need to perform a traditional mandibulotomy. Robot-assisted reconstruction may substitute for existing surgical methods and is accepted as the most up-to-date method.
Tayfur, Volkan; Magden, Orhan; Edizer, Mete; Atabey, Atay
A vastus lateralis muscle flap is used as a pedicled and free flap. In this study, the vastus lateralis muscles of 15 adult formalin-fixed cadavers (30 cases) were dissected. The dominant pedicle was found to be descending branch of the lateral circumflex femoral artery. The mean diameter of the artery was found to be 2.1 mm. This pedicle was located 119.4 mm distal to the pubic symphysis. The mean length of the major pedicle was found to be 56.8 mm when the dominant pedicle was chosen to nourish the flap. The dominant pedicle entered the muscle 155.8 and 213.7 mm from the greater trochanter and the anterior superior iliac spine, respectively. The muscle had proximal minor pedicles from the ascending and transverse branches of lateral circumflex femoral artery. These arteries had mean diameters of 1.8 and 2.0 mm, respectively. The distal minor branches were present in all of the dissections. The distal branch had a mean diameter of 1.8 mm. The origin of this distal branch was located 83.7 mm proximal to the intercondylar line. The motor nerve of the vastus lateralis was found to be originating from femoral nerve. The nerve entered the muscle 194.6 mm from the anterior superior iliac spine.
Berry, John D.; May, Matthew J.
Aerodynamics of helicopter rotor systems cannot be investigated without consideration for the dynamics of the rotor. One of the principal properties of the rotor which affects the rotor dynamics is the inertia of the rotor blade about its root attachment. Previous aerodynamic investigation have been performed on rotor blades with a variety of planforms to determine the performance differences due to blade planform. The blades tested for this investigation have been tested on the U.S. Army 2 meter rotor test system (2MRTS) in the NASA Langley 14 by 22 foot subsonic tunnel for hover performance. This investigation was intended to provide fundamental information on the flapping inertia of five rotor blades with differing planforms. The inertia of the bare cuff and the cuff with a blade extension were also measured for comparison with the inertia of the blades. Inertia was determined using a swing testing technique, using the period of oscillation to determine the effective flapping inertia. The effect of damping in the swing test was measured and described. A comparison of the flapping inertials for rectangular and tapered planform blades of approximately the same mass showed the tapered blades to have a lower inertia, as expected.
Full Text Available A new axial pattern flap based on the terminal branches of the medial circumflex femoral artery is described for coverage of ischial pressure sore. Based on the terminal branches of the transverse branch of medial circumflex femoral artery, which exit through the gap between the quadratus femoris muscle above and the upper border of adductor magnus muscle below, this fascio cutaneous flap is much smaller than the posterior thigh flap but extremely useful to cover ischeal pressure sores. The skin redundancy below the gluteal fold allows a primary closure of the donor defect. It can also be used in combination with biceps femoris muscle flap.
Takahashi, Hiroyuki; Okano, Shinji; Iwasaki, Yasumasa; Mori, Tamotsu; Miyamoto, Yoshihiro; Shigeki, Sadayuki
Problems in the surgical treatment of radionecrotic ulcers, using a myocutaneous flap, have been reviewed in 21 patients. These problems included poor wound healing, radiation damage to important nerves and vessels there by making dissection difficult, malignant changes, infections, continuing necrosis of the tissue, and bleeding during surgery and secondary hemorrhaging. The use of a myocutaneous flap has many advantages when compared with conventional flaps and free skin grafts in the reconstruction of radionecrotic ulcers. Flap survival was good, but an incomplete excision of the ulcer delayed primary wound healing. Therefore, complete excision of the radionecrotic ulcer is imperative. (author)
Cavalcanti, Jacqueline V J; Barry, Sabrina L; Lanz, Otto I; Barnes, Katherine; Coutin, Julia V
The purpose of this retrospective study was to report the outcomes of 19 dogs and 1 cat undergoing reverse saphenous conduit flap between 1999 and 2016. Reverse saphenous conduit flap was used to treat traumatic wounds and wounds resulting from tumor excision in the hind limb; the majority of cases had medial shearing injuries. All animals had complete flap survival. In five animals (20%), minor donor site dehiscence occurred, which did not require surgery. Other postoperative complications included signs of severe venous congestion in one dog. Reverse saphenous conduit flap is a useful technique to repair skin defects of the distal hind limb.
Ko, Seung-Hee; Bae, Jae-Sung; Rho, Jin-Ho
The discontinuous contour of a wing with conventional flaps diminishes the aerodynamic performance of an aircraft. A wing with a continuous contour does not experience extreme flow stream fluctuations during flight, and consequently has good aerodynamic characteristics. In this study, a morphing flap using shape memory alloy actuators is proposed, designed and fabricated, and its aerodynamic characteristics are investigated using aerodynamic analyses and wind tunnel tests. The ribs of the morphing flap are designed and fabricated with multiple elements joined together in a way that allows relative rotations of adjacent elements and forms a smooth contour of the morphing flap. The aerodynamic analyses of this multiple-element morphing-flap wing are performed using XFLR pro; its aerodynamic performance is compared with that of a mechanical-flap wing, and is measured through wind-tunnel tests. (papers)
Lau, Tsz; Kaneko, Yuji; van Loveren, Harry; Borlongan, Cesario V.
Moderate to severe traumatic brain injury (TBI) often results in malformations to the skull. Aesthetic surgical maneuvers may offer normalized skull structure, but inconsistent surgical closure of the skull area accompanies TBI. We examined whether wound closure by replacement of skull flap and bone wax would allow aesthetic reconstruction of the TBI-induced skull damage without causing any detrimental effects to the cortical tissue. Adult male Sprague-Dawley rats were subjected to TBI using the controlled cortical impact (CCI) injury model. Immediately after the TBI surgery, animals were randomly assigned to skull flap replacement with or without bone wax or no bone reconstruction, then were euthanized at five days post-TBI for pathological analyses. The skull reconstruction provided normalized gross bone architecture, but 2,3,5-triphenyltetrazolium chloride and hematoxylin and eosin staining results revealed larger cortical damage in these animals compared to those that underwent no surgical maneuver at all. Brain swelling accompanied TBI, especially the severe model, that could have relieved the intracranial pressure in those animals with no skull reconstruction. In contrast, the immediate skull reconstruction produced an upregulation of the edema marker aquaporin-4 staining, which likely prevented the therapeutic benefits of brain swelling and resulted in larger cortical infarcts. Interestingly, TBI animals introduced to a delay in skull reconstruction (i.e., 2 days post-TBI) showed significantly reduced edema and infarcts compared to those exposed to immediate skull reconstruction. That immediate, but not delayed, skull reconstruction may exacerbate TBI-induced cortical tissue damage warrants a careful consideration of aesthetic repair of the skull in TBI. PMID:22438975
Sanai, Nader; Caldwell, Nolan; Englot, Dario J; Lawton, Michael T
Many neurosurgeons feel competent clipping posterior communicating artery (PCoA) aneurysms and include this lesion in their practice. However, endovascular therapy removes simple aneurysms that would have been easiest to clip with the best results. What remains are aneurysms with complex anatomy and technical challenges that are not well described. A contemporary surgical series with PCoA aneurysms is reviewed to define the patients, microsurgical techniques, and outcomes in current practice. A total of 218 patients had 218 PCoA aneurysms that were treated microsurgically during an 11-year period. Complexities influencing aneurysm management included (1) large/giant size; (2) fetal posterior cerebral artery; (3) previous coiling; (4) anterior clinoidectomy; (5) adherence of the anterior choroidal artery (AChA); (6) intraoperative aneurysm rupture; (7) complex clipping; and (8) atherosclerotic calcification. Simple PCoA aneurysms were encountered in 113 patients (51.8%) and complex aneurysms in 105 (48.2%). Adherent AChA (13.8%) and intraoperative rupture (11.5%) were the most common complexities. Simple aneurysms had favorable outcomes in 86.6% of patients, whereas aneurysms with 1 or multiple complexities had favorable outcomes in 78.2% and 75.0%, respectively. Intraoperative rupture (P PCoA aneurysms requires advanced techniques including clinoidectomy, AChA microdissection, complex clipping, and facility with intraoperative rupture. Microsurgery is recommended for recurrent aneurysms after coiling, complex branches, aneurysms causing oculomotor nerve palsy, multiple aneurysms, and patients with hematomas.
Fan, Yong; Li, Rong; Huang, Jin; Yu, Yang; Qiao, Jie
Human embryonic stem cells have shown tremendous potential in regenerative medicine, and the recent progress in haploid embryonic stem cells provides new insights for future applications of embryonic stem cells. Disruption of normal fertilized embryos remains controversial; thus, the development of a new source for human embryonic stem cells is important for their usefulness. Here, we investigated the feasibility of haploid and diploid embryo reconstruction and embryonic stem cell derivation using microsurgically repaired tripronuclear human zygotes. Diploid and haploid zygotes were successfully reconstructed, but a large proportion of them still had a tripolar spindle assembly. The reconstructed embryos developed to the blastocyst stage, although the loss of chromosomes was observed in these zygotes. Finally, triploid and diploid human embryonic stem cells were derived from tripronuclear and reconstructed zygotes (from which only one pronucleus was removed), but haploid human embryonic stem cells were not successfully derived from the reconstructed zygotes when two pronuclei were removed. Both triploid and diploid human embryonic stem cells showed the general characteristics of human embryonic stem cells. These results indicate that the lower embryo quality resulting from abnormal spindle assembly contributed to the failure of the haploid embryonic stem cell derivation. However, the successful derivation of diploid embryonic stem cells demonstrated that microsurgical tripronuclear zygotes are an alternative source of human embryonic stem cells. In the future, improving spindle assembly will facilitate the application of triploid zygotes to the field of haploid embryonic stem cells. PMID:23255130
Oishi, Makoto; Fukuda, Masafumi; Saito, Akihiko; Hiraishi, Tetsuya; Fujii, Yukihiko; Ishida, Go
The surgery of skull base tumors (SBTs) is difficult due to the complex and narrow surgical window that is restricted by the cranium and important structures. The utility of three-dimensional multi-fusion volumetric imaging (3-D MFVI) for visualizing the predicted window for SBTs was evaluated. Presurgical simulation using 3-D MFVI was performed in 32 patients with SBTs. Imaging data were collected from computed tomography, magnetic resonance imaging, and digital subtraction angiography. Skull data was processed to imitate actual bone resection and integrated with various structures extracted from appropriate imaging modalities by image-analyzing software. The simulated views were compared with the views obtained during surgery. All craniotomies and bone resections except opening of the acoustic canal in 2 patients were performed as simulated. The simulated window allowed observation of the expected microsurgical anatomies including tumors, vasculatures, and cranial nerves, through the predicted operative window. We could not achieve the planned tumor removal in only 3 patients. 3-D MFVI afforded high quality images of the relevant microsurgical anatomies during the surgery of SBTs. The intraoperative deja-vu effect of the simulation increased the confidence of the surgeon in the planned surgical procedures. (author)
Boyd, D. Douglas, Jr.
A computational study of a generic wing with a half span flap shows the mean flow effects of several blown flap configurations. The effort compares and contrasts the thin-layer, Reynolds averaged, Navier-Stokes solutions of a baseline wing-flap configuration with configurations that have blowing normal to the flap surface through small slits near the flap side edge. Vorticity contours reveal a dual vortex structure at the flap side edge for all cases. The dual vortex merges into a single vortex at approximately the mid-flap chord location. Upper surface blowing reduces the strength of the merged vortex and moves the vortex away from the upper edge. Lower surface blowing thickens the lower shear layer and weakens the merged vortex, but not as much as upper surface blowing. Side surface blowing forces the lower surface vortex farther outboard of the flap edge by effectively increasing the aerodynamic span of the flap. It is seen that there is no global aerodynamic penalty or benefit from the particular blowing configurations examined.
Full Text Available An active control method utilizing the multiple trailing edge flap configuration for rotorcraft vibration suppression and blade loads control is presented. A comprehensive model for rotor blade with active trailing edge flaps is used to calculate the vibration characteristics, natural frequencies and mode shapes of any complex composite helicopter rotor blade. A computer program is developed to calculate the system response, rotor blade root forces and moments under aerodynamic forcing conditions. Rotor blade system response is calculated using the proposed solution method and the developed program depending on any structural and aerodynamic properties of rotor blades, structural properties of trailing edge flaps and properties of trailing edge flap actuator inputs. Rotor blade loads are determined first on a nominal rotor blade without multiple active trailing edge flaps and then the effects of the active flap motions on the existing rotor blade loads are investigated. Multiple active trailing edge flaps are controlled by using open loop controllers to identify the effects of the actuator signal output properties such as frequency, amplitude and phase on the system response. Effects of using multiple trailing edge flaps on controlling rotor blade vibrations are investigated and some design criteria are determined for the design of trailing edge flap controller that will provide actuator signal outputs to minimize the rotor blade root loads. It is calculated that using the developed active trailing edge rotor blade model, helicopter rotor blade vibrations can be reduced up to 36% of the nominal rotor blade vibrations.
Kivelev, Juri; Koskela, Elina; Setälä, Kirsi; Niemelä, Mika; Hernesniemi, Juha
Cavernomas in the occipital lobe are relatively rare. Because of the proximity to the visual cortex and incoming subcortical tracts, microsurgical removal of occipital cavernomas may be associated with a risk of visual field defects. The goal of the study was to analyze long-term outcome after operative treatment of occipital cavernomas with special emphasis on visual outcome. Of the 390 consecutive patients with cavernomas who were treated at Helsinki University Central Hospital between 1980 and 2011, 19 (5%) had occipital cavernomas. Sixteen patients (4%) were surgically treated and are included in this study. The median age was 39 years (range 3-59 years). Seven patients (56%) suffered from hemorrhage preoperatively, 5 (31%) presented with visual field deficits, 11 (69%) suffered from seizures, and 4 (25%) had multiple cavernomas. Surgery was indicated for progressive neurological deterioration. The median follow-up after surgery was 5.25 years (range 0.5-14 years). All patients underwent thorough neuroophthalmological assessment to determine visual outcome after surgery. Visual fields were classified as normal, mild homonymous visual field loss (not disturbing the patient, driving allowed), moderate homonymous visual field loss (disturbing the patient, driving prohibited), and severe visual field loss (total homonymous hemianopia or total homonymous quadrantanopia). At the last follow-up, 4 patients (25%) had normal visual fields, 6 (38%) had a mild visual field deficit, 1 (6%) complained of moderate visual field impairment, and 5 (31%) had severe homonymous visual field loss. Cavernomas seated deeper than 2 cm from the pial surface carried a 4.4-fold risk of postoperative visual field deficit relative to superficial ones (p = 0.034). Six (55%) of the 11 patients presenting with seizures were seizure-free postoperatively. Eleven (69%) of 16 patients had no disability during the long-term follow-up. Surgical removal of occipital cavernomas may carry a
Munk, E M; Drewes, A M; Gorst-Rasmussen, Anders
BACKGROUND: No studies have examined the risk of upper gastrointestinal diseases among patients with unexplained chest/epigastric pain (UCEP) and a normal upper endoscopy. AIM: To examine the relative risk of peptic ulcer, oesophagitis, pancreatitis or gallstone in UCEP patients. METHODS...... for peptic ulcer, oesophagitis, pancreatitis or gallstone. RESULTS: Compared with controls, the adjusted relative risks among UCEP patients or = 1 year after upper endoscopy were for peptic ulcer 2.0 [95% confidence interval (CI) 0.2-18.4] and 1.7 (95% CI 0.9-3.4), for oesophagitis 8.2 (95% CI 1.......2-59.2) and 1.9 (95% CI 0.7-5.0), for pancreatitis 9.2 (95% CI 2.0-41.8) and 3.9 (95% CI 1.4-10.5), and for gallstone 14.1 (95% CI 5.4-37.2) and 3.3 (95% CI 1.9-5.8). CONCLUSIONS: UCEP is positively associated with all study outcomes especially in the first year after upper endoscopy, indicating that peptic...
Gi Yeun Hur
Full Text Available Background Deep burns of the elbow lead to soft tissue necrosis and infection, with exposureof deep structures. Adequate wound coverage of this area requires thin, pliable, and durabletissue, while optimal functional recovery requires early coverage and functional rehabilitation.We have found 3 types of island flaps that provide reliable coverage for the elbow.Methods A retrospective study was performed on all patients who underwent flap coverageof an elbow defect at our hospital. The patients’ data including age, sex, cause of injury, wounddimensions, timing of flap coverage, postoperative elbow motion, and complications wereinvestigated.Results Between 2001 and 2012, 16 patients were treated at our hospital. The mean agewas 53.3 years. Three kinds of flaps were performed: 9 latissimus dorsi flaps, 4 lateral armflaps, and 4 radial forearm flaps. The average defect size was 183.5 cm2 (range, 28 to 670cm2. Wound coverage was performed at mean duration of 45.9 days (range, 14 to 91 days.The mean postoperative active elbow flexion was 98° (range, 85° to 115°. Partial flap failureoccurred in 1 latissimus dorsi flap. Minor complications included partial flap loss (11.8%,hematoma (23.5%, seroma (35.3%, and wound infection (5.9%.Conclusions Flap selection for elbow reconstruction is determined by the defect size andthe extent of the adjacent tissue injury. Elbow reconstruction using an island flap is a singlestaged,reliable, and relatively simple procedure that permits initiation of early rehabilitation,thereby improving a patient’s functional outcome.
Stowers, Amanda K; Lentink, David
We present a new mechanism for passive wing morphing of flapping wings inspired by bat and bird wing morphology. The mechanism consists of an unactuated hand wing connected to the arm wing with a wrist joint. Flapping motion generates centrifugal accelerations in the hand wing, forcing it to unfold passively. Using a robotic model in hover, we made kinematic measurements of unfolding kinematics as functions of the non-dimensional wingspan fold ratio (2-2.5) and flapping frequency (5-17 Hz) using stereo high-speed cameras. We find that the wings unfold passively within one to two flaps and remain unfolded with only small amplitude oscillations. To better understand the passive dynamics, we constructed a computer model of the unfolding process based on rigid body dynamics, contact models, and aerodynamic correlations. This model predicts the measured passive unfolding within about one flap and shows that unfolding is driven by centrifugal acceleration induced by flapping. The simulations also predict that relative unfolding time only weakly depends on flapping frequency and can be reduced to less than half a wingbeat by increasing flapping amplitude. Subsequent dimensional analysis shows that the time required to unfold passively is of the same order of magnitude as the flapping period. This suggests that centrifugal acceleration can drive passive unfolding within approximately one wingbeat in small and large wings. Finally, we show experimentally that passive unfolding wings can withstand impact with a branch, by first folding and then unfolding passively. This mechanism enables flapping robots to squeeze through clutter without sophisticated control. Passive unfolding also provides a new avenue in morphing wing design that makes future flapping morphing wings possibly more energy efficient and light-weight. Simultaneously these results point to possible inertia driven, and therefore metabolically efficient, control strategies in bats and birds to morph or recover
Zhihua Cheng; Zhilin Guo; Meixiu Ding
BACKGROUND: In recent years some reports have been published propagating microsurgical resection of ventral foramen magnum meningiomas (VFMMs). Operative approaches to these lesions have been studied by various authors, but remain controversial.OBJECTIVE: To discuss the operative technique and outcome in patients with VFMMs who had been treatedvia a far lateral suboccipital approach.DESIGN: Retrospectively clinic case investigation. SElrING: Department of Neurosurgery, the Ninth People's Hospital, Medical School of Shanghai Jiao Tong University.PARTICIPANTS: Between January 1997 and June 2003, 10 patients were treated surgically with VFMMs in Department of Neurosurgery, the Ninth People's Hospital, Medical School of Shanghai Jiao Tong University. In the series of 10 patients, ages ranged from 37 to 72 years, mean (53±10) years, were consisted of 6 males and 4 females. All the subjects were informed of the treatment plan and agreed to join the experiment. Early symptoms included headache and upper cervical pain. The time between the first occurrence of symptoms and the diagnosis ranged from 6 months to 17 months, mean (10.3±3.4) months. Main presenting symptoms were unilateral upper extremity sensory and motor deficits in 6 cases, swallowing difficulties in 2 and spastic quadriparesis in 2. VFMMs were demonstrated as round by the computed tomographic (CT) scan and magnetic resonance imaging (MRI) in all patients. The maximum diameter of tumors ranged from 2 to 4 cm,mean (2.55±0.57) cm, including 2 cm in one case, 2.0-3.0 cm in six and 3.0-4.0 cm in three.METHODS: ①All tumors were removed via the far lateral suboccipital approach. Resection of the posterior 5 mm of the condyle was necessary in one patient whose tumors' diameter were 2 cm. The patient was situated in the lateral decubitus position. The head was fixed in a Mayfield headrest. A C-shaped incision made behind the ear 2 cm medial to the mastoid process, turning vertically down to the level C4, to
Ashok R Koul
Full Text Available Background: A soft tissue defect requiring flap cover which is longer than that provided by the conventional "long" free flaps like latissimus dorsi (LD and anterolateral thigh (ALT flap is a challenging problem. Often, in such a situation, a combination of flaps is required. Over the last 3 years, we have managed nine such defects successfully with a free "Boomerang-shaped" Extended Rectus Abdominis Myocutaneous (BERAM flap. This flap is the slightly modified and "free" version of a similar flap described by Ian Taylor in 1983. Materials and Methods: This is a retrospective study of patients who underwent free BERAM flap reconstruction of soft tissue defects of extremity over the last 3 years. We also did a clinical study on 30 volunteers to compare the length of flap available using our design of BERAM flap with the maximum available flap length of LD and ALT flaps, using standard markings. Results: Our clinical experience of nine cases combined with the results of our clinical study has confirmed that our design of BERAM flap consistently provides a flap length which is 32.6% longer than the standard LD flap and 42.2% longer than the standard ALT flap in adults. The difference is even more marked in children. The BERAM flap is consistently reliable as long as the distal end is not extended beyond the mid-axillary line. Conclusion: BERAM flap is simple in design, easy to harvest, reliable and provides the longest possible free skin/myocutaneous flap in the body. It is a useful new alternative for covering long soft tissue defects in the limbs.
Koul, Ashok R; Nahar, Sushil; Prabhu, Jagdish; Kale, Subhash M; Kumar, Praveen H P
A soft tissue defect requiring flap cover which is longer than that provided by the conventional "long" free flaps like latissimus dorsi (LD) and anterolateral thigh (ALT) flap is a challenging problem. Often, in such a situation, a combination of flaps is required. Over the last 3 years, we have managed nine such defects successfully with a free "Boomerang-shaped" Extended Rectus Abdominis Myocutaneous (BERAM) flap. This flap is the slightly modified and "free" version of a similar flap described by Ian Taylor in 1983. This is a retrospective study of patients who underwent free BERAM flap reconstruction of soft tissue defects of extremity over the last 3 years. We also did a clinical study on 30 volunteers to compare the length of flap available using our design of BERAM flap with the maximum available flap length of LD and ALT flaps, using standard markings. Our clinical experience of nine cases combined with the results of our clinical study has confirmed that our design of BERAM flap consistently provides a flap length which is 32.6% longer than the standard LD flap and 42.2% longer than the standard ALT flap in adults. The difference is even more marked in children. The BERAM flap is consistently reliable as long as the distal end is not extended beyond the mid-axillary line. BERAM flap is simple in design, easy to harvest, reliable and provides the longest possible free skin/myocutaneous flap in the body. It is a useful new alternative for covering long soft tissue defects in the limbs.
Bozkurt, Mehmet; Kapi, Emin; Kuvat, Samet Vasfi; Selçuk, Caferi Tayyar
Tissue losses within the nose due to various reasons result in the loss of normal anatomy and function. The external nasal valve area is one of the most important functional components of the nose. The columella, lobule, nostril, and alar region are among the components forming the external nasal valve area. Deformities of the nostrils are among the most frequently observed features that interfere with the functional anatomy of the nose. Malformations of the nostrils often emerge subsequent to cleft lip repairs. Stenoses are a common type of pathology among nostril deformities. In cases where a stenosis has formed, breathing problems and developmental anomalies may occur. In the patient with nostril stenosis presented in this report, there was a serious alar collapse and contracture subsequent to a cleft lip repair. In order to repair the nostril stenosis, a "boomerang flap" was chosen. This boomerang flap was used in combination with a nasolabial flap, a vestibular rotation flap, and a conchal cartilage graft to achieve a satisfactory repair.
Full Text Available Large palatal fistulas are a challenging problem in cleft surgery. Many techniques are used to close the defect. The tongue flap is an easy and reproductible procedure for managing this complication. The authors report a case of a large palatal fistula closure with anteriorly based tongue flap.
Lin, Haodong; Hou, Chunlin; Xu, Zhen; Chen, Aiming
Despite a variety of flap reconstruction options, the ischium remains the most difficult pressure sore site to treat. This article describes the authors' successful surgical procedure for coverage of ischial ulcers using double adipofascial turnover flaps.After debridement, the adipofascial flaps are harvested both cephalad and caudal to the defect. The flaps are then turned over to cover the exposed bone in a manner so as to overlap the 2 flaps. The skin is then closed with sutures in 2 layers. A total of 15 patients with ischial sores were treated using this surgical procedure.The follow-up period ranged from 11 to 159 months, with a mean of 93.6 months. Overall, 86.7% of the flaps (13 of 15) healed primarily. One patient had a recurrent grade II ischial pressure sore again 11 months after the operation. The other 14 patients did not have a recurrence.Treatment of ischial pressure sores with adipofascial turnover flaps provides an easy, minimally invasive procedure, with preservation of future flap options, and a soft-tissue supply sufficient for covering the bony prominence and filling dead space. This technique is a reliable and safe reconstructive modality for the management of minor ischial pressure sores.
Mohammad M. Al-Qattan
Conclusion: We demonstrate that the pedicle flap is much simpler than the free flap and is adequate for reconstruction of partial upper lip defects. We also demonstrate a good cosmetic and functional outcome; and highlight several technical points to ensure a satisfactory outcome.
Brenner, Jason E; Fadlallah, Ali; Hatch, Kathryn M; Choi, Catherine; Sayegh, Rony R; Kouyoumjian, Paul; Wu, Simon; Frangieh, George T; Melki, Samir A
To assess the accuracy of surgeons' visual estimation of LASIK flap thickness when created by a femtosecond laser by comparing it to ultrasound measurements. Surgeons were asked to visually estimate the thickness of a femtosecond flap during the procedure. Total corneal thickness was measured by ultrasound pachymetry prior to the procedure and the stromal bed was similarly measured after flap lifting. The estimates from three experienced surgeons (cornea fellowship trained and more than 5 years in practice) were compared to those of three cornea fellows, with each surgeon evaluating 20 eyes (120 total). Surgeons were not told the thickness of the flaps unless required for safety reasons. The average difference between visual and ultrasonic estimation of LASIK flap thickness was 15.20 μm. The flap was 10 μm thicker than estimated in 37% of eyes, 20 μm thicker in 17% of eyes, and 30 μm thicker in 10% of eyes. The largest deviation was 53 μm. There was no statistically significant difference between the accuracy of experienced surgeons and fellows (P = .51). There are significant differences between surgeons' visual estimates and ultrasonic measurements of LASIK flap thickness. Relying on these visual estimates may lead to deeper excimer laser ablation than intended. This could lead to thinner residual stromal beds and higher percent tissue altered than planned. The authors recommend that surgeons measure flaps intraoperatively to maximize accuracy and safety. [J Refract Surg. 2017;33(11):765-767.]. Copyright 2017, SLACK Incorporated.
Bernhammer, L.O.; Navalkar, S.T.; Sodja, J.; De Breuker, R.; Karpel, M.
This paper presents the experimental and numerical study of an autonomous load alleviation concept using trailing edge flaps. The flaps are autonomous units, which for instance can be used for gust load alleviation. The unit is self-powered and self-actuated through trailing edge tabs which are
Smit, Jeroen M.; Dimopoulou, Angeliki; Liss, Anders G.; Zeebregts, Clark J.; Kildal, Morten; Whitaker, Iain S.; Magnusson, Anders; Acosta, Rafael
The use of perforator flaps in breast reconstructions has increased considerably in the past decade. A disadvantage of the perforator flap is difficult dissection, which results in a longer procedure. During spring 2006, we introduced CT angiography (CTA) as part of the diagnostic work-up in
Pressure ulcers or ischaemic necrosis of tissues over bony eminences due to pressure, heal very slowly. Vascularised tissues such as myocutaneous flaps are necessary to cover the ulcer and accelerate healing. This study was done to share our experience with methods of myocutaneous flaps in the treatment of pressure ...
Regional myocutaneous pedicle flaps (RMF) are known to be relevant in the reconstruction of major head and neck oncologic defects with pectoralis major myocutaneous pedicle flap (PMMC) being the best-known RMF. For over three decades, since first described by Ariyan in 1979, PMMC has continually been used in the ...
Several scrotal reconstructive options are available including split thickness skin grafts, scrotal advancement flaps, local fasciocutaneous, muscle or myocutaneous flaps, and free tissue transfer. We report a case of a 34 year old African male who presented as a referral from a district hospital with a scrotal defect and ...
The propeller flap has become a versatile and important component in our reconstructive algorithm following complex lower limb trauma. First described by Hyakusoku in 1991, it has since been adapted and modified by Hallock and Teo. This article outlines our experience specifically with perforator pedicled propeller flaps ...
Background and Aim: The urinary bladder becomes small, contracted and is associated with excess pelvic fat in long standing cases of vesico-vaginal fistulas (VVFs). The aim of this new technique was to use this excess pelvic fat for harvesting an interposition flap. Materials and Methods: An interposition flap of peri-vesical ...
Full Text Available Tsung-Han Tsai,1 Kai-Ling Peng,1 Chien-Jen Lin2 1Department of Ophthalmology, 2Department of Radiology, Chi Mei Medical Center, Tainan, Taiwan Background: Laser in situ keratomileusis (LASIK is the most common and popular procedure performed for the correction of refractive errors in the last two decades. We report a case of traumatic flap displacement with flap folding which occurred 3 years after LASIK was performed. Previous literature suggests that vision prognosis would be closely related to proper and prompt management of traumatic flap displacement with flap folding 3 years after LASIK.Case presentation: A 23-year-old female presented to our hospital who had undergone uneventful LASIK in both eyes 3 years prior. Unfortunately, she had suffered a blunt trauma in her right eye in a car accident. A late onset of corneal flap displacement was found with upper and lower portion of the flap being folded inside the corneal bed. Surgical intervention for debridement with subsequent reposition of corneal flap was performed as soon as possible in the operating room. A bandage contact lens was placed, and topical antibiotic and corticosteroids were given postoperatively. Two days after the operation, the displaced corneal flap was found to be well attached smoothly on the corneal bed without folds. The best-corrected visual acuity was 6/6 with refraction of −0.75 D to 1.0 D ×175° in her right eye 1 month later.Literature review: We reviewed a total of 19 published cases of late-onset traumatic flap dislocations or displacements after LASIK with complete data from 2000 to 2014.Conclusion: Traumatic displacement of corneal flaps after LASIK may occur after blunt injury with specific direction of force to the flap margin, especially tangential one. According to the previous literature, late-onset traumatic flap displacement may happen at any time after LASIK and be caused by various types of injuries. Fortunately, good visual function could
Kymionis, George D; Portaliou, Dimitra M; Karavitaki, Alexandra E; Krasia, Maria S; Kontadakis, Georgios A; Stratos, Aimilianos; Yoo, Sonia H
To describe the visual outcomes of three patients who had LASIK flap buttonhole and were treated immediately with photorefractive keratectomy (PRK) and topical mitomycin C (MMC) 0.02%. Three patients underwent bilateral LASIK with the SCHWIND Carriazo-Pendula 90 microm head microkeratome. In all three cases, a buttonhole flap occurred in the left eye. The flap was repositioned and phototherapeutic keratectomy for 50 microm was used for epithelial removal while immediate PRK with MMC was performed to treat the buttonhole flap. Three months after the procedure, uncorrected distance visual acuity and corrected distance visual acuity were 20/20 with regular topographic findings. Using PRK with MCC immediately after the occurrence of the LASIK flap buttonhole may be an effective treatment.
Zhuo, Qinqiang; Li, Shirong; Wu, Julong; Wang, Zhenxiang; Yang, Dongyun; Tao, Ling
To investigate the clinical application of the scrotal flap on penis lengthening. One hundred and fifty-two patients were operated using the scrotal flap from July 1998 to January 2008 at the Department of Plastic and Aesthetic, Surgery Southwest Hospital, Chongqing, China. The procedure consisted of designing a positive sign shaped incision 1.5cm above the root of the penis, dissect and release the superficial suspensory ligament and part of the deep suspensory ligament, then cover the elongated cavernosum with proper scrotal flap. Six-month to 5-year follow-up showed that all patients were satisfied with the good contour and function of the penis. The operation was successful. The method of using scrotal flap on penis lengthening has the following advantages: simple operation, reliable blood supply of the flap, one-stage operation, and satisfactory postoperative results. It is a preferable operation technique for penis lengthening.
Devranjan, S.; Jalikop, Shreyas V.; Sreenivas, K. R.
In recent times, research in the area of flapping flight has attracted renewed interest with an endeavor to use this mechanism in Micro Air vehicles (MAVs). For a sustained and high-endurance flight, having larger payload carrying capacity we need to identify a simple and efficient flapping-kinematics. In this paper, we have used flow visualizations and Discrete Vortex Method (DVM) based simulations for the study of flapping flight. Our results highlight that simple flapping kinematics with down-stroke period (tD) shorter than the upstroke period (tU) would produce a sustained lift. We have identified optimal asymmetry ratio (Ar = tD/tU), for which flapping-wings will produce maximum lift and find that introducing optimal wing flexibility will further enhances the lift.
Anderson, R D
A new combination of expanded simultaneous transposition and advancement flaps is reported for the treatment of extensive male pattern baldness. Although vertical transposition and parieto-occipital advancement flaps in themselves are not new, their combination and simultaneous bilateral use combined with the use of expansion is new. The advantages of the expanded bilateral advancement transposition flap procedure are presented, along with the technique and results. The results are predictable, providing a more pleasing result, with a natural immediate temporal recession, avoidance of temporal dog-ears, and desirable anterior-superior direction of hair growth. Although flaps do require surgical skill and training, and there are risks and possible complications involved, the results are achieved in a relatively short time compared with grafting techniques. Flaps also provide the advantages of a full and natural hairline contrasted with the sparse look afforded by multiple grafts. The described procedures are very effective and reliable when properly planned and properly executed.
Kim, Youn Hwan; Kim, Sang Wha; Kim, Jeong Tae; Kim, Chang Yeon
Tensor fascia lata (TFL) musculocutaneous flaps often require a donor site graft when harvesting a large flap. However, a major drawback is that it also sacrifices the muscle. To overcome this disadvantage, we designed a TFL perforator-based island flap that was harvested from a site near the defect and involved transposition within 90 degrees without full isolation of the pedicles. We performed procedures on 17 musculocutaneous flaps and 23 perforator-based island flaps, and compared the outcomes of these surgeries. The overall complication rate was 27.5% (11 regions). There were 7 complications related to the musculocutaneous flaps and 4 complications related to the perforator flaps. Although there were no statistical differences between those groups, lower complication rates were associated with procedures involving perforator flaps. The TFL perforator procedure is a simple and fast operation that avoids sacrificing muscle. This decreases complication rates compared to true perforator flap techniques that require dissection around the perforator or pedicle.
Li, Bin; Li, Hua; Jin, Rui; Cheng, Chen; Wang, Jing; Zhu, Hainan; Zan, Tao; Li, Qingfeng; Hao, Lijun
Prefabricated flaps are an ideal alternative to repair massive and complex tissue defects. Nevertheless, the risk of necrosis due to unpredictable blood supplies is a major obstacle to the application of prefabricated flaps. The survival of a prefabricated flap depends on the neovascularization between the vascular carrier and the donor tissue. Here, we proposed that the iron chelator, desferrioxamine (DFX), owned therapeutic effects that promoted the neovascularization of prefabricated flaps. An abdominal prefabricated flap model was created in rats via a 2-stage operation. The rats were allocated into 4 groups as follows: 2 groups of rats received DFX treatments during the first or the second stage of the operation, respectively; 1 group of rats received a delay procedure 1 week before the second operation; and the final group was used as a blank control. Flap survival rates and capillary densities were evaluated between groups. The influence of DFX on the dermal fibroblasts was also studied in vitro. Desferrioxamine treatment during the first stage of the operation greatly increased flap survival rate compared to the blank control. The results were similar to those produced by the delay treatment. The vessel count results were consistent with the flap survival rate findings. In vitro, DFX treatment up-regulated the expression levels of several angiogenic factors in the dermal fibroblasts. Nevertheless, DFX treatment during the second stage of the operation was therapeutically detrimental. The application of DFX around the time of vascular carrier implantation greatly promoted neovascularization of prefabricated flaps, but was therapeutically detrimental after the flaps had been elevated.
Misani, M; Zirak, C; Hau, Lê Thua Trung; De Mey, A; Boeckx, W
The use of microsurgery in the management of burn sequelae is not a new idea. According to the properties of various types of free flaps different goals can be achieved or various additional procedures have to be combined. We report the comparison of two different free flaps on a single patient for reconstruction of both upper extremities for burn sequelae. A 1-year-old child sustained severe burns on both hands, arms and thorax and was initially only treated conservatively. This resulted in severe contractures. At the age of 4-years a free gracilis flap was selected for reconstruction of his left hand and a free anterolateral thigh flap for the right hand. We noticed a better functional and esthetic result for the gracilis flap associated with a shorter operative time and a minor donor site morbidity. The intraoperative technique and time, postoperative complications, functional and esthetic results and donor site morbidities were studied in the two types of flaps chosen. A review of literature was also performed. Our experience reported a better success of the gracilis muscle flap covered with a split skin graft compared to the anterolateral thigh flap in the reconstruction of hand function after severe burn sequelae. Copyright © 2013 Elsevier Ltd and ISBI. All rights reserved.
Full Text Available Objectives. Severe penile inadequacy in adolescents is rare. Phallic reconstruction to treat this devastating condition is a major challenge to the reconstructive surgeon. Phallic reconstruction using the free radial forearm flap (RFF or the pedicled anterolateral thigh flap (ALTF has been routinely used in female-to-male transsexuals. Recently we started to use these techniques in the treatment of severe penile inadequacy. Methods. Eleven males (age 15 to 42 years were treated with a phallic reconstruction. The RFF is our method of choice; the ALTF is an alternative when a free flap is contraindicated or less desired by the patient. The RFF was used in 7 patients, the ALTF in 4 patients. Mean followup was 25 months (range: 4–49 months. Aesthetic and functional results were evaluated. Results. There were no complications related to the flap. Aesthetic results were judged as “good” in 9 patients and “moderate” in 2 patients. Sensitivity in the RFF was superior compared to the ALTF. Four patients developed urinary complications (stricture and/or fistula. Six patients underwent erectile implant surgery. In 2 patients the erectile implant had to be removed due to infection or erosion. Conclusion. In case of severe penile inadequacy due to whatever condition, a phalloplasty is the preferred treatment nowadays. The free radial forearm flap is still the method of choice. The anterolateral thigh flap can be a good alternative, especially when free flaps are contraindicated, but sensitivity is markedly inferior in these flaps.
... 50 Wildlife and Fisheries 7 2010-10-01 2010-10-01 false Escape Opening and Flap Dimensions for the Double Cover Flap TED 16 Figure 16 to Part 223 Wildlife and Fisheries NATIONAL MARINE FISHERIES SERVICE, NATIONAL OCEANIC AND ATMOSPHERIC ADMINISTRATION, DEPARTMENT OF COMMERCE MARINE MAMMALS THREATENED MARINE AND ANADROMOUS SPECIES Pt. 223, Fig. 1...
Al-Hayder, Shems; Elberg, Jens Jørgen; Charabi, Birgitte
L in patients with oral or oropharyngeal cancer following free flap reconstruction. Methods: A retrospective review of medical records and self-administered HRQoL questionnaires, EORTC QLQ-C30, and -H&N35. All patients who underwent surgery for oral or oropharyngeal cancer followed by primary reconstruction...
Background: Open fractures of the distal third of the tibia and fibular offer a challenge to the orthopedic surgeon because of skin coverage. The reconstructive surgeon's help is often required in trying to achieve this. There are several options: - local flap, free flap or a cross leg flap. Local flaps have always had limitations ...
van Wijk, MP; Damen, A; Nauta, JM; Lichtendahl, DHE; Dhar, BK
The results of reconstruction of the anterior floor of the mouth, using 105 nasolabial flaps in 79 patients were reviewed in a retrospective study. Of those flaps, 82% healed uneventfully; flap survival was 95%. Considerable flap loss occurred in 5%. Primary dehiscence was observed in 5% of all
Carolyn L. Mulvey, BS
Conclusions: Flaps with increasing weight have increased risk of fat necrosis. These data suggest that inclusion of more than 1 perforator may decrease odds of fat necrosis in large flaps. Perforator flap breast reconstruction can be performed safely; however, considerations concerning race, body mass index, staging with tissue expanders, perforator number, and flap weight may optimize outcomes.
Egeberg, Alexander; Rasmussen, Mads Kløvgaard; Sørensen, Jens Ahm
Countless studies have compared the use of autologous tissue for breast reconstruction; however, rates of donor-site morbidity differ greatly. This study examined the donor-site morbidity of superficial inferior epigastric artery (SIEA), deep inferior epigastric perforator (DIEP) and muscle-spari...
Full Text Available Abstract Introduction Williams syndrome is rare genetic disorder resulting in neurodevelopmental problems. Hernias of the foramen of Morgagni are rare diaphragmatic hernias and they mostly present on the right side, in the anterior mediastinum. They are usually asymptomatic and are difficult to diagnose, especially in patients with learning disabilities. Case presentation This 49-year-old woman with Williams syndrome, cognitive impairment and aortic stenosis presented to physicians with right-sided chest pain. She had previously undergone repair of her right spigelian and epigastric hernia. Her abdominal examination was unremarkable. Chest X-ray suggested right-sided diaphragmatic hernia and pleural effusion for which she received treatment. The computed tomography scan showed a diaphragmatic hernia with some collapse/consolidation of the adjacent lung. Furthermore, the patient had aortic stenosis and was high risk for anaesthesia (ASA grade 3. She underwent successful laparoscopic repair of her congenital diaphragmatic hernia leading to a quick and uneventful postoperative recovery. Conclusion These multiple hernias suggest that patients with Williams syndrome may have some connective tissue disorder which makes them prone to develop hernias especially associated with those parts of the body which may have intracavity pressure variations like the abdomen. Diaphragmatic hernia may be the cause of chest pain in these patients. A computed tomography scan helps in early diagnosis, and laparoscopic repair helps in prevention of further complications, and leads to quick recovery especially in patients with learning disabilities. In the presence of significant comorbidities, a less invasive operative procedure with quick recovery becomes advisable.
Full Text Available Management of skin avulsion with tissue exposure is a challenge for plastic surgeons. Clinical observations have suggested that longer survival of skin flap prevents further contamination and infection. Less well known is the role of atorvastatin in avulsion skin flap. Therefore, we attempted to determine whether atorvastatin could alleviate avulsion skin flap in a rat model. Twenty male Sprague–Dawley rats were randomized into two groups: the atorvastatin group and the control. Before operation, each rat received an initial blood perfusion scan as baseline data. Then, each rat received an operation of skin flap incision, elevation, and resuturing to the original position under general anesthesia. Another blood perfusion scan was performed on each rat 30 minutes, 4 days, and 7 days postoperatively. On the 7th postoperative day, the necrotic area of skin flap was measured as the skin flap viability. The skin flap tissues at 2.5 and 5 cm distal to the skin flap base were collected for histopathological analysis, as well as measurement of vascular endothelial growth factor (VEGF mRNA expression, and vascular density. Compared with 30 minutes postoperation, there was a significant increase in the ratio of skin flap blood perfusion on the 4th and 7th days postoperation in both control and atorvastatin groups (p<0.05. Compared with the control group, there was a significant decrease in necrotic area, significant increase in ratio of skin flap blood perfusion on postoperation days 4 and 7, and significant increase in vascular density under high field at 2.5 cm distal to the base of skin flap in the atorvastatin group (p<0.05. The VEGF121 and VEGF165 mRNA expression at 2.5 cm distal to the base of skin flap differed significantly between the two groups (p<0.05. Compared with the control group, atorvastatin treatment improved skin flap blood perfusion, vascular density, and necrotic area dependent on VEGF mRNA expression.
Masood, T.; Ahmed, R.; Obaidullah, M.
Background: Distally based sural fascio-cutaneous flap is a commonly performed plastic surgery procedure for the coverage of distal third of leg, ankle and foot defects. However congestion is the main complication of this flap which results into partial or complete loss of the flap. We devised a special splint to reduce this complication and retrospectively reviewed its effect on this complication between two groups. Methods: This retrospective study was carried out at Northwest General hospital between 1995 and 2012. Group-A included 30 patients who were managed without the splint between 1995 and 2005 and group B comprised of 35 patients were treated with the splint between 2006 and 2012. Complications like venous congestion, epidermolysis, and partial and complete flap failure were documented. Data were analyzed by SPSS.16.5 software. Chi- square test was used for data analysis. P value less than 0.05 was considered as the level of significance. Results: Total 65 patients were operated. Age of the patients ranged from 7 to 60 years. Road traffic accident and spoke wheel injury was the main cause of soft tissue loss in our patients. In group A 12 patients suffered from venous congestion. Out of 12, three patients had epidermolysis while partial flap necrosis occurred in 9 patients. Only 3 patients had venous congestion in group B. Two patients suffered from epidermolysis and one had partial flap necrosis. None of patient suffered from complete flap loss in both groups. Conclusion: Reverse sural artery flap continues to be a versatile flap for distal lower extremity reconstruction. By using a special splint to reduce pressure on the pedicle site as a modification, flap complication rate can be decreased significantly. (author)
Full Text Available Use of an autologous latissimus flap in breast reconstruction accounts for a supple and natural look of reconstructed breast. Most common postoperative complication, seroma, became more of a rule then an exception when it comes to postoperative evaluation of the patients who underwent this reconstructive procedure. A retrospective study analysing and evaluating different complication rates in 20 patients who underwent breast reconstruction by autologous latissimus flap, was conducted. All patients included in the study were operated at the Department of plastic surgery of Hôpital Civil in Strasbourg, France, between 1996 and 2008. The complication rates were noted as follows: seroma in 19 of our 20 patients (95%, late hypertrophic scarring in 3 patients (15%, postoperative surgical site hematoma in 3 patients (15%, and 2 patients (10% presented postoperative chronic back pain. Different options used in seroma treatment and prevention (subcutaneous-fascia anchor sutures of donor site, application of corticosteroids by injection into donor site postoperatively, passive drainage can reduce seroma formation and thus overall complication rates, leading to much faster patient’s recovery time and return to normal daily activities.
Full Text Available La espalda es una excelente zona dadora de colgajos. El colgajo perforante tóracodorsal basado en ramas cutáneas de la arteria y vena tóracodorsales que perforan el músculo dorsal ancho, es una modifica ción del tradicional colgajo musculocutáneo de dorsal ancho que permite lograr una mayor flexibilidad en su traslado y una disminución de su volumen. Puede emplearse como colgajo libre o en isla. Presentamos su anatomía, disección e indicaciones.Back is an excellent donor site for flaps. The tora codorsal perforator flap, based on cutaneous vessels from toracodorsal artery and vein that pass through Latissimus Dorsi muscle, is a modified conventional musculocutaneous Latissimus Dorsi flap that allows easier movility and a volume reduction. This flap can be used both, free flap or island flap. We present the anatomy, dissection and applica tions of this flap.
Full Text Available Water recovery and subsequent reuse are required for human consumption as well as industrial, and agriculture applications. Moist air streams, such as cooling tower plumes and fog, represent opportunities for water harvesting. In this work, we investigate a flapping mechanism to increase droplet shedding on thin, hydrophobic films for two vibrational cases (e.g., ± 9 mm and 11 Hz; ± 2 mm and 100 Hz. Two main mechanisms removed water droplets from the flapping film: vibrational-induced coalescence/sliding and droplet ejection from the surface. Vibrations mobilized droplets on the flapping film, increasing the probability of coalescence with neighboring droplets leading to faster droplet growth. Droplet departure sizes of 1–2 mm were observed for flapping films, compared to 3–4 mm on stationary films, which solely relied on gravity for droplet removal. Additionally, flapping films exhibited lower percentage area coverage by water after a few seconds. The second removal mechanism, droplet ejection was analyzed with respect to surface wave formation and inertia. Smaller droplets (e.g., 1-mm diameter were ejected at a higher frequency which is associated with a higher acceleration. Kinetic energy of the water was the largest contributor to energy required to flap the film, and low energy inputs (i.e., 3.3 W/m2 were possible. Additionally, self-flapping films could enable novel water collection and condensation with minimal energy input.
Kim, S; Dennis, M; Holland, J; Terrell, M; Loukas, M; Schober, J
Transgender surgeries are becoming more frequent and visual interpretation of anatomy is essential for both surgeons and patients. Since the forearm free flap phalloplasty was introduced in 1984, it has been known to provide reliable cosmetic and functional results for transitioning men compared with phalloplasty by different flaps. Surgical text descriptions were enhanced by the creation of new anatomic illustrations. The forearm free flap consists of the anterior forearm skin, subcutaneous tissue, fascia containing the radial artery as the perforator and its venae comitantes, cephalic and basilic veins, and lateral and medial antebrachial cutaneous nerves are demonstrated in relation to the surgically derived flap. Song's forearm free flap phalloplasty requires two surgical stages with a three-month interval between the stages: prelamination of a neourethra and construction of a neophallus. The neophallus created by forearm flap phalloplasty is reported to achieve acceptable aesthetical and psychological satisfaction, appropriate size and shape, and satisfying sexual intercourse. Despite increasing experiences in gender confirming surgery with modifications made by many authors, urethral complications including fistula and/or stricture formation are the leading causes of reoperation. The poor esthetic outcome of the forearm donor site and a decrease in rigidity of the neophallus are the main limitations. Illustrations of anatomy help inform surgical choice and understanding of risks and benefits by patients. The anatomy of the free forearm flap phalloplasty supports creation of a neophallus for transsexual anatomy revision. Clin. Anat. 31:145-151, 2018. © 2017 Wiley Periodicals, Inc. © 2017 Wiley Periodicals, Inc.
Full Text Available BACKGROUND The reverse sural artery flap has been a workhorse for the reconstruction of distal third of leg, ankle, sole and foot. Major limitation of reverse sural flap has been venous congestion particularly when harvested from proximal third of the leg. Objective- To evaluate the efficacy, safety of the extended reverse sural flap from proximal third of the leg. MATERIALS AND METHODS A prospective study was conducted at the department of plastic surgery on twenty patients who needed soft tissue reconstruction in the distal third of the leg, ankle, heel, forefoot and midfoot due to various cause. In all cases flap was extended proximally to the upper third of the calf and neurovenoadipo fascial pedicled sural fasciocutaneous flap was harvested. RESULTS There were only two cases of marginal necrosis. None of the patients had complete necrosis. Two patients developed hypertrophy of the flap margin. CONCLUSION Distally based neuroveno adipofascial pedicled sural fasciocutaneous flap can be safely extended to proximal third of the leg and is a reliable option for reconstruction of the defects in the foot, ankle and sole.
Marinho, Paulo; Vermandel, Maximilien; Bourgeois, Philippe; Lejeune, Jean-Paul; Mordon, Serge; Thines, Laurent
The safety and success of intracranial aneurysm (IA) surgery could be improved through the dedicated application of simulation covering the procedure from the 3-dimensional (3D) description of the surgical scene to the visual representation of the clip application. We aimed in this study to validate the technical feasibility and clinical relevance of such a protocol. All patients preoperatively underwent 3D magnetic resonance imaging and 3D computed tomography angiography to build 3D reconstructions of the brain, cerebral arteries, and surrounding cranial bone. These 3D models were segmented and merged using Osirix, a DICOM image processing application. This provided the surgical scene that was subsequently imported into Blender, a modeling platform for 3D animation. Digitized clips and appliers could then be manipulated in the virtual operative environment, allowing the visual simulation of clipping. This simulation protocol was assessed in a series of 10 IAs by 2 neurosurgeons. The protocol was feasible in all patients. The visual similarity between the surgical scene and the operative view was excellent in 100% of the cases, and the identification of the vascular structures was accurate in 90% of the cases. The neurosurgeons found the simulation helpful for planning the surgical approach (ie, the bone flap, cisternal opening, and arterial tree exposure) in 100% of the cases. The correct number of final clip(s) needed was predicted from the simulation in 90% of the cases. The preoperatively expected characteristics of the optimal clip(s) (ie, their number, shape, size, and orientation) were validated during surgery in 80% of the cases. This study confirmed that visual simulation of IA clipping based on the processing of high-resolution 3D imaging can be effective. This is a new and important step toward the development of a more sophisticated integrated simulation platform dedicated to cerebrovascular surgery.
Full Text Available BackgroundA thinned anterolateral thigh (ALT flap is often harvested to achieve optimal skin resurfacing. Several techniques have been described to thin an ALT flap including an adipocutaneous flap, an adipofascial flap and delayed debulking.MethodsBy systematically reviewing all of the available literature in English and French, the present manuscript attempts to identify the common surgical indications, complications and donor site morbidity of the adipofascial variant of the ALT flap. The studies were identified by performing a systematic search on Medline, Ovid, EMBASE, the Cochrane Database of Systematic Reviews, Current Contents, PubMed, Google, and Google Scholar.ResultsThe study selection process was adapted from the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement, and 15 articles were identified using the study inclusion criteria. These articles were then reviewed for author name(s, year of publication, flap dimensions and thickness following defatting, perforator type, type of transfer, complications, thinning technique, number of cases with a particular area of application and donor site morbidity.ConclusionsThe adipofascial variant of the ALT flap provides tissue to fill large defects and improve pliability. Its strong and safe blood supply permits adequate immediate or delayed debulking without vascular complications. The presence of the deep fascia makes it possible to prevent sagging by suspending and fixing the flap for functional reconstructive purposes (e.g., the intraoral cavity. Donor site morbidity is minimal, and thigh deformities can be reduced through immediate direct closure or liposuction and direct closure. A safe blood supply was confirmed by the rate of secondary flap debulking.
Kim, Sang Hun; Shin, Ho Seong; Lee, Sang Hwan
Free flaps are a common treatment option for head and neck reconstruction in plastic reconstructive surgery, and monitoring of the free flap is the most important factor for flap survival. In this study, the authors performed real-time free flap monitoring based on an implanted Doppler system and "internet of things" (IoT)/wireless Wi-Fi, which is a convenient, accurate, and efficient approach for surgeons to monitor a free flap. Implanted Doppler signals were checked continuously until the patient was discharged by the surgeon and residents using their own cellular phone or personal computer. If the surgeon decided that a revision procedure or exploration was required, the authors checked the consumed time (positive signal-to-operating room time) from the first notification when the flap's status was questioned to the determination for revision surgery according to a chart review. To compare the efficacy of real-time monitoring, the authors paired the same number of free flaps performed by the same surgeon and monitored the flaps using conventional methods such as a physical examination. The total survival rate was greater in the real-time monitoring group (94.7% versus 89.5%). The average time for the real-time monitoring group was shorter than that for the conventional group (65 minutes versus 86 minutes). Based on this study, real-time free flap monitoring using IoT technology is a method that surgeon and reconstruction team can monitor simultaneously at any time in any situation.
Thornton, J.W.; Stevenson, T.R.; VanderKolk, C.A.
Osteoradionecrosis of the olecranon is an unusual pathologic entity, treated best by debridement and wound closure using vascularized tissue. Local skin is often unavailable for flap design and transposition. The radial forearm flap can be isolated on a proximal vascular pedicle and transposed to cover the wound. In the case presented, healing was brisk and complete, allowing early elbow mobilization. Although the donor site is not easily concealed, no functional impairment results from flap elevation and all full-thickness wounds are confined to the involved extremity
Full Text Available Seven years after uneventful laser in situ keratomileusis (LASIK, a 48-year-old woman presented one week after being hit with an iron cord with blurry vision, pain, and irritation. The injury resulted in traumatic flap dislocation, epithelial ingrowth, and macrostriae. Following epithelial removal, the flap was refloated and repositioned. Nine interrupted sutures were used to secure the flap. Three-weeks after surgery with no sutures remaining, the epithelial ingrowth and macrostriae had resolved with a visual acuity of 20/20.
Barlas, Athanasios; Akay, Busra
This article describes the design optimization of morphing trailing edge flaps for wind turbines with ‘smart blades’. A high fidelity Fluid Structure Interaction (FSI) simulation framework is utilized, comprised of 2D Finite Element Analysis (FEA) and Computational Fluid Dynamics (CFD) models....... A coupled aero-structural simulation of a 10% chordwise length morphing trailing edge flap for a 4 MW wind turbine rotor is carried out and response surfaces are produced with respect to the flap internal geometry design parameters for the design conditions. Surrogate model based optimization is applied...
Gudjon L. Gunnarsson, MD
Full Text Available Summary:. Total loss of the lower lip is debilitating and poses a reconstructive challenge. Aiming to restore oral continence and function and also cosmetic appearance, a successful reconstruction has a huge impact on the quality of life for the individual patient. Early sources of local tissue rearrangement for lip reconstruction date back 3000 years, with earliest reports of lip switch procedures more than 2 centuries ago in Europe, when noma was still endemic in Europe, indicating that the anatomy was better understood by the barber surgeons of the past than we like to acknowledge. We are still faced with such challenging cases all over the world where resources are limited. Our current understanding of perforator anatomy and blood supply makes more frequent revisits to flaps of the past with modern advances. Innovative solutions are imperative for salvage, and old ideas tend to reappear when they prove to be useful. Herein, we describe in open access a new reconstructive method where we combined a large lip switch flap together with a composite advancement modiolus flap to reconstruct a whole lower lip and the donor defect of the upper lip all at once, a procedure that is simple to perform and works in settings where it is greatly needed.
Ortega-Usobiaga, J; Llovet-Osuna, F; Katz, T; Djodeyre, M R; Druchkiv, V; Bilbao-Calabuig, R; Baviera, J
To assess visual outcomes of retreatment after laser in situ keratomileusis (LASIK) by lifting the flap or performing photorefractive keratectomy (PRK) on the flap, as well as to establish whether there was an increased risk of epithelial ingrowth (EIG) when LASIK and lifting of the flap are separated by a long time interval and to determine the incidence of corneal haze after PRK. Retrospective study of 4077 patients (5468 eyes) who underwent LASIK and subsequent retreatment were reviewed in order to study their visual results and identify cases of EIG and corneal haze. Enhancements included 5196 eyes from 3876 patients that were retreated by lifting the flap, and 272 eyes from 201 patients that were retreated by PRK on the flap. No statistically significant differences were found between the retreatments in terms of predictability, efficacy, and safety. A total of 704 cases of EIG were found after lifting the flap, for which surgical cleansing was necessary in 70. Surgical cleansing decreased the efficacy index when compared with patients with EIG who did not need cleansing (P=.01). Differences in terms of safety and predictability were not statistically significant. The incidence of corneal haze after ablation of the surface of the previous flap was 14.34%, although none of these cases were clinically relevant. Visual outcomes were similar between patients who were retreated by lifting the flap and those who underwent PRK. The incidence of EIG when the flap was lifted was 13.55%. The incidence of EIG increases with the time elapsed between the primary procedure and retreatment. Copyright © 2017 Sociedad Española de Oftalmología. Publicado por Elsevier España, S.L.U. All rights reserved.
Flap endonucleases catalyze cleavage of single-stranded DNA flaps formed during replication, repair and recombination, and are therefore essential for genome processing and stability. Recent crystal structures of DNA-bound human flap endonuclease (hFEN1) offer new insights into how conformational changes in the DNA and hFEN1 may facilitate the reaction mechanism. For example, previous biochemical studies of DNA conformation performed under non-catalytic conditions with Ca2+ have suggested that base unpairing at the 5\\'-flap:template junction is an important step in the reaction, but the new structural data suggest otherwise. To clarify the role of DNA changes in the kinetic mechanism, we measured a series of transient steps - from substrate binding to product release - during the hFEN1-catalyzed reaction in the presence of Mg2+. We found that while hFEN1 binds and bends DNA at a fast, diffusion-limited rate, much slower Mg2+-dependent conformational changes in DNA around the active site are subsequently necessary and rate-limiting for 5\\'-flap cleavage. These changes are reported overall by fluorescence of 2-aminopurine at the 5\\'-flap:template junction, indicating that local DNA distortion (e.g., disruption of base stacking observed in structures), associated with positioning the 5\\'-flap scissile phosphodiester bond in the hFEN1 active site, controls catalysis. hFEN1 residues with distinct roles in the catalytic mechanism, including those binding metal ions (Asp-34, Asp-181), steering the 5\\'-flap through the active site and binding the scissile phosphate (Lys-93, Arg-100), and stacking against the base 5\\' to the scissile phosphate (Tyr-40), all contribute to these rate-limiting conformational changes, ensuring efficient and specific cleavage of 5\\'-flaps.
Sowa, Yoshihiro; Itsukage, Sizu; Sakaguchi, Kouichi; Taguchi, Tetsuya; Numajiri, Toshiaki
The C-V flap for nipple reconstruction is now one of standard surgical techniques. But decreased projection is still a problem. In recent years, it has been suggested that projection can be more easily maintained when raising of the C-flap is performed with a split thickness dermis. In this study, we examined whether decrease of projection can be prevented by raising of a C-flap with a split dermis rather than with full dermis. A total of 49 consecutive patients who underwent reconstruction of a nipple using the C-V flap technique were enrolled. The patients included 22 who underwent surgery using a C-flap with a full thickness dermis (Group F), and 27 who underwent surgery with raising of a flap with a split thickness dermis (Group S). The size of the reconstructed nipple was measured at 2 weeks, 6 months and 1 year postoperatively for comparison between Groups F and S. Partial necrosis of the C-flap end occurred in 4 subjects in only Group S. The decrease in projection after 1 year postoperatively in Group S was significantly lower than that in Group F. In contrast, the teat base size in Group F tended to be greater than that in Group S, suggesting a tendency for an expanded base using a flap with a full dermis. Our results indicated that it is recommended to use a C-flap with a split dermis for cases with high projection of the nipple on the contralateral side.
Song, Bo; Hamdan, Samir; Hingorani, Manju M
Flap endonucleases catalyze cleavage of single-stranded DNA flaps formed during replication, repair and recombination, and are therefore essential for genome processing and stability. Recent crystal structures of DNA-bound human flap endonuclease (hFEN1) offer new insights into how conformational changes in the DNA and hFEN1 may facilitate the reaction mechanism. For example, previous biochemical studies of DNA conformation performed under non-catalytic conditions with Ca2+ have suggested that base unpairing at the 5'-flap:template junction is an important step in the reaction, but the new structural data suggest otherwise. To clarify the role of DNA changes in the kinetic mechanism, we measured a series of transient steps - from substrate binding to product release - during the hFEN1-catalyzed reaction in the presence of Mg2+. We found that while hFEN1 binds and bends DNA at a fast, diffusion-limited rate, much slower Mg2+-dependent conformational changes in DNA around the active site are subsequently necessary and rate-limiting for 5'-flap cleavage. These changes are reported overall by fluorescence of 2-aminopurine at the 5'-flap:template junction, indicating that local DNA distortion (e.g., disruption of base stacking observed in structures), associated with positioning the 5'-flap scissile phosphodiester bond in the hFEN1 active site, controls catalysis. hFEN1 residues with distinct roles in the catalytic mechanism, including those binding metal ions (Asp-34, Asp-181), steering the 5'-flap through the active site and binding the scissile phosphate (Lys-93, Arg-100), and stacking against the base 5' to the scissile phosphate (Tyr-40), all contribute to these rate-limiting conformational changes, ensuring efficient and specific cleavage of 5'-flaps.
Lhuissier, Henri; Villermaux, Emmanuel
When punctured, a flat soap film bursts by opening a hole driven by liquid surface tension. The hole rim does not, however, remain smooth but soon develops indentations at the tip of which ligaments form, ultimately breaking and leaving the initially connex film into a mist of disjointed drops. We report on original observations showing that these indentations result from a flaglike instability between the film and the surrounding atmosphere inducing an oscillatory motion out of its plane. Just like a flag edge flaps in the wind, the film is successively accelerated on both sides perpendicularly to its plane, inducing film thickness modulations and centrifuging liquid ligaments that finally pinch off to form the observed spray. This effect exemplifies how the dynamics of fragile objects such as thin liquid films is sensitive to their embedding medium.
Ristroph, Leif; Zhang, Jun
In aggregates of objects moving through a fluid, bodies downstream of a leader generally experience reduced drag force. This conventional drafting holds for objects of fixed shape, but interactions of deformable bodies in a flow are poorly understood, as in schools of fish. In our experiments on “schooling” flapping flags, we find that it is the leader of a group who enjoys a significant drag reduction (of up to 50%), while the downstream flag suffers a drag increase. This counterintuitive inverted drag relationship is rationalized by dissecting the mutual influence of shape and flow in determining drag. Inverted drafting has never been observed with rigid bodies, apparently due to the inability to deform in response to the altered flow field of neighbors.
Transferências microcirúrgicas do músculo grácil para flexão do cotovelo na lesão do plexo braquial do adulto: estudo retrospectivo de oito casos Microsurgical transfer of the gracilis muscle for elbow flexion in brachial plexus injury in adults: retrospective study of eight cases
Luiz Koiti Kimura
Full Text Available OBJETIVO: O tratamento das lesões do plexo braquial representa um grande desafio, principalmente as lesões tardias, com mais de 12 meses de evolução. Analisamos retrospectivamente pacientes que foram submetidos a uma das possibilidades para tentar restaurar a função do membro superior afetado nestas condições, a transferência microcirúrgica do músculo grácil para flexão do cotovelo. MÉTODOS: Foram incluídos oito pacientes, divididos em dois grupos: um cujo procedimento realizado consistia em neurorrafia do retalho muscular com enxerto de nervo sural e anastomoses mais distais; o outro em que a neurorrafia era realizada diretamente no nervo espinal acessório, e anastomose nos vasos toracoacromiais. RESULTADOS: Encontramos significante diferença entre os grupos, sendo que aqueles submetidos à neurorrafia direta obtiveram resultados satisfatórios em maior número (75% M4 quando comparados com o outro grupo, que fez uso de enxerto para neurorrafia, em que foi menor o sucesso do procedimento (25% M4. CONCLUSÃO: Pacientes submetidos à transferência funcional microcirúrgica do músculo grácil cujas anastomoses vasculares foram realizadas nos vasos toracoacromiais apresentaram melhor resultado funcional do que aqueles que tiveram suas anastomoses realizadas na artéria braquial e consequente utilização de enxerto de nervo.OBJECTIVE: Treating brachial plexus injuries is a major challenge, especially lesions that are presented late, with more than 12 months of evolution. We retrospectively analyzed patients who underwent one of the possibilities for attempting to restore the function of upper limbs affected under such conditions: microsurgical transfer of the gracilis muscle for elbow flexion. METHODS: Eight patients were included, divided into two groups: one in which the procedure consisted of neurorrhaphy of the muscle flap with sural nerve grafting and anastomosis more distally; and the other, in which the neurorrhaphy was
Full Text Available AIM: To research the application of scleral flap suture in trabeculectomy. METHODS: Totally 114 primary angle-closure glaucoma patients, aged from 36-72 years old, were selected as the objects, and randomly divided into research group and control group. The two groups received different administration methods. Traditional sewing method of sclera flap was used in research group and improved sewing method of sclera flap was used in control group. RESULTS: There was statistical differences between postoperative intraocular pressure of the patients in the observation group and the control group after 1d; 2wk; 1, 3mo(PPP>0.05.CONCLUSION: It is safe and effective that the improved sewing method of sclera flap for trabeculectomy of acute angle-closure glaucoma, and it is a better method to avoid the occurrence of shallow anterior chamber than the traditional sewing method in the early stage after operation.
Ghommem, Mehdi; Collier, Nathan; Niemi, Antti; Calo, Victor M.
optimised shapes produce efficient flapping flights, the wake pattern and its vorticity strength are examined. This work described in this paper should facilitate better guidance for shape design of engineered flying systems.
Cifuentes, Ignacio J; Yañez, Ricardo A; Salisbury, Maria C; Rodriguez, José R; Varas, Julian E; Dagnino, Bruno L
Living animal models are frequently used for perforator flap dissection training, but no ex vivo models have been described. The aim of this study is to present a novel nonliving model for perforator flap training based on a constant perforator in the chicken leg. A total of 15 chicken legs were used in this study. Anatomical dissection of the perforator was performed after its identification using ink injection, and in four of these specimens a perforator-based flap was raised. The anatomical dissection revealed a constant intramuscular perforator with a median length of 5.7 cm. Median proximal and distal vessel diameters were 0.93 and 0.4 mm, respectively. The median dissection time was 77.5 minutes. This study introduces a novel, affordable, and reproducible model for the intramuscular dissection of a perforator-based flap using an ex vivo animal model. Its consistent perforator and appropriate-sized vessels make it useful for training.
Zhu, Wei Jun; Shen, Wen Zhong; Sørensen, Jens Nørkær
The present work considers incompressible flow over a 2D airfoil with a deformable trailing edge. The aerodynamic characteristics of an airfoil with a trailing edge flap is numerically investigated using computational fluid dynamics. A novel hybrid immersed boundary (IB) technique is applied...... to simulate the moving part of the trailing edge. Over the main fixed part of the airfoil the Navier-Stokes (NS) equations are solved using a standard body-fitted finite volume technique whereas the moving trailing edge flap is simulated with the immersed boundary method on a curvilinear mesh. The obtained...... results show that the hybrid approach is an efficient and accurate method for solving turbulent flows past airfoils with a trailing edge flap and flow control using trailing edge flap is an efficient way to regulate the aerodynamic loading on airfoils....
Jones, Michael G. (Inventor); Khorrami, Mehdi R. (Inventor); Choudhari, Meelan M. (Inventor); Howerton, Brian M. (Inventor)
One or more acoustic liners comprising internal chambers or passageways that absorb energy from a noise source on the aircraft are disclosed. The acoustic liners may be positioned at the ends of flaps of an aircraft wing to provide broadband noise absorption and/or dampen the noise producing unsteady flow features, and to reduce the amount of noise generated due to unsteady flow at the inboard and/or outboard end edges of a flap.
Taylor, Erin M; Iorio, Matthew L
Background Three-dimensional (3D) printing has developed as a revolutionary technology with the capacity to design accurate physical models in preoperative planning. We present our experience in surgeon-based design of 3D models, using home 3D software and printing technology for use as an adjunct in vascularized bone transfer. Methods Home 3D printing techniques were used in the design and execution of vascularized bone flap transfers to the upper extremity. Open source imaging software was used to convert preoperative computed tomography scans and create 3D models. These were printed in the surgeon's office as 3D models for the planned reconstruction. Vascularized bone flaps were designed intraoperatively based on the 3D printed models. Results Three-dimensional models were created for intraoperative use in vascularized bone flaps, including (1) medial femoral trochlea (MFT) flap for scaphoid avascular necrosis and nonunion, (2) MFT flap for lunate avascular necrosis and nonunion, (3) medial femoral condyle (MFC) flap for wrist arthrodesis, and (4) free fibula osteocutaneous flap for distal radius septic nonunion. Templates based on the 3D models allowed for the precise and rapid contouring of well-vascularized bone flaps in situ, prior to ligating the donor pedicle. Conclusions Surgeon-based 3D printing is a feasible, innovative technology that allows for the precise and rapid contouring of models that can be created in various configurations for pre- and intraoperative planning. The technology is easy to use, convenient, and highly economical as compared with traditional send-out manufacturing. Surgeon-based 3D printing is a useful adjunct in vascularized bone transfer. Level of Evidence Level IV. Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.
Sutthiphong Srigrarom; Woei-Leong Chan
In this paper, an ornithopter prototype that mimics the flapping motion of bird flight is developed, and the lift and thrust generation characteristics of different wing designs are evaluated. This project focused on the spar arrangement and material used for the wings that could achieves improved performance. Various lift and thrust measurement techniques are explored and evaluated. Various wings of insects and birds were evaluated to understand how these natural flyers with flapping wings a...
NAVAL POSTGRADUATE SCHOOL MONTEREY, CALIFORNIA THESIS Approved for public release; distribution is unlimited WATER TUNNEL...Master’s Thesis 4. TITLE AND SUBTITLE WATER TUNNEL STUDIES OF DYNAMIC WING FLAP EFFECTS 5. FUNDING NUMBERS 6. AUTHOR(S) Edgar E. González 7. PERFORMING...ABSTRACT (maximum 200 words ) The flow features developing over a two-element NACA 0012 airfoil, with the rear portion serving as a trailing edge flap
O'Neill, J P
BACKGROUND: With the advent of microsurgery the pedicled flap is considered by many to be an outdated surgical option. AIMS: To explore the relationship between flap survival and pre-morbid risk factors, conduct a comparative analysis of flap and systemic morbidities and complete a cosmesis and functionality assessment for oral and oropharyngeal reconstruction patients. METHODS: 114 patients, over a 13-year period, who had a one-stage reconstructive procedure employing the pectoralis major myocutaneous flap (PMMF) or radial forearm-free flap (RFFF). RESULTS: Variables, including age, smoking and radiation exposure were not statistically significant predictors of flap survival probability. Atelectasis was a significant post-op finding of RFFF patients. Flap dehiscence of >50% was a significant morbidity of PMMF. No statistical difference in cosmetic deformity, diet and socialisation was noted. CONCLUSIONS: Pectoralis major myocutaneous flap remains an enduring and safe flap; however, the RFFF has markedly improved speech performance over the PMMF.
M. Agoes Moelyadi
Full Text Available The unsteady flow behavior and time-dependent aerodynamic characteristics of the flapping motion of a bird’s wing were investigated using a computational method. During flapping, aerodynamic interactions between bird wing surfaces and surrounding flow may occur, generating local time-dependent flow changes in the flow field and aerodynamic load of birds. To study the effect of flapping speed on unsteady aerodynamic load, two kinds of computational simulations were carried out, namely a quasi-steady and an unsteady simulation. To mimic the movement of the down-stroke and the upstroke of a bird, the flapping path accorded to a sinus function, with the wing attitude changing in dihedral angle and time. The computations of time-dependent viscous flow were based on the solution of the Reynolds Averaged Navier-Stokes equations by applying the k-e turbulence model. In addition, the discretization for the computational domain around the model used multi-block structured grid to provide more accuracy in capturing viscous flow, especially in the vicinity of the wing and body surfaces, to obtain a proper wing-body geometry model. For this research, the seagull bird was chosen, which has high aspect ratio wings with pointed wing-tips and a high camber wing section. The results include mesh movement, velocity contours as well as aerodynamic coefficients of the flapping motion of the bird at various flapping frequencies.
Antonyshyn, O.; Colcleugh, R.G.; Hurst, L.N.; Anderson, C.
The present paper investigates the anatomy and vascularization of the temporalis myo-osseous flap. This is a calvarial bone flap that employs temporalis muscle and its distal pericranial extension as a pedicle. In six human cadavers the flap was raised as an island on the anterior deep temporal artery after transecting the zygomatic arch and coronoid process. Maximal mobilization was thus obtained, allowing rotation of the flap into the mouth for intraoral reconstruction. The arc of rotation and potential surgical applications were noted. A comparative study of the temporalis myo-osseous flap and free calvarial bone graft was then conducted in a rabbit model. Vascularization of the calvarial bone flap was confirmed by technetium scintigraphy performed on the first postoperative day. The uptake of fluorochrome labels immediately after transfer verified the adequacy of the periosteal circulation in maintaining viability and new osteoid formation throughout the full thickness of calvarial bone. The transplantation of free calvarial bone grafts was followed by necrosis of most cellular elements. This was demonstrated by an absence of fluorochrome uptake up to 19 days postoperatively and a predominance of empty lacunae and nonviable marrow
Pauchet, D; Pigot, J-L; Chabolle, F; Bach, C-A
Free fibula transplant is routinely used for mandibular reconstruction in head and neck cancer. Dental rehabilitation, the objective of mandibular reconstruction, requires the use of dental implants as supports for fixed or removable dentures. Positioning of fibular bone grafts and implants determines implant osseointegration and the possibilities of dental rehabilitation. Prefabrication of a fibula free flap with dental implants prior to harvesting as a free flap can promote implant osseointegration. The position of the implants must then be precisely planned. Virtual surgery and computer-assisted design and prefabrication techniques are used to plan the reconstruction and then reproduce this planning by means of tailored fibula and mandible cutting guides, thereby ensuring correct positioning of fibular bone fragments and implants. The prefabricated fibula free flap technique requires two surgical procedures (prefabrication and flap transfer) and precise preoperative planning. Prefabricated fibula free flap with dental implants, by improving the quality of osseointegration of the implants before flap transfer, extends the possibilities of prosthetic rehabilitation in complex secondary mandibular reconstructions. Copyright © 2018 Elsevier Masson SAS. All rights reserved.
Baek, Rongmin; Heo, Chanyeong; Kim, Baek-kyu
Romberg disease is an uncommon condition manifested by progressive hemifacial atrophy of the skin, soft tissue, and bone. Facial asymmetry with soft tissue deficiency in Romberg disease causes a significant disability affecting the social life and can bring about many psychological problems. The aim of surgical treatment is cosmetic amelioration of the defect. Several conventional reconstructive procedures have been used for correcting facial asymmetry. They include fat injections, dermal fat grafts, filler injections, cartilage and bone grafts, and pedicled and free flaps. We report our experiences with 11 patients involving 11 free flaps with a minimum 1-year follow-up. All patients were classified as having moderate to severe atrophy. The average age at disease onset was 4.5 years; the average duration of atrophy was 5.2 years. No patients were operated on with a quiescent interval of less than 1 year. The average age at operation was 20.1 years, ranging from 10 to 55 years. Reconstruction was performed using 4 groin dermofat free flaps, 4 latissimus dorsi muscle free flaps, and 3 other perforator flaps. To achieve the finest symmetrical and aesthetic results, several ancillary procedures were performed in 4 patients. These procedures included Le Fort I leveling osteotomy, sagittal split ramus osteotomy, reduction malarplasty and angle plasty, rib and calvarial bone graft, correction of alopecia, and additional fat graft. All patients were satisfied with the results. We believe that a free flap transfer is the requisite treatment modality for severe degree of facial asymmetry in Romberg disease.
Full Text Available An analysis of 2D subsonic flow over an NACA 0015 airfoil with a 30% trailing edge flap at a constant Reynolds number of 106 for various incidence angles and a range of flap deflections is presented. The steady-state governing equations of continuity and momentum conservation are solved combined with the realizable k-ε turbulence model using the ANSYS-Fluent code (Version 13.7, ANSYS, Inc., Canonsburg, PA, USA. The primary objective of the study is to provide a comprehensive understanding of flow characteristics around the NACA 0015 airfoil as a function of the angle of attack and flap deflection at Re = 106 using the realizable k-ε turbulence model. The results are validated through comparison of the predictions with the free field experimental measurements. Consistent with the experimental observations, the numerical results show that increased flap deflections increase the maximum lift coefficient, move the zero-lift angle of attack (AoA to a more negative value, decrease the stall AoA, while the slope of the lift curve remains unchanged and the curve just shifts upwards. In addition, the numerical simulations provide limits for lift increment Δ C l and Cl, max values to be 1.1 and 2.2, respectively, obtained at a flap deflection of 50°. This investigation demonstrates that the realizable k-ε turbulence model is capable of predicting flow features over an airfoil with and without flap deflections with reasonable accuracy.
Nangole F. Wanjala
Full Text Available Persistent posttraumatic CSF fluid leakage may present a challenge to manage. Failure to address the leakage may result in complications such as meningitis, septicemia, radiculopathy, muscle weakness, and back pains. While the majority of the leakages may be managed conservatively, large dura defects as a result of gunshot wounds or motor vehicle accidents are best managed by surgical interventions. This may range from primary closure of the defect to fascial grafts, adhesive glues, and flaps. We present our experience with the use of flaps in a patient who had sustained such wounds in the thoracic spine. An island latissimus dorsal flap and a perforator fasciocutaneous flap were used to close the defect. Postoperatively the patient recovered well and the wounds healed without any complications.
E. Cabrera Sánchez
Full Text Available La reconstrucción mamaria tras mastectomía se realiza primordialmente para proporcionar calidad de vida a la paciente. Este estudio se desarrolló para valorar la satisfacción y calidad de vida de las pacientes reconstruidas mediante colgajo D.I.E.P. (Deep Inferior Epigastric Perforator y evaluar el resultado estético de la reconstrucción. Treinta y tres pacientes, de 51 reconstrucciones mamarias con colgajo DIEP realizadas entre enero de 2000 y noviembre de 2004 fueron preguntadas acerca de aspectos generales relativos a la cirugía, imagen corporal y sensación subjetiva. El resultado de imagen corporal fue evaluado por dos observadores externos, un cirujano plástico y una enfermera, además de por la propia paciente. Para valorar la reconstrucción mamaria, se utilizó una escala de 4 puntos. La satisfacción general de nuestro estudio fue más elevada que la observada en estudios precedentes. Hemos conseguido una valoración alta en simetría, dentro de los parámetros objetivos y en integridad corporal entre los subjetivos. Hemos encontrado una correlación alta entre las respuestas de los observadores comparada con las respuestas de las propias pacientes. Por último, hemos visto una fuerte correlación entre integridad corporal y satisfacción generalBreast reconstructions after breast cancer surgery are primarily performed to improve patient’s quality of life. This study investigates patient’s satisfaction and quality of life with breast reconstruction after deep inferior epigastric perforator (D.I.E.P. flap surgery and to evaluate the aesthetic result of the breast reconstruction. Thirty-three patiens, from fifty-one DIEP breast reconstruction made between january 2000 and december 2004 were answered about three questionnaires concerning to general aspect, body image, and subjective sensation. The body image outcome was also evaluated by one plastic surgeon and a nurse. The panel evaluated breast reconstruction on 4 subescales
Full Text Available In this paper, an ornithopter prototype that mimics the flapping motion of bird flight is developed, and the lift and thrust generation characteristics of different wing designs are evaluated. This project focused on the spar arrangement and material used for the wings that could achieves improved performance. Various lift and thrust measurement techniques are explored and evaluated. Various wings of insects and birds were evaluated to understand how these natural flyers with flapping wings are able to produce sufficient lift to fly. The differences in the flapping aerodynamics were also detailed. Experiments on different wing designs and materials were conducted and a paramount wing was built for a test flight. The first prototype has a length of 46.5 cm, wing span of 88 cm, and weighs 161 g. A mechanism which produced a flapping motion was fabricated and designed to create flapping flight. The flapping flight was produced by using a single motor and a flexible and light wing structure. A force balance made of load cell was then designed to measure the thrust and lift force of the ornithopter. Three sets of wings varying flexibility were fabricated, therefore lift and thrust measurements were acquired from each different set of wings. The lift will be measured in ten cycles computing the average lift and frequency in three different speeds or frequencies (slow, medium and fast. The thrust measurement was measure likewise but in two cycles only. Several observations were made regarding the behavior of flexible flapping wings that should aid in the design of future flexible flapping wing vehicles. The wings angle or phase characteristic were analyze too and studied. The final ornithopter prototype weighs only 160 g, has a wing span of 88.5 cm, that could flap at a maximum flapping frequency of 3.869 Hz, and produce a maximum thrust and lift of about 0.719 and 0.264 N respectively. Next, we proposed resonance type flapping wing utilizes the near
Dalli, Uğbreve;ur; Yüksel, Şcedilefaatdin
An active control method utilizing the multiple trailing edge flap configuration for rotorcraft vibration suppression and blade loads control is presented. A comprehensive model for rotor blade with active trailing edge flaps is used to calculate the vibration characteristics, natural frequencies and mode shapes of any complex composite helicopter rotor blade. A computer program is developed to calculate the system response, rotor blade root forces and moments under aerodynamic forcing condit...
Clavin, H D; Owsley, J Q
A combinaation vomer mucoperiosteal flap and nasal floor mucoperiosteal flap is described which is used to achieve nasal coverage in unilateral cleft palate patients requiring pushbacks. A posteriorly based readily accessible vomer flap is raised on the cleft side and used as nasal lining for the palatal mucoperiosteal flap on the non-cleft side. On the cleft side, a symmetrically sized nasal floor flap is easily elevated under direct vision and used to cover the nasal aspect of the corresponding mucoperiosteal palatal flap.
Hekner, D D; Roeling, T A P; Van Cann, E M
The aim of this study was to investigate the vascular anatomy of the distal forearm in order to optimize the choice between the radial forearm free flap and the ulnar forearm free flap and to select the best site to harvest the flap. The radial and ulnar arteries of seven fresh cadavers were injected with epoxy resin (Araldite) and the perforating arteries were dissected. The number of clinically relevant perforators from the radial and ulnar arteries was not significantly different in the distal forearm. Most perforators were located in the proximal half of the distal one third, making this part probably the safest location for flap harvest. Close to the wrist, i.e. most distally, there were more perforators on the ulnar side than on the radial side. The ulnar artery stained 77% of the skin surface area of the forearm, showing the ulnar forearm free flap to be more suitable than the radial forearm free flap for the restoration of large defects. Copyright © 2016 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Grant, Michael D
One of the most challenging procedures in breast surgery is the skin-sparing mastectomy (SSM). Various techniques and incisions have evolved that characterize this procedure; however, what is common in all of them is the smaller the incision, the more difficult it is to develop the skin flaps. A procedure was developed that incorporates the use of liposuction cannulas (without suction) to create the skin flaps. The technique and results are described in this manuscript. From October of 2012 to April 2014, 289 mastectomies (171 patients) were performed using the CAFE procedure on women of all shapes and sizes. Postoperatively, no problems were experienced with flap viability using this technique. The main difference in side effects between the CAFE technique and other standard techniques for developing flaps in SSMs was more bruising than normal, but this resolved rapidly. The results for use of this technique were consistently impressive. The learning curve for this procedure is very short, especially for those who perform SSMs using sharp technique (scissors). Residents and fellows became proficient with the CAFE technique in a relatively short amount of time. Plastic surgeons were pleased with the cosmetic outcomes of their reconstructions that follow this type of mastectomy. Patients were extremely satisfied with their reconstructions as well. Incorporating the use of liposuction cannulas (without suction) makes the creation of flaps for SSM a relatively simple and rapid method. It is especially useful to assist in developing skin flaps with even the smallest of skin incisions.
Gonzalez-Darder, J.M.; Pesudo-Martinez, J.V.; Feliu-Tatay, R.A.
Objective. To study the possibilities of the microsurgical management of ruptured intracranial aneurysms with the sole preoperative information provided by computed tomography angiography with three-dimensional reconstruction (3D-CTA). Methods. Patients were studied with 3D-CTA after diagnosis of subarachnoid hemorrhage. If the study had an adequate quality and revealed an aneurysm congruent with the clinical findings or neurological examination and/or with the location of the bleeding on computed tomography (CT) scan an early microsurgical clipping of the lesion was done. When the quality of the 3D-CTA study was not adequate or the quality being adequate displayed no lesions or the findings were not accurate enough to warrant direct microsurgical treatment, the patient was studied with cerebral digital substraction (DS) angiography. A total of 44 consecutive patients harboring a total of 47 intracranial aneurysms diagnosed by 3D-CTA and without preoperative DS angiography were submitted to microsurgical clipping and included in the study. Results. The overall mortality was 15.9 % and the favorable results evaluated 6 months after discharge by means of the Glasgow outcome scale reached 70.4 %. All lesions were successfully clipped. Surgery was done a mean of 4.1 days after the admission bleeding. A total of four microlesions undiagnosed by 3D-CTA were found at surgery and clipped. Postoperative DS angiography and necropsy findings were also used as control of the 3D-CTA findings but no additional information was provided excepting the finding in DS angiography of an asymptomatic intracavemous aneurysm. Therefore the sensitivity of the 3D-CTA for diagnosis of symtomatic aneurysms was 100 % and the overall sensitivity 90.4 %. Conclusions. We have reached similar results in patients operated on with or without preoperative angiography. 3D-CTA provides very valuable anatomical information, which has an additional value in the microsurgical treatment of aneurysms of the
Tarantino, Mary E; Bilotti, Katharina; Huang, Ji; Delaney, Sarah
Flap endonuclease 1 (FEN1) is a structure-specific nuclease responsible for removing 5'-flaps formed during Okazaki fragment maturation and long patch base excision repair. In this work, we use rapid quench flow techniques to examine the rates of 5'-flap removal on DNA substrates of varying length and sequence. Of particular interest are flaps containing trinucleotide repeats (TNR), which have been proposed to affect FEN1 activity and cause genetic instability. We report that FEN1 processes substrates containing flaps of 30 nucleotides or fewer at comparable single-turnover rates. However, for flaps longer than 30 nucleotides, FEN1 kinetically discriminates substrates based on flap length and flap sequence. In particular, FEN1 removes flaps containing TNR sequences at a rate slower than mixed sequence flaps of the same length. Furthermore, multiple-turnover kinetic analysis reveals that the rate-determining step of FEN1 switches as a function of flap length from product release to chemistry (or a step prior to chemistry). These results provide a kinetic perspective on the role of FEN1 in DNA replication and repair and contribute to our understanding of FEN1 in mediating genetic instability of TNR sequences. © 2015 by The American Society for Biochemistry and Molecular Biology, Inc.
Full Text Available INTRODUCTION : Face represents complete personality of human being. Cosmetically it is very important part of a person especially for woman. There are many situations when due to disease or trauma, facial defect arises, which requires reconstruction by either local or distant surgical flaps . METHODS AND MATERIALS : In rural places, we come across many patients suffering from trauma and skin malignancy of face. These patients require reconstruction done esthetically with local flaps. Objective of this study is to share our exper ience of providing esthetically good results at our secondary referral care center. Hereby, we present case series of 14 patients operated at our institute. These patients were analyzed according to the age, sex, nature of injury and anatomical location of lesion on the face. All these patients were operated and reconstruction of defect was done with various local flaps best suited for respective lesion, under local anesthesia or sedation. Post - operative nature of wound was analyzed for flap viability or fl ap necrosis . RESULTS : Amongst them were 7 male and 7 female, ages ranging from 4 to 80 years. 7out of 14 patients were of basal cell carcinoma, 4 were due to trauma, 2 were due to dog bite and 1 case of recurrent pleomorphic adenoma at root of nose. All patients had excellent flap viability at end of 6 months and flap achieving almost similar color and contour as that of surrounding skin. CONCLUSION : Reconstruction of facial defects by local flaps is very easy and cost effective technique. This can be don e even at secondary referral care centre with minimal availability of facilities
Li, Ke; Zhang, Zheng; Nicoli, Fabio; D'Ambrosia, Christopher; Xi, Wenjing; Lazzeri, Davide; Feng, Shaoqing; Su, Weijie; Li, Hua; Ciudad, Pedro; Tremp, Mathias; Zhang, Yi Xin
The vascularization of the distal portions of transferred tissue represents the most critical factor in the success of reconstructive surgery. In recent years, indocyanine green (ICG) fluorescence imaging techniques have been applied during surgery to evaluate flap perfusion. However, this investigation has found that there is little consensus regarding the standard dose of ICG as well as the pre-operative requirements of ICG allergy testing. The aim of this study is to summarize the applications of ICG to tissue transfers and safe dosing practices and to provide insight to the possible adverse effects of ICG on flap surgery with the goal of helping clinicians apply ICG safely and efficiently to tissue transfer procedures. A literature search was performed using, Wiley InterScience, and Springer with the key words, 'Flap,' 'indocyanine green,' 'surgery,' and related mesh words for all publications between 2005 and 2015. Title and abstract screening was performed using predefined in- and exclusion criteria. Seventy-three articles were included. These were classified as "application of ICG in flap surgery" and "the security of applying ICG in flap surgery". ICG fluorescence imaging preoperatively facilitates the detection of perforators in tissue flaps with thickness <20 mm, aids in the evaluation of flap microcirculation and perfusion, and allows surgeons to select dominant cutaneous nerves while evaluating the quality of vascular anastomoses and locating thromboses. The literature also concluded that potential allergic reactions to ICG should be taken into consideration. Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.
Morita, Akio; Sora, Shigeo; Mitsuishi, Mamoru; Warisawa, Shinichi; Suruman, Katopo; Asai, Daisuke; Arata, Junpei; Baba, Shoichi; Takahashi, Hidechika; Mochizuki, Ryo; Kirino, Takaaki
To enhance the surgeon's dexterity and maneuverability in the deep surgical field, the authors developed a master-slave microsurgical robotic system. This concept and the results of preliminary experiments are reported in this paper. The system has a master control unit, which conveys motion commands in six degrees of freedom (X, Y, and Z directions; rotation; tip flexion; and grasping) to two arms. The slave manipulator has a hanging base with an additional six degrees of freedom; it holds a motorized operating unit with two manipulators (5 mm in diameter, 18 cm in length). The accuracy of the prototype in both shallow and deep surgical fields was compared with routine freehand microsurgery. Closure of a partial arteriotomy and complete end-to-end anastomosis of the carotid artery (CA) in the deep operative field were performed in 20 Wistar rats. Three routine surgical procedures were also performed in cadavers. The accuracy of pointing with the nondominant hand in the deep surgical field was significantly improved through the use of robotics. The authors successfully closed the partial arteriotomy and completely anastomosed the rat CAs in the deep surgical field. The time needed for stitching was significantly shortened over the course of the first 10 rat experiments. The robotic instruments also moved satisfactorily in cadavers, but the manipulators still need to be smaller to fit into the narrow intracranial space. Computer-controlled surgical manipulation will be an important tool for neurosurgery, and preliminary experiments involving this robotic system demonstrate its promising maneuverability.
Tayebi Meybodi, Ali; Lawton, Michael T; Mokhtari, Pooneh; Yousef, Sonia; Gandhi, Sirin; Benet, Arnau
Animal models using rodents are frequently used for practicing microvascular anastomosis-an essential technique in cerebrovascular surgery. However, safely and efficiently exposing rat's target vessels is technically difficult. Such difficulty may lead to excessive hemorrhage and shorten animal survival. This limits the ability to perform multiple anastomoses on a single animal and may increase the overall training time and costs. We report our model for microsurgical bypass training in rodents in 2 consecutive articles. In part 1, we describe the technical nuances for a safe and efficient exposure of the rat abdominal aorta and common iliac arteries (CIAs) for bypass. Over a 2-year period, 50 Sprague-Dawley rats underwent inhalant anesthesia for practicing microvascular anastomosis on the abdominal aorta and CIAs. Lessons learned regarding the technical nuances of vessel exposure were recorded. Several technical nuances were important for avoiding intraoperative bleeding and preventing animal demise while preparing an adequate length of vessels for bypass. The most relevant technical nuances include (1) generous subcutaneous dissection; (2) use of cotton swabs for the blunt dissection of the retroperitoneal fat; (3) combination of sharp and blunt dissection to isolate the aorta and iliac arteries from the accompanying veins; (4) proper control of the posterior branches of the aorta; and (5) efficient division and mobilization of the left renal pedicle. Applying the aforementioned technical nuances enables safe and efficient preparation of the rat abdominal aorta and CIAs for microvascular anastomosis. Copyright © 2017 Elsevier Inc. All rights reserved.
Rogério de Castro Bittencourt
Full Text Available PURPOSE: To evaluate the influence of minoxidil, a well known vasodilator, on ischemic flap necrosis prevention in rats. METHODS: Ventral cutaneous flaps, measuring 8x4cm, were designed in 20 Wistar rats based on the right cranial epigastric artery. In the experiment group, 50 mg/kg/day of minoxidil sulfate was administered by orogastric tube and the same amount of saline solution was administered to the control group. Such procedure was initiated 24h before surgery and kept once a day through the 7th postoperative day. Microcirculation was evaluated with laser fluxometry 24h before surgical procedure, at immediate postoperative and at the 7th postoperative day. Flap necrosis area was evaluated by 2 methods: planimetry and weight/paper ratio. RESULTS: A significant flow increase in distal and medial extremity at M1 (medial point 1 (p=0,0484 was observed in the experiment group. There was significant difference in flap necrosis prevention in the experiment group (p=0,0433, although after necrosis took place there was no significant difference in necrosis size. (p=0,1051 and p=0,2799. CONCLUSION: Minoxidil sulfate is effective in avoiding necrosis in ischemic flaps, but after necrosis is present there is no difference in survival area between experimental and control groups.OBJETIVOS: Avaliar a influência do minoxidil, um vasodilatador, na prevenção de necrose, em retalhos isquêmicos, em ratos. MÉTODOS: Preparam-se retalhos cutâneos ventrais, medindo 8x4 cm, baseados na artéria epigástrica cranial direita, em 20 ratos - Wistar. Administrou-se 50 mg/kg/dia de sulfato de minoxidil aos ratos do grupo experimento e o mesmo volume de solução salina isotônica aos do grupo controle, por sonda oro-gástrica. Iniciou-se o tratamento 24 horas antes da operação e manteve-se, diariamente, por 7 dias, no pós-operatório. Realizou-se a avaliação da microcirculação dos retalhos fluxometria a laser 24 horas antes da operação, no p
Mohammad Sayed Abdel-Kader
Conclusion: Free penile skin flaps offer good results (functional and cosmetic in long anterior urethral stricture. Meticulously fashioned longitudinal, circular or spiral penile skin flaps could bridge urethral defects up to 15 cm long.
Conclusion: Continuous non-invasive tissue oxygen saturation is suitable for postoperative monitoring of DIEP-flaps, and StO2 pattern may aid in early identification of vascular compromise in DIEP-flaps.
Steven F. S. Korteweg, MD
Conclusions: The ESS is a useful instrument to score the severity of paralytic ectropion. The periosteal flap canthoplasty is an effective procedure, with durable results in paralytic ectropion patients. The same periosteal flap can be used in a revision procedure.
Shyy, Wei; Berg, Mats; Ljungqvist, Daniel
Micro air vehicles (MAVs) with wing spans of 15 cm or less, and flight speed of 30-60 kph are of interest for military and civilian applications. There are two prominent features of MAV flight: (i) low Reynolds number (10 4-10 5), resulting in unfavorable aerodynamic conditions to support controlled flight, and (ii) small physical dimensions, resulting in certain favorable scaling characteristics including structural strength, reduced stall speed, and low inertia. Based on observations of biological flight vehicles, it appears that wing motion and flexible airfoils are two key attributes for flight at low Reynolds number. The small size of MAVs corresponds in nature to small birds, which do not glide like large birds, but instead flap with considerable change of wing shape during a single flapping cycle. With flapping and flexible wings, birds overcome the deteriorating aerodynamic performance under steady flow conditions by employing unsteady mechanisms. In this article, we review both biological and aeronautical literatures to present salient features relevant to MAVs. We first summarize scaling laws of biological and micro air vehicles involving wing span, wing loading, vehicle mass, cruising speed, flapping frequency, and power. Next we discuss kinematics of flapping wings and aerodynamic models for analyzing lift, drag and power. Then we present issues related to low Reynolds number flows and airfoil shape selection. Recent work on flexible structures capable of adjusting the airfoil shape in response to freestream variations is also discussed.
Sampathirao, Leela Mohan C S R; Thankappan, Krishnakumar; Duraisamy, Sriprakash; Hedne, Naveen; Sharma, Mohit; Mathew, Jimmy; Iyer, Subramania
Background The purpose of this study is to evaluate the outcome of orbital floor reconstruction with free flaps after maxillectomy. Methods This was a retrospective analysis of 34 consecutive patients who underwent maxillectomy with orbital floor removal for malignancies, reconstructed with free flaps. A cross-sectional survey to assess the functional and esthetic outcome was done in 28 patients who were alive and disease-free, with a minimum of 6 months of follow-up. Results Twenty-six patients had bony reconstruction, and eight had soft tissue reconstruction. Free fibula flap was the commonest flap used (n = 14). Visual acuity was normal in 86%. Eye movements were normal in 92%. Abnormal globe position resulted in nine patients. Esthetic satisfaction was good in 19 patients (68%). Though there was no statistically significant difference in outcome of visual acuity, eye movement, and patient esthetic satisfaction between patients with bony and soft tissue reconstruction, more patients without bony reconstruction had abnormal globe position (p = 0.040). Conclusion Free tissue transfer has improved the results of orbital floor reconstruction after total maxillectomy, preserving the eye. Good functional and esthetic outcome was achieved. Though our study favors a bony orbital reconstruction, a larger study with adequate power and equal distribution of patients among the groups would be needed to determine this. Free fibula flap remains the commonest choice when a bony reconstruction is contemplated.
A. C. Salgarelli
Full Text Available Reconstruction of nasal defects must preserve the integrity of complex facial functions and expressions, as well as facial symmetry and a pleasing aesthetic outcome. The reconstructive modality of choice will depend largely on the location, size, and depth of the surgical defect. Individualized therapy is the best course, and numerous flaps have been designed to provide coverage of a variety of nasal-specific defects. We describe our experience in the aesthetic reconstruction of nasal skin defects following oncological surgery. The use of different local flaps for nasal skin cancer defects is reported in 286 patients. Complications in this series were one partial flap dehiscence that healed by secondary intention, two forehead flaps, and one bilobed flap with minimal rim necrosis that resulted in an irregular scar requiring revision. Aesthetic results were deemed satisfactory by all patients and the operating surgeons. The color and texture matches were aesthetically good, and the nasal contour was distinct in all patients. All scars were inconspicuous and symmetrical. No patient had tenting or a flat nose.
Full Text Available It was a revolutionary enhancement for lower limb reconstruction when fasciocutaneous flaps were first described and used in clinical practice in 1981. Subsequently persistent studies were made to emphasize and confirm the rich vascular network associated with deep fascia. Thereafter studies were directed to identify the various types of perforators supplying the deep fascia and the overlying subcutaneous tissue and skin. Accordingly the scientists classified these flaps keeping in mind their clinical applications. The authors of this article have also performed extensive research on various aspects. This has led to better understanding about the finer details of vascularity. Based on this various modifications have been made for safe application of reconstruction for defects extending from knee to sole. To avoid complications the clinician should be able to select the proper procedure as regards the donor site and the possible preoperative and postoperative technical faults. A well-designed and meticulously executed flap usually has smooth recovery. Both Colour Doppler and Audio Doppler are useful tools in planning a safe flap. Now these flaps have proved to be standard technique without requiring a special set up extensive training.
Salgarelli, A. C.; Bellini, P.; Multinu, A.; Consolo, U.; Magnoni, C.; Francomano, M.; Fantini, F.; Seidenari, S.
Reconstruction of nasal defects must preserve the integrity of complex facial functions and expressions, as well as facial symmetry and a pleasing aesthetic outcome. The reconstructive modality of choice will depend largely on the location, size, and depth of the surgical defect. Individualized therapy is the best course, and numerous flaps have been designed to provide coverage of a variety of nasal-specific defects. We describe our experience in the aesthetic reconstruction of nasal skin defects following oncological surgery. The use of different local flaps for nasal skin cancer defects is reported in 286 patients. Complications in this series were one partial flap dehiscence that healed by secondary intention, two forehead flaps, and one bilobed flap with minimal rim necrosis that resulted in an irregular scar requiring revision. Aesthetic results were deemed satisfactory by all patients and the operating surgeons. The color and texture matches were aesthetically good, and the nasal contour was distinct in all patients. All scars were inconspicuous and symmetrical. No patient had tenting or a flat nose.
Woolard, H. W.
Thin airfoil theories of an ejector flapped wing section are reviewed. The global matching of the external airfoil flow with the ejector internal flow and the overall ejector flapped wing section aerodynamic performance are examined. Mathematical models of the external and internal flows are presented. The delineation of the suction flow coefficient characteristics are discussed. The idealized lift performance of an ejector flapped wing relative to a jet augmented flapped wing are compared.
Yang, Heping; Zhang, Hongwu; Chen, Haidi; Yang, Shuxiong; Wang, Jun; Hu, Dawang
To compare the effectiveness of complex defects repair between using chimeric anterolateral thigh flap and series-wound flaps after resection of oral and maxillofacial cancer. After resection of oral and maxillofacial cancer, defect was repaired with chimeric anterolateral thigh flap in 39 patients between January 2011 and July 2014 (chimeric anterolateral thigh flap group); and defect was repaired with series-wound flaps in 35 patients between January 2009 and December 2010 (series-wound flaps group). There was no significant difference in gender, age, duration of disease, tumor type, tumor staging, defect location, and defect area between 2 groups (P > 0.05). The operation time, flap harvesting and microvascular anastomosis time, stomach tube extraction time, and oral feeding time were recorded and compared between 2 groups, and postoperative complications were observed; the effectiveness was evaluated according to clinical efficacy evaluation table of bone and soft tissue defects reconstruction surgery in oral and maxillofacial region. Vascular crisis occurred in 2 cases of chimeric anterolateral thigh flap group, and 4 cases of series-wound flaps group. Partial necrosis appeared at distal end of a series-wound flaps, and oral fistula and infection developed in 3 series-wound flaps. The other flaps and the grafted skin at donor site survived; wounds at recipient site healed by first intention. The operation time, stomach tube extraction time, and oral feeding time of chimeric anterolateral thigh flap group were significantly shorter than those of series-wound flaps group (P oral closure function, chew, language performance, and swallowing scores of the chimeric anterolateral thigh-flap group were significantly better than those of the series-wound flaps group (P oral cavity holding water test, and occlusion scores between the 2 groups (P > 0.05). Using chimeric anterolateral thigh flap for defect repair after resection of oral and maxillofacial cancer can
Nemiroff, P.M.; Merwin, G.E.; Brant, T.; Cassisi, N.J.
This study investigated the effects of hyperbaric oxygen (HBO) and irradiation (RT) on experimental skin flaps in rats under varying conditions. Animals were assigned at random to 1 of 15 groups that represented all possible ordering effects of HBO, RT, and flap, as well as controls that included flap-only, RT-only, and HBO-only groups. Cranially based skin flaps measuring 3 x 9 cm were elevated on the dorsum. The surviving length was evaluated with fluorescein dye 7 days after the operation. Depending on the treatment condition, HBO was given either 48 hours or 24 hours before flap elevation, or within 4 hours or 48 hours after flap elevation. Rats receiving RT ( 60 Co) were given a single dose of 1000 rads to the dorsum. Results showed that all groups receiving HBO within 4 hours after flap elevation had significantly greater flap survival length, with as much as a 22% greater length of surviving flap. HBO given 48 hours before flap elevation also significantly improved flap survival over controls. RT appeared to have no immediate significant effect on flap survival. However, rats receiving RT, regardless of other factors, gained significantly less weight than did controls. Findings clearly indicate that, to be effective, HBO needs to be given as soon after surgery as possible
Krammer, Caspar W; Ibrahim, Rami Mossad; Hansen, Tom G
BACKGROUND: Intraoperative reduction in arterial pressure may cause hypoperfusion of skin flaps, which may increase the risk of flap failure. There is no international consensus regarding the use of vasoactive or inotropic agents to restore or maintain flap perfusion. The purpose of this study...
Yoon, Tae Ho; Yun, In Sik; Rha, Dong Kyun; Lee, Won Jai
Classical flaps for perinasal defect reconstruction, such as forehead or nasolabial flaps, have some disadvantages involving limitations of the arc of rotation and two stages of surgery. However, a perforator-based flap is more versatile and allows freedom in flap design. We introduced our experience with reconstruction using a facial artery perforator-based propeller flap on the perinasal area. We describe the surgical differences between different defect subtypes. Between December 2005 and August 2013, 10 patients underwent perinasal reconstruction in which a facial artery perforator-based flap was used. We divided the perinasal defects into types A and B, according to location. The operative results, including flap size, arc of rotation, complications, and characteristics of the perforator were evaluated by retrospective chart review and photographic evaluation. Eight patients were male and 2 patients were female. Their mean age was 61 years (range, 35-75 years). The size of the flap ranged from 1 cm×1.5 cm to 3 cm×6 cm. Eight patients healed uneventfully, but 2 patients presented with mild flap congestion. However, these 2 patients healed by conservative management without any additional surgery. All of the flaps survived completely with aesthetically pleasing results. The facial artery perforator-based flap allowed for versatile customized flaps, and the donor site scar was concealed using the natural nasolabial fold.
Tsutakawa, Susan E.
DNA replication and repair enzyme Flap Endonuclease 1 (FEN1) is vital for genome integrity, and FEN1 mutations arise in multiple cancers. FEN1 precisely cleaves single-stranded (ss) 5\\'-flaps one nucleotide into duplex (ds) DNA. Yet, how FEN1 selects for but does not incise the ss 5\\'-flap was enigmatic. Here we combine crystallographic, biochemical and genetic analyses to show that two dsDNA binding sites set the 5\\'polarity and to reveal unexpected control of the DNA phosphodiester backbone by electrostatic interactions. Via phosphate steering\\', basic residues energetically steer an inverted ss 5\\'-flap through a gateway over FEN1\\'s active site and shift dsDNA for catalysis. Mutations of these residues cause an 18,000-fold reduction in catalytic rate in vitro and large-scale trinucleotide (GAA) repeat expansions in vivo, implying failed phosphate-steering promotes an unanticipated lagging-strand template-switch mechanism during replication. Thus, phosphate steering is an unappreciated FEN1 function that enforces 5\\'-flap specificity and catalysis, preventing genomic instability.
Jun Sik Kim
Full Text Available Squamous cell carcinoma infrequently occurs at the soft palate. Although various methodscan be used for reconstruction of soft palate defects that occur after resecting squamous cellcarcinoma, it is difficult to obtain satisfactory results from the perspective of the functionalrestoration of the soft palate. A combination of bilateral palatal mucomuscular flap for theoral side and superiorly based posterior pharyngeal flap for the nasal side were performed ontwo patients who were diagnosed with squamous cell carcinoma of the soft palate in orderto reconstruct the soft palate defects after surgical resection. After surgery, the patients werefollowed-up for a mean period of 11 months. The flaps were well maintained in both patients.The donor site defects were epithelialized and completely recovered. Additionally, no recurrenceof the primary sites was shown. Slight hyponasality was observed in the voice assessmentsthat were conducted 6 months after surgery. No food regurgitation or aspiration was observedin the swallowing tests. We used a combination of bilateral palatal mucomuscular flap andsuperiorly based posterior pharyngeal flap to reconstruct the soft palate defects that occurredafter resecting the squamous cell carcinomas. We reduced the donor site complications andachieved functionally satisfactory outcomes.
Ghommem, Mehdi; Hajj, M. R.; Mook, Dean T.; Stanford, Bret K.; Bé ran, Philip S.; Watson, Layne T.
The kinematics of a hovering wing are optimized by combining the 2-d unsteady vortex lattice method with a hybrid of global and local optimization algorithms. The objective is to minimize the required aerodynamic power under a lift constraint. The hybrid optimization is used to efficiently navigate the complex design space due to wing-wake interference present in hovering aerodynamics. The flapping wing is chosen so that its chord length and flapping frequency match the morphological and flight properties of two insects with different masses. The results suggest that imposing a delay between the different oscillatory motions defining the flapping kinematics, and controlling the way through which the wing rotates at the end of each half stroke can improve aerodynamic power under a lift constraint. Furthermore, our optimization analysis identified optimal kinematics that agree fairly well with observed insect kinematics, as well as previously published numerical results.
Luce, E A; McClinton, M; Hoopes, J E
We analyzed all 104 island flap pushback palatal repairs done through our Facial Rehabilitation Clinic in the period from 1965 to 1971. The results were compared to those in a group of 109 standard pushback repairs. The island flap group had a higher incidence of operative complications, of velopharyngeal insufficiency, and of secondary procedures to correct the latter. (The differences between the two groups were not statistically significant, however.) In this group of patients the island flap repair offered no particular advantage over the V-Y or the Dorrance pushback; in fact, it may have been deleterious. A hypothetical explanation for these results is offered, based on possible continuing osteogenesis by the transplanted mucoperiosteum, to produce an inflexible and poorly functioning velum.
Balakrishnan, Shankar K.; Shariff, Karim R.
Detached Eddy Simulation (DES) of flap side-edge flow was performed with a wing and half-span flap configuration used in previous experimental and numerical studies. The focus of the study is the unsteady flow features responsible for the production of far-field noise. The simulation was performed at a Reynolds number (based on the main wing chord) of 3.7 million. Reynolds Averaged Navier-Stokes (RANS) simulations were performed as a precursor to the DES. The results of these precursor simulations match previous experimental and RANS results closely. Although the present DES simulations have not reached statistical stationary yet, some unsteady features of the developing flap side-edge flowfield are presented. In the final paper it is expected that statistically stationary results will be presented including comparisons of surface pressure spectra with experimental data.
Holmgaard, Rikke; Duffy, Jonas; Warburg, Finn Edgar
of 11). Flap-loss occurred in one patient, presumably due to leakage at the anastomotic site, which necessitated another free flap procedure. All patients received rehabilitation services following discharge from the inpatient unit, including prosthetic fitting. The mean follow-up time was 26 months....... CONCLUSIONS: This report is the first to detail the reconstructive procedures in soldiers treated at a public hospital in Denmark. The treatment of war casualties has not only been a challenge to the surgeons tasked with managing these devastating injuries, but also to Danish healthcare in general....... The outcome of multidisciplinary treatment, combining the expertise of various specialties, is highly encouraging. The rate of complications was low, and the aesthetic appearance of the reconstructed limbs and the functional recovery were satisfactory. We therefore recommend the use of free flaps...
Surgical excision of tumors from the face may create a defect that is difficult to restore. Skin grafts can only cover superficial defects and has a natural tendency to contract and may not take properly. Also, because of the colour mismatch, it is not cosmetically identical to the face. The use of regional flaps such as the median forehead flaps are usually bulky, can not cover a wide range of facial reconstruction and usually require the donor area to be grafted. The naso-labial flaps are very useful and versatile local flaps, with robust vascularity that can be readily elevated without a delay. The flap can be superiorly based to reconstruct defects on the cheek, side wall or the dorsum of the nose, alae, collumula and the lower eye lid. Inferiorly based flaps can be used to reconstruct defects in the upper lip, anterior floor of the mouth and the lower lip. The flap can be turned over and used as a lining of the nose and the lip. Aim of the Study: In the current study we present our experience with utilization of the nasolabial flaps in facial reconstruction. We evaluated the indications, flap designs, technique, and complications. We will also assess the final functional and aesthetic results. Material and Methods: The study included 20 patients (12 males and 8 females) presented at the surgical department, National Cancer Institute (NCl) Cairo University with skin cancer at different areas of the face. Preoperative assessment includes. Assessment of the stage of the disease, the flap design and patient general condition. The mean age of the patients was 56.3±6 years (range ]6-62 years). Fifteen patients presented with basal cell carcinoma, 2 squamous cell carcinoma, one malignant melanoma, one keratoacanthoma, and one xeroderma pigmentosa. Nasal defects constituted 75% of cases, the rest were lower eye lid (2), one upper lip and one oral commisure beside a case of cheek reconstruction. There was no major complication; only one patient suffered a reactionary
Balachandran, Chandrashekar; Aslanides, Ioannis M
We describe the case of a 40-year-old female myope who presented for bilateral LASIK. Intra-operatively, the microkeratome oscillating pin broke during flap creation resulting in the separation of the disposable blade from the motor. This resulted in an irregular flap with missing pieces. The procedure was abandoned and the macerated partial flap repositioned as best as possible. The patient recovered a BCVA of 6/7.5. The manufacturer has since reported taking corrective measures to prevent this problem in the future. This case is a reminder that despite care and maintenance by user and manufacturer, extreme and rare hardware malfunctions can occur. Furthermore, although potentially sight threatening if managed well these complications can be followed by good recovery of vision.
Højvig, Jens B; Bonde, Christian Torsten
of 13 patients (10%) had local complications and were re-operated within the first 30 days. We observed one flap loss and only one systemic complication; a urinary tract infection. In all, 38 patients (28%) received antibiotic treatment after the operations and 27 (20%) developed a seroma at the donor...... of the clinical pathway and post-operative regimen could be future focus-points for this procedure. FUNDING: The review was performed as part of the pre-graduate research year project, "Donor-site morbidity after m. latissimus dorsi reconstruction", funded by Concordiafonden. TRIAL REGISTRATION: not relevant.......INTRODUCTION: The latissimus dorsi (LD) myocutaneous flap has long been regarded as the second choice flap for autologous breast reconstruction following a mastectomy in our department. Despite uncertainty about donor-site morbidity, it is regarded as a relatively safe procedure; moreover...
The kinematics of a hovering wing are optimized by combining the 2-d unsteady vortex lattice method with a hybrid of global and local optimization algorithms. The objective is to minimize the required aerodynamic power under a lift constraint. The hybrid optimization is used to efficiently navigate the complex design space due to wing-wake interference present in hovering aerodynamics. The flapping wing is chosen so that its chord length and flapping frequency match the morphological and flight properties of two insects with different masses. The results suggest that imposing a delay between the different oscillatory motions defining the flapping kinematics, and controlling the way through which the wing rotates at the end of each half stroke can improve aerodynamic power under a lift constraint. Furthermore, our optimization analysis identified optimal kinematics that agree fairly well with observed insect kinematics, as well as previously published numerical results.
Muhlmann, Mark D; Hayes, Julian L; Merrie, Arend E H; Parry, Bryan R; Bissett, Ian P
Rectal mucosal advancement flaps (RMAF) and fistula plugs (FP) are techniques used to manage complex anal fistulas. The purpose of this study was to review and compare the results of these methods of repair. A retrospective review of all complex anal fistulas treated by either a RMAF or a FP at Auckland City Hospital from 2004 to 2008. Comparisons were made in terms of successful healing rates, time to failure and the use of magnetic resonance imaging. Overall, 70 operations were performed on 55 patients (55.7% male). The mean age was 44.9 years. Twenty-one patients (30%) had had at least one previous unsuccessful repair. Indications for repair included 57 high cryptoglandular anal (81%), 4 Crohn's anal (6%), 7 rectovaginal (10%), 1 rectourethral (1%) and 1 pouch-vaginal fistula (1%). All patients were followed up with a mean of 4.5 months. Forty-eight RMAFs (69% of total) were performed with 16 successful repairs (33%). Twenty-two FPs (31% of total) were performed with 7 successful repairs (32%, P = 0.9). In failed repairs, there was no difference in terms of mean time to failure (RMAF 4.8 months versus FP 4.1 months, P = 0.62). Magnetic resonance imaging was performed in 21 patients (37%) before the repair. The success rate in these patients was 20%. The results of treatment of complex anal fistulas are disappointing. The choice of operation of either a RMAF or a FP did not alter the poor healing rates of about one third of patients in each group.
Jeremić Jelena V.
Full Text Available Introduction. The radial forearm free flap has an important role in reconstruction of the oncologic defects in the region of head and neck. Objective. The aim was to present and evaluate clinical experience and results in the radial forearm free transfer for intraoral reconstructions after resections due to malignancies. Methods. This article illustrates the versatility and reliability of forearm single donor site in 21 patients with a variety of intraoral oncologic defects who underwent immediate (19 patients, 90.5% or delayed (2 patients, 9.5% reconstruction using free flaps from the radial forearm. Fascio-cutaneous flaps were used in patients with floor of the mouth (6 cases, buccal mucosa (5 cases, lip (1 case and a retromolar triangle (2 cases defects, or after hemiglossectomy (7 cases. In addition, the palmaris longus tendon was included with the flap in 2 patients that required oral sphincter reconstruction. Results. An overall success rate was 90.5%. Flap failures were detected in two (9.5% patients, in one patient due to late ischemic necrosis, which appeared one week after the surgery, and in another patient due to venous congestion, which could not be salvaged after immediate re-exploration. Two patients required re-exploration due to vein thrombosis. The donor site healed uneventfully in all patients, except one, who had partial loss of skin graft. Conclusion. The radial forearm free flap is, due to multiple advantages, an acceptable method for reconstructions after resection of intraoral malignancies. [Projekat Ministarstva nauke Republike Srbije, br. 41006
Chen, Baoguo; Song, Huifeng; Xu, Minghuo; Gao, Quanwen
A high-quality flap is necessary for repairing faciocervical scar contractures. The supraclavicular region and chest wall are the preferred choices for reconstruction. The supraclavicular island flap (SIF) pedicled by the transverse cervical artery (TCA) has been reported. Compared to the traditional SIF flap, another type of flap pedicled by the anterior perforator of transverse cervical artery (ap-TCA) is more convenient for transfer to the faciocervical area. In this article, we use this type of perforator flap and expanded perforator flap to repair the faciocervical contracture. In this study, 10 cases (deformity caused by burn or trauma to the face and neck sites) with an average age of 32 years-old, were treated by ap-TCA flap and this type of expanded flap. In between, the flap was pre-expanded for approximately 3 months prior to transfer in 6 patients. Another 4 cases did not want the expander because of the long duration required for saline filling and potential complications of the expander. Bilateral prefabricated flaps were designed in two female cases. All 12 flaps in 10 patients were transferred tension-free to the defects and no flap was lost. The size of the flap ranged from 12 cm × 8 cm to 15 cm × 20 cm. All 12 flaps survived completely. The donor sites were closed directly in the above 6 patients where an expander had been used and reconstructed by split skin graft in 4 patients where no expander had been employed. Through a mean time of 6 months' follow-up, only one female patient was disappointed with the cicatrix that presented on the upper polar skin of both breasts, the other 9 patients were satisfied with both recipient function and appearance. The color and the texture matched well with the recipient area. The ap-TCA flap and expanded ap-TCA flap can be considered reliable options for faciocervical deformities as it can be easily elevated and it matches well with faciocervical area in color. With regards to the expanded flap, we
Justin R. Bryant, DO, MBA
Full Text Available Summary:. An alternative surgical treatment is proposed for closure of tracheocutaneous fistulas. The authors present a new technique for reconstruction of persistent tracheocutaneous fistula resultant from temporary tracheostomy. The single-stage closure under local anesthesia involves a fistulous tract turnover flap with a perforated 0.15 mm polydioxanone plate between the flap and the subcutaneous closure. This article presents 3 cases of persistent tracheocutaneous fistula treated by this method. At follow-up examination after follow-up, no recurrent fistula formation had occurred, and no respiratory deformity was present.
Full Text Available Background. Alar rim defects are mostly acquired, resulting from burns, traumas or tumor excision. Sometimes they can accompany craniofacial clefts. However, isolated congenital alar defects are extremely rare. Case report. We presented two cases of congenital isolated alar cleft. The defect was closed by the use of an advancement flap, the technique described by Denonvilliers. We achieved both symmetry and appropriate thickness of the nostrils. Skin color and texture of the alar rim were excellent, with scars not excessively visible. Conclusion. Denonvilliers' z-plasty technique by using advancement flap provides both functionally and aesthetically satisfying outcome in patients with congenital alar rim defects.
Full Text Available Anterior palatal fistulae or residual anterior clefts are a frequent problem following palatoplasty. Various techniques have been used to repair such fistulae, each having its own advantages and disadvantages. We have successfully used orbicularis oris musculomucosal flap to close anterior fistula and residual clefts in 25 patients. This study shows the superiority of this flap over other techniques because of its reliable blood supply, easy elevation and transfer to fistula site and finally because it is a single-stage procedure.
Full Text Available Reconstruction of finger extensor zone defects with or without tendon gaps still remains a challenge for surgeons. Although surgical treatments may differ, and range from the use of local, regional, to free flaps, the outcomes for all cases are not satisfactory. In this case report, we present a case of a 3rd finger extensor side crush injury including a defect of Dd (Digit Dorsal 1, Dd2 and Dd3 defects of extensor zones with tendon gap. Tendon gap was reconstructed using m. palmaris longus tendon graft and the defect was covered with reversed cross-finger flap (random pattern with good cosmetic and excellent functional results.
Speina, Elzbieta; Dawut, Lale; Hedayati, Mohammad
devoid of RECQL1 and RECQL5 display increased chromosomal instability. Here, we report the physical and functional interaction of the large isomer of RECQL5, RECQL5beta, with the human flap endonuclease 1, FEN1, which plays a critical role in DNA replication, recombination and repair. RECQL5beta...... dramatically stimulates the rate of FEN1 cleavage of flap DNA substrates. Moreover, we show that RECQL5beta and FEN1 interact physically and co-localize in the nucleus in response to DNA damage. Our findings, together with the previous literature on WRN, BLM and RECQL4's stimulation of FEN1, suggests...
Saba, Luca; Piga, Mario; Atzeni, Matteo; Ribuffo, Diego; Rozen, Warren Matthew; Alonso-Burgos, Alberto; Bura, Raffaella
Preoperative imaging using a range of imaging modalities has become increasingly popular for preoperative planning in plastic surgery, in particular in perforator flap surgery. Modalities in this role include ultrasound (US), magnetic resonance angiography (MRA), and computed tomographic angiography (CTA). The evidence for the use of these techniques has been reported in only a handful of studies. In this paper we conducted a non-systematic review of the literature to establish the role for each of these modalities. The role of state-of-the-art vascular imaging as an application in perforator flap surgery is thus offered
Mooney, Michael A; Hendricks, Benjamin; Sarris, Christina E; Spetzler, Robert F; Almefty, Kaith K; Porter, Randall W
Objectives This study aimed at evaluating facial nerve outcomes in vestibular schwannoma patients presenting with preoperative facial nerve palsy. Design A retrospective review. Setting Single-institution cohort. Participants Overall, 368 consecutive patients underwent vestibular schwannoma resection. Patients with prior microsurgery or radiosurgery were excluded. Main Outcome Measures Incidence, House-Brackmann grade. Results Of 368 patients, 9 had confirmed preoperative facial nerve dysfunction not caused by prior treatment, for an estimated incidence of 2.4%. Seven of these nine patients had Koos grade 4 tumors. Mean tumor diameter was 3.0 cm (range: 2.1-4.4 cm), and seven of nine tumors were subtotally resected. All nine patients were followed up clinically for ≥ 6 months. Of the six patients with a preoperative House-Brackmann grade of II, two improved to grade I, three were stable, and one patient worsened to grade III. Of the three patients with grade III or worse, all remained stable at last follow-up. Conclusions Preoperative facial nerve palsy is rare in patients with vestibular schwannoma; it tends to occur in patients with relatively large lesions. Detailed long-term outcomes of facial nerve function after microsurgical resection for these patients have not been reported previously. We followed nine patients and found that eight (89%) of the nine patients had either stable or improved facial nerve outcomes after treatment. Management strategies varied for these patients, including rates of subtotal versus gross-total resection and the use of stereotactic radiosurgery in patients with residual tumor. These results can be used to help counsel patients preoperatively on expected outcomes of facial nerve function after treatment.
Yousaf, Muhammad Amin; Abidin, Zain Ul; Khalid, Kamran; Haq, Ata Ul; Khalid, Farrukh Aslam; Tarar, Faraz Ahmad; Asif, Muhammad Umar; Tarar, Moazzam Nazeer
Obective:To assess the outcome of extended delayed reverse sural artery flap for reconstruction of foot defects proximal to toes in terms of flap survival, complication and extended area. Case series. Jinnah Burn and Reconstructive Surgery Centre, Lahore, from February 2015 to April 2017. Cases who underwent delayed sural artery flap were inducted. Preoperative hand-held doppler was done to confirm the location of perforator. Two suitable perforators were chosen to raise the extended flap by crossing the proximal limit in all cases. The pedicle was kept minimum 3 cm wide and perfusion was assessed. Flap was delayed for one week and vaccum-assisted closure (VAC) dressing was applied over wound. The second surgery was performed after one week. Proximal perforator was clamped and ligated after checking adequate perfusion of flap. Flap was insetted into defect. Thirty-two patients were reconstructed with delayed reverse sural artery flap. The mean age of the patients was 26.5 12.2 years. Twenty-four (75%) patients were males and 8 (25%) were females. Twenty-two (68.7%) cases were degloving wounds after road traffic accidents (RTA), 6 (18.7%) were diabetic foot wounds, 4 (12.5%) sustained injury after falling from height and 7 (21.8%) patients had fracture of metatarsals. Twenty-eight flaps were transferred after one week delay, and only in 4 cases, flap were transferred after two weeks. All flaps survived completely. Complications of infection noted in 3 (9.3%) flaps, 3 (9.3%) flaps showed tip necrosis, 2 (6.2%) flaps undergone epidermolysis and only 2 (6.2%) showed venous congestion. Delayed islanded reverse sural artery perforator flap is a reliable and versatile option for resurfacing soft tissue defects of lower limb proximal to the toes with lesser complications and extended coverage area.
Yousaf, M.A.; Abidin, Z.U.; Khalid, K.; Haq, A.U.; Tarar, F.A.; Asif, M.U.; Tarar, M.N.
To assess the outcome of extended delayed reverse sural artery flap for reconstruction of foot defects proximal to toes in terms of flap survival, complication and extended area. Study Design:Case series. Place and Duration of Study:Jinnah Burn and Reconstructive Surgery Centre, Lahore, from February 2015 to April 2017. Methodology:Cases who underwent delayed sural artery flap were inducted. Preoperative hand-held doppler was done to confirm the location of perforator. Two suitable perforators were chosen to raise the extended flap by crossing the proximal limit in all cases. The pedicle was kept minimum 3 cm wide and perfusion was assessed. Flap was delayed for one week and vaccum-assisted closure (VAC) dressing was applied over wound. The second surgery was performed after one week. Proximal perforator was clamped and ligated after checking adequate perfusion of flap. Flap was insetted into defect. Results:Thirty-two patients were reconstructed with delayed reverse sural artery flap. The mean age of the patients was 26.5 +12.2 years. Twenty-four (75%) patients were males and 8 (25%) were females. Twenty-two (68.7%) cases were degloving wounds after road traffic accidents (RTA), 6 (18.7%) were diabetic foot wounds, 4 (12.5%) sustained injury after falling from height and 7 (21.8%) patients had fracture of metatarsals. Twenty-eight flaps were transferred after one week delay, and only in 4 cases, flap were transferred after two weeks. All flaps survived completely. Complications of infection noted in 3 (9.3%) flaps, 3 (9.3%) flaps showed tip necrosis, 2 (6.2%) flaps undergone epidermolysis and only 2 (6.2%) showed venous congestion. Conclusion:Delayed islanded reverse sural artery perforator flap is a reliable and versatile option for resurfacing soft tissue defects of lower limb proximal to the toes with lesser complications and extended coverage area. (author)
Fabricio W. Medeiros
Full Text Available OBJECTIVE: To evaluate the impact of the creation of corneal flaps at different thicknesses on the biomechanical properties of swine corneas. METHOD: Twelve swine eyes were obtained to form two groups: 100 μm flap thickness and 300 μm flap thickness. Each eye was submitted to the following examinations: raster topography to investigate corneal curvature alterations, ocular response analyzer to investigate corneal hysteresis change, optical coherence tomography to measure central corneal and flap thickness and sonic wave propagation velocity as a measure of stiffness, before and immediately after flap creation. After flap amputation, surface wave velocity measurements were repeated. RESULTS: Measured flap thicknesses were statistically different for thin and thick flap groups, with an average of 108.5 + 6.9 and 307.8 + 11.5 μm respectively. Hysteresis and corneal resistance factor did not change significantly after flap creation in the thin flap group. With thicker flaps, both parameters decreased significantly from 8.0 +1.0 to 5.1 +1.5 mmHg and from 8.2 + 1.6 to 4.1 +2.5 mmHg respectively. Simulated keratometry values increased in the thick flap group (from 39.5 + 1 D to 45.9+1.2 D after flap creation but not in the thin flap group (from 40.6 + 0.6 D to 41.4+ 1.0 D. Regarding surface wave velocity analysis, the surgical procedures induced statistically lower results in some positions. CONCLUSION: In the experimental conditions established by this model, thicker flaps presented a greater biomechanical impact on the cornea.
Gümüş, Nazım; Odemiş, Yusuf; Yılmaz, Sarper; Tuncer, Ersin
Flap necrosis still is a challenging problem in reconstructive surgery that results in irreversible tissue loss. This study evaluated the effect of topically applied minoxidil on angiogenesis and survival of a caudally based dorsal rat skin flap. For this study, 24 male Wistar rats were randomly divided into three groups of eight each. A caudally based dorsal skin flap with the dimensions of 9 × 3 cm was raised. After elevation of the flaps, they were sutured back into their initial positions. In group 1 (control group), 1 ml of isotonic saline was applied topically to the flaps of all the animals for 14 days. In group 2, minoxidil solution was spread uniformly over the flap surface for 7 days after the flap elevation. In group 3, minoxidil solution was applied topically to the flap surface during a 14-day period. On day 7 after the flap elevation, the rats were killed. The average area of flap survival was determined for each rat. Subdermal vascular architecture and angiogenesis were evaluated under a light microscope after two full-thickness skin biopsy specimens had been obtained from the midline of the flaps. The lowest flap survival rate was observed in group 1, and no difference was observed between groups 1 and 2. Compared with groups 1 and 2, group 3 had a significantly increased percentage of flap survival (P minoxidil is vasodilation and that prolonged use before flap elevation leads to angiogenesis, increasing flap viability. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
Full Text Available A 77-year-old woman presented with a 1-year history of a right medial canthal tumor, which was histopathologically diagnosed as a basal cell carcinoma. After removal of the tumor with a 4-mm safety margin, the defect occupied the areas superior and inferior to the medial canthal tendon. We first reconstructed the lower part of the defect using a nasolabial V-Y advancement flap to make an elliptic defect in the upper part. We then created a glabellar subcutaneous pedicled flap to match the residual upper elliptic defect with the major axis set along a relaxed skin tension line. The pedicled glabellar flap was passed through a subcutaneous tunnel to the upper residual defect. At 6 months postoperatively, the patient showed no tumor recurrence and a good cosmetic outcome.
Klinger, Daniel R; Reinard, Kevin A; Ajayi, Olaide O; Delashaw, Johnny B
The binocular operating microscope has been the visualization instrument of choice for microsurgical clipping of intracranial aneurysms for many decades. To discuss recent technological advances that have provided novel visualization tools, which may prove to be superior to the binocular operating microscope in many regards. We present an operative video and our operative experience with the BrightMatterTM Servo System (Synaptive Medical, Toronto, Ontario, Canada) during the microsurgical clipping of an anterior communicating artery aneurysm. To the best of our knowledge, the use of this device for the microsurgical clipping of an intracranial aneurysm has never been described in the literature. The BrightMatterTM Servo System (Synaptive Medical) is a surgical exoscope which avoids many of the ergonomic constraints of the binocular operating microscope, but is associated with a steep learning curve. The BrightMatterTM Servo System (Synaptive Medical) is a maneuverable surgical exoscope that is positioned with a directional aiming device and a surgeon-controlled foot pedal. While utilizing this device comes with a steep learning curve typical of any new technology, the BrightMatterTM Servo System (Synaptive Medical) has several advantages over the conventional surgical microscope, which include a relatively unobstructed surgical field, provision of high-definition images, and visualization of difficult angles/trajectories. This device can easily be utilized as a visualization tool for a variety of cranial and spinal procedures in lieu of the binocular operating microscope. We anticipate that this technology will soon become an integral part of the neurosurgeon's armamentarium. Copyright © 2017 by the Congress of Neurological Surgeons
Abdelrahman, Ahmed; Johnson, David A
One of the strategies used to improve performance and increase the life-span of wind turbines is active flow control. It involves the modification of the aerodynamic characteristics of a wind turbine blade by means of moveable aerodynamic control surfaces. Trailing edge flaps are relatively small moveable control surfaces placed at the trailing edge of a blade's airfoil that modify the lift of a blade or airfoil section. An instrumented wind turbine test rig and rotor were specifically developed to enable a wide-range of experiments to investigate the potential of trailing edge flaps as an active control technique. A modular blade based on the S833 airfoil was designed to allow accurate instrumentation and customizable settings. The blade is 1.7 meters long, had a constant 178mm chord and a 6° pitch. The modular aerodynamic parts were 3D printed using plastic PC-ABS material. The blade design point was within the range of wind velocities in the available large test facility. The wind facility is a large open jet wind tunnel with a maximum velocity of 11m/s in the test area. The capability of the developed system was demonstrated through an initial study of the effect of stationary trailing edge flaps on blade load and performance. The investigation focused on measuring the changes in flapwise bending moment and power production for different trailing edge flap spanwise locations and deflection angles. The relationship between the load reduction and deflection angle was linear as expected from theory and the highest reduction was caused by the flap furthest from the rotor center. Overall, the experimental setup proved to be effective in measuring small changes in flapwise bending moment within the wind turbine blade and will provide insight when (active) flap control is targeted
Thankappan, Krishnakumar; Trivedi, Nirav P.; Sharma, Mohit; Kuriakose, Moni A.; Iyer, Subramania
A free radial forearm fascial flap has been described for intraoral reconstruction. Adiposo-fascial flap harvesting involves few technical modifications from the conventional radial forearm fascio-cutaneous free flap harvesting. We report a case of inferior maxillectomy defect reconstruction in a 42-year-old male with a free radial forearm adiposo-fascial flap with good aesthetic and functional outcome with minimal primary and donor site morbidity. The technique of raising the flap and closing the donor site needs to be meticulous in order to achieve good cosmetic and functional outcome. PMID:19881028
Full Text Available A free radial forearm fascial flap has been described for intraoral reconstruction. Adiposo-fascial flap harvesting involves few technical modifications from the conventional radial forearm fascio-cutaneous free flap harvesting. We report a case of inferior maxillectomy defect reconstruction in a 42-year-old male with a free radial forearm adiposo-fascial flap with good aesthetic and functional outcome with minimal primary and donor site morbidity. The technique of raising the flap and closing the donor site needs to be meticulous in order to achieve good cosmetic and functional outcome.
Keijzers, Guido; Bohr, Vilhelm A; Juel Rasmussen, Lene
structures, we determined factors essential for the thermodynamic stability of EXO1. We show that enzymatic activity and stability of EXO1 on DNA is modulated by temperature. By characterization of EXO1 flap activity using various DNA flap substrates, we show that EXO1 has a strong capacity for degrading...... double stranded DNA and has a modest endonuclease or 5' flap activity. Furthermore, we report novel mechanistic insights into the processing of flap structures, showing that EXO1 preferentially cleaves one nucleotide inwards in a double stranded region of a forked and nicked DNA flap substrates...
Lim, Hyoseob; Han, Dae Hee; Lee, Il Jae; Park, Myong Chul
Extensive degloving injuries of the extremities usually result in necrosis of the flap, necessitating comprehensive skin grafting. Provided there is a sufficient tool to evaluate flap viability, full-thickness skin can be used from a nonviable avulsed flap. We used a Wood's lamp to determine the viability of avulsed flaps in the operation field after intravenous injection of fluorescein dye. We experienced 13 cases during 16 months. Fifteen minutes after the intravenous injection of fluorescein dye, the avulsed skin flaps were examined and non-fluorescent areas were marked under Wood's lamp illumination. The marked area was defatted for full-thickness skin grafting. The fluorescent areas were sutured directly without tension. The non-fluorescent areas were covered by defatted skin. Several days later, there was soft tissue necrosis within the flap area. We measured necrotic area and revised the flap. Among all the cases, necrotic area was 21.3% of the total avulsed area. However, if we exclude three cases, one of a carelessly managed patient and two cases of the flaps were inappropriately applied, good results were obtained, with a necrotic area of only 8.4%. Eight patients needed split-thickness skin grafts, and heel pad reconstruction was performed with free flap. A full-thickness skin graft from an avulsed flap is a good method for addressing aesthetic concerns without producing donor site morbidity. Fluorescein dye is a useful, simple, and cost-effective tool for evaluating flap viability. Avulsed flap injuries can be managed well with Wood's lamp illumination and a full-thickness skin graft.
Full Text Available Background Extensive degloving injuries of the extremities usually result in necrosis of the flap, necessitating comprehensive skin grafting. Provided there is a sufficient tool to evaluate flap viability, full-thickness skin can be used from a nonviable avulsed flap. We used a Wood's lamp to determine the viability of avulsed flaps in the operation field after intravenous injection of fluorescein dye. Methods We experienced 13 cases during 16 months. Fifteen minutes after the intravenous injection of fluorescein dye, the avulsed skin flaps were examined and non-fluorescent areas were marked under Wood's lamp illumination. The marked area was defatted for full-thickness skin grafting. The fluorescent areas were sutured directly without tension. The non-fluorescent areas were covered by defatted skin. Several days later, there was soft tissue necrosis within the flap area. We measured necrotic area and revised the flap. Results Among all the cases, necrotic area was 21.3% of the total avulsed area. However, if we exclude three cases, one of a carelessly managed patient and two cases of the flaps were inappropriately applied, good results were obtained, with a necrotic area of only 8.4%. Eight patients needed split-thickness skin grafts, and heel pad reconstruction was performed with free flap. Conclusions A full-thickness skin graft from an avulsed flap is a good method for addressing aesthetic concerns without producing donor site morbidity. Fluorescein dye is a useful, simple, and cost-effective tool for evaluating flap viability. Avulsed flap injuries can be managed well with Wood's lamp illumination and a full-thickness skin graft.
Viswamurthy, S. R.; Ganguli, Ranjan
This study aims to determine optimal locations of dual trailing-edge flaps to achieve minimum hub vibration levels in a helicopter, while incurring low penalty in terms of required trailing-edge flap control power. An aeroelastic analysis based on finite elements in space and time is used in conjunction with an optimal control algorithm to determine the flap time history for vibration minimization. The reduced hub vibration levels and required flap control power (due to flap motion) are the two objectives considered in this study and the flap locations along the blade are the design variables. It is found that second order polynomial response surfaces based on the central composite design of the theory of design of experiments describe both objectives adequately. Numerical studies for a four-bladed hingeless rotor show that both objectives are more sensitive to outboard flap location compared to the inboard flap location by an order of magnitude. Optimization results show a disjoint Pareto surface between the two objectives. Two interesting design points are obtained. The first design gives 77 percent vibration reduction from baseline conditions (no flap motion) with a 7 percent increase in flap power compared to the initial design. The second design yields 70 percent reduction in hub vibration with a 27 percent reduction in flap power from the initial design.
Lichon, Vanessa; Barbosa, Naiara; Gomez, Doug; Goldman, Glenn
Variation in the design of a rotation flap may affect wound closure tension. Lengthening the leading edge of a rotation flap has been a method of reducing the tension of closure in the primary motion. An in vitro study negating this tenant has been published. The authors set out to design an in vivo experiment to determine if lengthening the leading edge of a rotation flap has the effect of reducing closure tension in the primary motion of the repair. An animal study approved by Institutional Animal Care and Use Committee was undertaken in a pig model. A tension-measuring apparatus was designed using Teflon-coated wires and digital tensiometers. Rotation flaps of a standard design and with elongated leading edges were incised on the flanks of pigs under general anesthesia. Flap closure tensions were measured at points along the leading edge of the flap and in the secondary motion. Elongating the leading edge of a flap led to a statistically significant reduction in closure tension in the primary motion of the flap and at the flap tip. The secondary motion closure tensions were essentially unaffected. The authors confirm that elongating the leading edge of a standard rotation flap will reduce closure tension in the primary flap motion.
Hai, Heng-lin; Shen, Chuan-an; Chai, Jia-ke; Li, Hua-tao
To explore the clinical effect of transplantation of the long head of biceps femoris muscle flap in combination with semi-V posterior thigh fasciocutaneous flap for repair of pressure sores over ischial tuberosity. Eight patients with 10 deep pressure sores over ischial tuberosity were admitted to the First Affiliated Hospital to the PLA General Hospital and the 98th Hospital of PLA from April 2004 to June 2010. The wounds measured from 2 cm × 2 cm to 6 cm × 4 cm were covered with the long head of biceps femoris muscle flap and semi-V posterior thigh fasciocutaneous flap (ranged from 10 cm × 6 cm to 13 cm × 8 cm). The condition of flaps was observed and followed up for a long time. All flaps survived. Nine wounds healed by first intention. Subcutaneous accumulation of fluids occurred in one wound with formation of a sinus at drainage site, and it healed after dressing change for 25 days. Patients were followed up for 7 to 34 months. Sore recurred in one patient 9 months after surgery, and it was successfully repaired with the same flap for the second time. Flaps in the other 7 patients appeared satisfactory with soft texture and without ulceration. This combined flap is easy in formation and transfer, and it causes little side injury with good resistance against pressure. It is a new method for repair of pressure sore over sacral region.
Markoulli, Maria; Francis, Ian C; Yong, Jim; Jalbert, Isabelle; Carnt, Nicole; Cole, Nerida; Papas, Eric
To study the histopathology of paralimbal bulbar conjunctival flaps occurring secondary to soft contact lens wear. Slit-lamp biomicroscopy using sodium fluorescein, cobalt blue light, and a Wratten filter was used to observe the presence, location, and dimensions of bulbar conjunctival flaps presenting in a cohort of contact lens wearers. Two subjects who exhibited such flaps agreed to undergo conjunctival biopsy. Tissue samples, obtained from the region of the flap, and an adjacent unaffected area were processed by standard histopathological methods. In the first subject, analysis of the flap tissue showed even collagen distribution and overall normal histology. The flap of the second subject displayed a mild focal increase in collagen and mild degeneration of collagen, but no increase in elastic tissue. Conjunctival epithelium was normal in both cases. In these 2 subjects, conjunctival flap tissue either was normal or showed only minimal abnormality. There is insufficient evidence for significant pathological change on the time scale of this study.
consecuencia, parece aconsejable que el cirujano plástico relacionado con los colgajos de perforante se involucre decididamente en el postprocesamiento de las imágenes de angiotomografía computerizada. El visor de imágenes DICOM gratuito OsiriX es una alternativa eficiente, comparable a aplicaciones más profesionales sólo disponibles en servicios de Radiología.With the advent of perforator-based skin transfer, computed tomography angiography has emerged as an invaluable tool in the preoperative planning of perforator flaps. But most likely, the exploitation of the technique is less than desirable. Through our experience with 144 patients, we evaluate the use of the free DICOM viewer OsiriX for Mac in the preoperative planning of perforator flaps with three objectives: 1 increase the present knowledge related with the preoperative planning of perforator flaps with computed tomography angiography, 2 evaluate the OsiriX application in the image post-processing of perforator flaps and 3 evaluate the performance of the procedure when performed by a surgeon (not specialized in Radiology. The experience has shown that the image post-processing performed by the surgeon with the OsiriX application usually allows an adequate evaluation of different structures and parameters of great preoperative interest in perforator flap surgery: 1 source artery, 2 diameter of artery and vein/s at the hypothetical site of microsurgical anastomoses, 3 course and branching pattern of the flap pedicle, 4 perforator course in the subcutaneous fat (theoretical flap axis, 5 measurement of the skin and fat where the perforator pierces the deep fascia (theoretical flap thickness , 6 measurement of the distance between the point of entrance of the perforator in the subcutaneous fat to the source artery (theoretical maximal pedicle length and 7 measurement of the perforator diameter where it pierces the deep fascia. Ultimately, in the authors' opinion, those plastic surgeons involved in perforator flap
Zeltzer, Assaf A; Anzarut, Alexander; Braeckmans, Delphine; Seidenstuecker, Katrin; Hendrickx, Benoit; Van Hedent, Eddy; Hamdi, Moustapha
A growing number of surgeons perform lymph node transfers for the treatment of lymphedema. When harvesting a vascularized lymph node groin flap (VGLNF) one of the major concerns is the potential risk of iatrogenic lymphedema of the donor-site. This article helps understanding of the lymph node distribution of the groin in order to minimize this risk. Fifty consecutive patients undergoing abdominal mapping by multi-detector CT scanner were included and 100 groins analyzed. The groin was divided in three zones (of which zone II is the safe zone) and lymph nodes were counted and mapped with their distances to anatomic landmarks. Further node units were plotted and counted. The average age was 48 years. A mean number of nodes of 6.5/groin was found. In zone II, which is our zone of interest a mean of 3.1 nodes were counted with a mean size of 7.8 mm. In three patients no nodes were found in zone II. In five patients nodes were seen in zone II but were not sufficient in size or number to be considered a lymph node unit. On average the lymph node unit in zone II was found to be 48.3 mm from the pubic tubercle when projected on a line from the pubic tubercle to the anterior superior iliac spine, 16.0 mm caudal to this line, and 20.4 mm above the groin crease. On average the lymph node unit was a mean of 41.7 mm lateral to the SCIV-SIEV confluence. This study provides increased understanding of the lymphatic anatomy in zone II of the groin flap and suggests a refined technique for designing the VGLNF. As with any flap there is a degree of individual patient variability. However, having information on the most common anatomy and flap design is of great value. © 2017 Wiley Periodicals, Inc.
Atwood-Blaine, Dana; Rule, Audrey C.; Morgan, Hannah
In the lesson on which this practical article is based, third grade students constructed a "lift-the-flap" page to explore food webs on the prairie. The moveable papercraft focused student attention on prairie animals' external structures and how the inferred functions of those structures could support further inferences about the…
... in the two groups. No statistically significant differences were found in these 2 groups. It was concluded that partial de-epithelialisation did not have a detrimental effect on duration of flap length survival, thus encouraging the continued use of the clinical technique described above in the handling of degloving injuries.
Full Text Available Keeping skin graft or a flap adherent to the underlying surface can sometimes be a difficult job, particularly inside a cavity. Different methods have been used for this function with varying success but the search is still on for an ideal pressure dressing.
nonviable tissue is removed and a granulation bed suitable for .... The pedicled or free greater omental flap as well as scrotal tissue ... Bien-keem Tan, Mohammed ZulfikarRasheed,. WofflesT.L.Wu ... Honda Hsu Chih Ming Lin, Tzong-Bon Sun,.
Flap surgery for reconstruction is an integral part in the surgical management of head and neck tumors. After resection of the tumors of oral cavity adjacent to the mandible, but not requiring a marginal mandibulectomy (tumors of the tongue, on the labial side, and tumors of the buccal mucosa on the buccal aspect),.
Liu, Shu; Liang, Weizhong; Song, Kexin; Wang, Youbin
Facial keloids commonly occur in young patients. Multiple keloid masses often converge into a large lesion on the face, representing a significant obstacle to keloid mass excision and reconstruction. We describe a new surgical method that excises the keloid mass and resurfaces the wound by saving the keloid skin as a skin flap during facial keloid treatment. Forty-five patients with facial keloids were treated in our department between January 2013 and January 2016. Multiple incisions were made along the facial esthetic line on the keloid mass. The keloid skin was dissected and elevated as a skin flap with one or two pedicles. The scar tissue in the keloid was then removed through the incision. The wound was covered with the preserved keloid skin flap and closed without tension. Radiotherapy and hyperbaric oxygen were applied after surgery. Patients underwent follow-up examinations 6 and 12 months after surgery. Of the 45 total patients, 32 patients were cured and seven patients were partially cured. The efficacy rate was 88.9%, and 38 patients (84.4%) were satisfied with the esthetic result. We describe an efficacious and esthetically satisfactory surgical method for managing facial keloids by preserving the keloid skin as a skin flap. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
Aguiar Vieira Caetano, J.V.
Different flapping wing micro aerial vehicles (FWMAV) have been developed for academic (Harvard’s RoboBee), military (Israel Aerospace Industries’ Butterfly) and technology demonstration (Aerovironment’s NanoHummingBird) purposes. Among these, theDelFly II is recognized as one of themost successful
Jun 11, 2018 ... 4 weeks of surgery. Two patients ... allows others to remix, tweak, and build upon the work non-commercially, as long ... that the pedicle of the flap was not compressed with the ... to the 8th week after surgery [Figure 4].
Nieminen, H; Kuokkanen, H; Tukiainen, E; Asko-Seljavaara, S
The cases of 15 patients are presented where microvascular soft-tissue reconstructions became necessary after internal fixation of tibial fractures. Primarily, seven of the fractures were closed. Eleven fractures had originally been treated by open reduction and internal fixation using plates and screws, and four by intramedullary nailing. All of the patients suffered from postoperative complications leading to exposure of the bone or fixation material. The internal fixation material was removed and radical revision of dead and infected tissue was carried out in all cases. Soft tissue reconstruction was performed using a free microvascular muscle flap (11 latissimus dorsi, three rectus abdominis, and one gracilis). In eight cases the nonunion of the fracture indicated external fixation. The microvascular reconstruction was successful in all 15 patients. In one case the recurrence of deep infection finally indicated a below-knee amputation. In another case, chronic infection with fistulation recurred postoperatively. After a mean follow-up of 26 months the soft tissue coverage was good in all the remaining 13 cases. All the fractures united. Microvascular free muscle flap reconstruction of the leg is regarded as a reliable method for salvaging legs with large soft-tissue defects or defects in the distal leg. If after internal fixation of the tibial fracture the osteosynthesis material or fracture is exposed, reconstruction of the soft-tissue can successfully be performed by free flap transfer. By radical revision, external fixation, bone grafting, and a free flap the healing of the fracture can be achieved.
Arashiro, Ken; Nishizeki, Osamu; Ishida, Kunihiro
During the past 10 years, seven pedicled rectus femoris muscle or musculocutaneous flaps were used to repair lower abdominal defects; three recalcitrant incisional hernias with previous radiotherapy, two long-standing wound infections after synthetic mesh reconstruction, one posttraumatic wall defect and one metastatic tumor. There were two flap complications, one skin paddle necrosis and one wound infection. There was no significant disability of the donor limb encountered. During the two-year and seven month average follow-up, there was no recurrence of the problems except for one minor fascial dehiscence in the patient with metastatic abdominal wall tumor. Easy approach, rapid harvest, relatively large and reliable overlying fascia lata, a single dominant neurovascular pedicle, easy primary closure of the donor site, and minimal donor site morbidity all make the rectus femoris flap a good alternative flap for lower abdominal wall reconstruction. It is especially useful in a condition where synthetic mesh would be unsuitable for defects with infection or recurrent incisional hernia after radiotherapy. (author)
van Wingerden, Jan J.; Coret, Matijn E. H.; van Nieuwenhoven, Christianne A.; Totté, Eric R.
To report our experience with the laparoscopically harvested omental flap in the treatment of deep sternal wound infection, and to present a modification and introduce two supportive techniques in the perioperative management. Between June 2005 and September 2007, six patients with grade IV (El
Abdominal wall reconstruction using De-epithelialized dermal flap: A new technique. ... Journal of Surgical Technique and Case Report ... Background: Although autogenous materials have been used in abdominal wall hernioplasty for a long time, the introduction of prosthetic materials diminished their popularity. However ...
Tanaka, Hiroto [School of Engineering and Applied Sciences, Harvard University, 60 Oxford Street, Cambridge, MA 02138 (United States); Shimoyama, Isao, E-mail: email@example.com [Department of Mechano-Informatics, Graduate School of Information Science and Technology, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8656 (Japan)
Unlike other flying insects, the wing motion of swallowtail butterflies is basically limited to flapping because their fore wings partly overlap their hind wings, structurally restricting the feathering needed for active control of aerodynamic force. Hence, it can be hypothesized that the flight of swallowtail butterflies is realized with simple flapping, requiring little feedback control of the feathering angle. To verify this hypothesis, we fabricated an artificial butterfly mimicking the wing motion and wing shape of a swallowtail butterfly and analyzed its flights using images taken with a high-speed video camera. The results demonstrated that stable forward flight could be realized without active feathering or feedback control of the wing motion. During the flights, the artificial butterfly's body moved up and down passively in synchronization with the flapping, and the artificial butterfly followed an undulating flight trajectory like an actual swallowtail butterfly. Without feedback control of the wing motion, the body movement is directly affected by change of aerodynamic force due to the wing deformation; the degree of deformation was determined by the wing venation. Unlike a veinless wing, a mimic wing with veins generated a much higher lift coefficient during the flapping flight than in a steady flow due to the large body motion.
Tanaka, Hiroto; Shimoyama, Isao
Unlike other flying insects, the wing motion of swallowtail butterflies is basically limited to flapping because their fore wings partly overlap their hind wings, structurally restricting the feathering needed for active control of aerodynamic force. Hence, it can be hypothesized that the flight of swallowtail butterflies is realized with simple flapping, requiring little feedback control of the feathering angle. To verify this hypothesis, we fabricated an artificial butterfly mimicking the wing motion and wing shape of a swallowtail butterfly and analyzed its flights using images taken with a high-speed video camera. The results demonstrated that stable forward flight could be realized without active feathering or feedback control of the wing motion. During the flights, the artificial butterfly's body moved up and down passively in synchronization with the flapping, and the artificial butterfly followed an undulating flight trajectory like an actual swallowtail butterfly. Without feedback control of the wing motion, the body movement is directly affected by change of aerodynamic force due to the wing deformation; the degree of deformation was determined by the wing venation. Unlike a veinless wing, a mimic wing with veins generated a much higher lift coefficient during the flapping flight than in a steady flow due to the large body motion.
Ronold, K O [Det Norske Veritas, Hoevik (Norway); Larsen, G C [Risoe National Lab., Wind Energy and Atmospheric Physics Dept., Roskilde (Denmark)
The variability of extreme flap loads is of utmost importance for design of wind-turbine rotor blades. The flap loads of interest consist of the flap-wise bendin moment response at the blade root whose variability in the short-term, for a given wind climate, can be represented by a stationary process. A model for the short-term bending moment process is presented, and the distribution of its associated maxima is derived. A model for the wind climate is given in terms of the probability distributions for the 10-minute mean wind speed and the standard deviation of the arbitrary wind speed. This is used to establish the distribution of the largest flap-wise bending moment in a specific reference period, and it is outlined how a characteristic bending moment for use in design can be extracted from this distribution. The application of the presented distribution models is demonstrated by a numerical example for a site-specific wind turbine. (au)
S Air Med J 1993; 83: 97-99. TIe inevitable concomitant ... include surface fluorometry, ultrasound, laser Doppler, ... This is the cut-off area beyond which the dis- tal flap should .... groups according to weight loss measurements. The timing of ...
... Palatal Island Advancement Flap was effective in bone graft coverage in premaxillary edentulous area. Conclusion: It can be used as an aid for bone graft coverage of premaxillary edentulous ridge, where the need for mucosa is small in width but long in length. Keywords: Anterior maxilla, bone graft, dental implant, ...
The use of pedicled prepucial skin flap urethroplasty for proximal bulbomembraneous urethral stricture in children: an easy alternative to transpubic urethroplasty. Harshjeet S. Bal, Jujju J. Kurian and Sudipta Sen. Objective Pediatric urethral strictures are not uncommon, and a myriad of treatment options is available.
Aagaard Madsen, Helge; Barlas, Athanasios; Løgstrup Andersen, Tom
system has been further developed in corporation with the industrial partners Hydratech Industries (DK) and Rehau (DE). A new trailing edge flap design with spanwise voids (channels) and with a chord of 15cm suitable for a 1m chord blade section was developed. It was then manufactured by extrusion...
Wang, Tao; Zhao, Gang; Rui, Yong-Jun; Mi, Jing-Yi
Abstract Rationale: Necrotizing fasciitis (NF), characterized by widespread fascial necrosis, is a rare disease in clinic. Fournier gangrene (FG) is a special type of NF involved of perineum and scrotum. To our knowledge, no article has reported on bilateral femoral posterior neurocutaneous perforater flap treating for FG. Patient concerns: A 61-year-old Chinese male complained of perineal skin necrosis for 19 days. The patient received treatment in other hospital due to chronic bronchitis on April 15th and body temperature ranged from 38 to 39 °C. Then he received antiinfection therapy. Perianal cutaneous occurred mild necrosis on May 08th. And the necrosis generally deteriorated. He came to our hospital for treating necrosis in area of perineum and scrotum on May 28th. Diagnoses: He was diagnosed with FG and chronic bronchitis. Interventions: The patient underwent debridement on June 2nd and received bilateral femoral posterior neurocutaneous perforater flap on June 29th. Besides, the patient was treated with whole-body nutrition support and antibiotic treatment. Outcomes: One week after the 2nd operation, the flap showed normal color. The result shows good outcome and no recurrence of the clinical symptoms occur till now. Lessons: FG is rare. Bilateral femoral posterior neurocutaneous perforater flap is an effective procedure to treat FG. The outcome of combined therapy is satisfactory. PMID:29145312
Holmgaard, R.; Jakobsen, Linda Plovmand
Cervical spondylodiscitis was diagnosed in a 31-year-old man 2 months after palatopharyngeal flap surgery. Symptoms included pain in the neck and tingling and numbness in the left arm. The diagnosis was confirmed by magnetic resonance imaging, and the patient recovered on antibiotic treatment. We...
Sakamoto, Yuki; Yanamoto, Souichi; Ota, Yoshihide; Furudoi, Shungo; Komori, Takahide; Umeda, Masahiro
Myocutaneous flaps are often used to repair oral and maxillofacial defects after surgery for oral cancer; however, their volume decreases during the postoperative period. To facilitate treatment planning, the authors measured the extent of such postoperative flap volume loss and identified associated factors in patients who underwent oral reconstruction with myocutaneous flaps. The authors designed and performed a retrospective observational study of patients who underwent reconstructive procedures involving rectus abdominal myocutaneous (RAM) or pectoralis major myocutaneous (PMMC) flaps at Tokai University Hospital, Kobe University Hospital, or Nagasaki University Hospital from April 2009 through March 2013. Flap type and other clinical variables were examined as potential predictors of flap loss. The primary outcome was flap loss at 6 months postoperatively. Correlations between each potential predictor and the primary outcome were examined using multiple regression analysis. The subjects were 75 patients whose oral defects were reconstructed with RAM flaps (n = 57) or PMMC flaps (n = 18). RAM flaps exhibited a mean volume shrinkage of 22% at 6 months postoperatively, which was less than the 27.5% displayed by the PMMC flaps, but the difference was not important. Renal failure, previous surgery of the oral region, postoperative radiotherapy, and postoperative serum albumin level were found to be meaningful risk factors for postoperative flap volume loss. The results of this study suggest that larger flaps should be used in patients who possess these risk factors or are scheduled to undergo postoperative radiotherapy. Future studies should examine the utility of postoperative nutritional management for preventing flap volume loss. Copyright © 2016 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.
Kim, Bitna; Yoon, Dae Young; Seo, Young Lan; Park, Min Woo; Kwon, Kee Hwan; Rho, Young Soo; Chung, Chul Hoon [Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul (Korea, Republic of)
To identify post-operative computed tomography (CT) findings associated with delayed flap failures following head and neck cancer surgery. We retrospectively reviewed 60 patients who underwent flap reconstruction after head and neck cancer surgery and post-operative (3–14 days) contrast-enhanced CT scans for suspected complications. Patients were divided into two groups: delayed flap failure patients (patients required flap revision) (n = 18) and flap success patients (n = 42). Clinical data (age, sex, T-stage, type of flap, and time interval between reconstruction surgery and CT) and post-operative CT findings of flap status (maximum dimension of the flap, intra- or peri-flap fluid collection and intra- or peri-flap air collection, fat infiltration within the flap, fistula to adjacent aerodigestive tract or skin, and enhanced vascular pedicle) were assessed and compared between the two groups. CT findings showed that the following flap anomalies were observed more frequently in the delayed flap failure group than in the flap success group: intra- or peri-flap fluid collection > 4 cm (61.1% vs. 23.8%, p < 0.05), intra- or peri-flap air collection > 2 cm (61.1% vs. 2.4%, p < 0.001), and fistula to adjacent aerodigestive tract or skin (44.4% vs. 0%, p < 0.001). The maximum dimension of the flap, fat infiltration within the flap, and enhanced vascular pedicle were not associated with delayed flap failures. A large amount of fluid or air collection and fistula are the CT findings that were associated with delayed flap failures in patients with suspected post-operative complications after head and neck cancer surgery.
Matsen, Cindy B; Mehrara, Babak; Eaton, Anne; Capko, Deborah; Berg, Anastasia; Stempel, Michelle; Van Zee, Kimberly J; Pusic, Andrea; King, Tari A; Cody, Hiram S; Pilewskie, Melissa; Cordeiro, Peter; Sclafani, Lisa; Plitas, George; Gemignani, Mary L; Disa, Joseph; El-Tamer, Mahmoud; Morrow, Monica
Rates of mastectomy with immediate reconstruction are rising. Skin flap necrosis after this procedure is a recognized complication that can have an impact on cosmetic outcomes and patient satisfaction, and in worst cases can potentially delay adjuvant therapies. Many retrospective studies of this complication have identified variable event rates and inconsistent associated factors. A prospective study was designed to capture the rate of skin flap necrosis as well as pre-, intra-, and postoperative variables, with follow-up assessment to 8 weeks postoperatively. Uni- and multivariate analyses were performed for factors associated with skin flap necrosis. Of 606 consecutive procedures, 85 (14 %) had some level of skin flap necrosis: 46 mild (8 %), 6 moderate (1 %), 31 severe (5 %), and 2 uncategorized (0.3 %). Univariate analysis for any necrosis showed smoking, history of breast augmentation, nipple-sparing mastectomy, and time from incision to specimen removal to be significant. In multivariate models, nipple-sparing, time from incision to specimen removal, sharp dissection, and previous breast reduction were significant for any necrosis. Univariate analysis of only moderate or severe necrosis showed body mass index, diabetes, nipple-sparing mastectomy, specimen size, and expander size to be significant. Multivariate analysis showed nipple-sparing mastectomy and specimen size to be significant. Nipple-sparing mastectomy was associated with higher rates of necrosis at every level of severity. Rates of skin flap necrosis are likely higher than reported in retrospective series. Modifiable technical variables have limited the impact on rates of necrosis. Patients with multiple risk factors should be counseled about the risks, especially if they are contemplating nipple-sparing mastectomy.
Matsushima, Ken; Komune, Noritaka; Matsuo, Satoshi; Kohno, Michihiro
The use of the retrosigmoid approach has recently been expanded by several modifications, including the suprameatal, transmeatal, suprajugular, and inframeatal extensions. Intradural temporal bone drilling without damaging vital structures inside or beside the bone, such as the internal carotid artery and jugular bulb, is a key step for these extensions. This study aimed to examine the microsurgical and endoscopic anatomy of the extensions of the retrosigmoid approach and to evaluate the clinical feasibility of an electromagnetic navigation system during intradural temporal bone drilling. Five temporal bones and 8 cadaveric cerebellopontine angles were examined to clarify the anatomy of retrosigmoid intradural temporal bone drilling. Twenty additional cerebellopontine angles were dissected in a clinical setting with an electromagnetic navigation system while measuring the target registration errors at 8 surgical landmarks on and inside the temporal bone. Retrosigmoid intradural temporal bone drilling expanded the surgical exposure to allow access to the petroclival and parasellar regions (suprameatal), internal acoustic meatus (transmeatal), upper jugular foramen (suprajugular), and petrous apex (inframeatal). The electromagnetic navigation continuously guided the drilling without line of sight limitation, and its small devices were easily manipulated in the deep and narrow surgical field in the posterior fossa. Mean target registration error was less than 0.50 mm during these procedures. The combination of endoscopic and microsurgical techniques aids in achieving optimal exposure for retrosigmoid intradural temporal bone drilling. The electromagnetic navigation system had clear advantages with acceptable accuracy including the usability of small devices without line of sight limitation. Copyright © 2017 Elsevier Inc. All rights reserved.
Smeele, Ludwig E.; Goldstein, David; Tsai, Vance; Gullane, Patrick J.; Neligan, Peter; Brown, Dale H.; Irish, Jonathan C.
To compare morbidity and cost in patients who underwent primary reconstruction with free tissue transfer with those with pectoralis major myocutaneous flap (PMMF) reconstructions after ablation of oral and oropharyngeal squamous cell carcinoma. Over a 6-year period, 36 patients had PMMF
Shpitzer, T.; Gullane, P. J.; Neligan, P. C.; Irish, J. C.; Freeman, J. E.; van den Brekel, M.; Gur, E.
OBJECTIVES/HYPOTHESIS: Reconstruction of the mandible and oral cavity after segmental resection is a challenging surgical problem. Although osteocutaneous free flaps are generally accepted to be optimal for reconstruction of anterior defects, the need for bony reconstruction for a pure lateral
Bianchi, Bernardo; Ferri, Andrea; Ferrari, Silvano; Copelli, Chiara; Sesenna, Enrico
The purpose of this article was to analyze the efficacy of facelift incision, sternocleidomastoid muscle flap, and superficial musculoaponeurotic system flap for improving the esthetic results in patients undergoing partial parotidectomy for benign parotid tumor resection. The usefulness of partial parotidectomy is discussed, and a statistical evaluation of the esthetic results was performed. From January 1, 1996, to January 1, 2007, 274 patients treated for benign parotid tumors were studied. Of these, 172 underwent partial parotidectomy. The 172 patients were divided into 4 groups: partial parotidectomy with classic or modified Blair incision without reconstruction (group 1), partial parotidectomy with facelift incision and without reconstruction (group 2), partial parotidectomy with facelift incision associated with sternocleidomastoid muscle flap (group 3), and partial parotidectomy with facelift incision associated with superficial musculoaponeurotic system flap (group 4). Patients were considered, after a follow-up of at least 18 months, for functional and esthetic evaluation. The functional outcome was assessed considering the facial nerve function, Frey syndrome, and recurrence. The esthetic evaluation was performed by inviting the patients and a blind panel of 1 surgeon and 2 secretaries of the department to give a score of 1 to 10 to assess the final cosmetic outcome. The statistical analysis was finally performed using the Mann-Whitney U test for nonparametric data to compare the different group results. P less than .05 was considered significant. No recurrence developed in any of the 4 groups or in any of the 274 patients during the follow-up period. The statistical analysis, comparing group 1 and the other groups, revealed a highly significant statistical difference (P esthetic results in benign parotid surgery. The evaluation of functional complications and the recurrence rate in this series of patients has confirmed that this technique can be safely
Kim, Bitna; Yoon, Dae Young; Seo, Young Lan; Park, Min Woo; Kwon, Kee Hwan; Rho, Young Soo; Chung, Chul Hoon
To identify post-operative computed tomography (CT) findings associated with delayed flap failures following head and neck cancer surgery. We retrospectively reviewed 60 patients who underwent flap reconstruction after head and neck cancer surgery and post-operative (3–14 days) contrast-enhanced CT scans for suspected complications. Patients were divided into two groups: delayed flap failure patients (patients required flap revision) (n = 18) and flap success patients (n = 42). Clinical data (age, sex, T-stage, type of flap, and time interval between reconstruction surgery and CT) and post-operative CT findings of flap status (maximum dimension of the flap, intra- or peri-flap fluid collection and intra- or peri-flap air collection, fat infiltration within the flap, fistula to adjacent aerodigestive tract or skin, and enhanced vascular pedicle) were assessed and compared between the two groups. CT findings showed that the following flap anomalies were observed more frequently in the delayed flap failure group than in the flap success group: intra- or peri-flap fluid collection > 4 cm (61.1% vs. 23.8%, p 2 cm (61.1% vs. 2.4%, p < 0.001), and fistula to adjacent aerodigestive tract or skin (44.4% vs. 0%, p < 0.001). The maximum dimension of the flap, fat infiltration within the flap, and enhanced vascular pedicle were not associated with delayed flap failures. A large amount of fluid or air collection and fistula are the CT findings that were associated with delayed flap failures in patients with suspected post-operative complications after head and neck cancer surgery
Objective To study the effect of postoperative radiation on free skin flaps.Methods Twenty-nine patients with free skin flaps applied to the plerosis of the postoperative defectwere followed up. Twenty-eight out of 29 patients received forearm free flaps while 1 had anterolater-al femoris skin flaps in a size ranging from 14 cm× 6 cm to 8 cm× 4 cm. These flaps were exposedto 60Co radiation ranging 40-69 Gy. Results Observation during irradiation: no visible changes ofskin flaps and oral mucous membrane were detected when irradiation dose was within 40 Gy; somechanges may be detected over 40 Gy. Observation 1 - 4 months after irradiation: pigmentations werefound in areas of erosion epidermis; skin flaps got dark but without evidence of necrosis. Observation2 years after irradiation: no necrosis happened in 29 skin flaps. Hairs were found on 15 of 29flaps. Sensation occurred within the margin of 1 cm. Conclusion Free skin flap can endure irradi-ation at the dose of 60 Gy.
Full Text Available Trailing-edge flap is traditionally used to improve the takeoff and landing aerodynamic performance of aircraft. In order to improve flight efficiency during takeoff, cruise and landing states, the flexible variable camber trailing-edge flap is introduced, capable of changing its shape smoothly from 50% flap chord to the rear of the flap. Using a numerical simulation method for the case of the GA (W-2 airfoil, the multi-objective optimization of the overlap, gap, deflection angle, and bending angle of the flap under takeoff and landing configurations is studied. The optimization results show that under takeoff configuration, the variable camber trailing-edge flap can increase lift coefficient by about 8% and lift-to-drag ratio by about 7% compared with the traditional flap at a takeoff angle of 8°. Under landing configuration, the flap can improve the lift coefficient at a stall angle of attack about 1.3%. Under cruise state, the flap helps to improve the lift-to-drag ratio over a wide range of lift coefficients, and the maximum increment is about 30%. Finally, a corrugated structure–eccentric beam combination bending mechanism is introduced in this paper to bend the flap by rotating the eccentric beam.
Scaglioni, Mario F; Kuo, Yur-Ren; Chen, Yen-Chou
The proximal peroneal artery perforator (PPAP) flap is a reliable, thin fasciocutaneous flap. The purpose of this article was to report our experience with the use of free PPAP flaps for reconstruction of defects of the distal hand and foot. From November 2012 to September 2013, 9 patients received reconstruction with 10 free PPAP flaps. The defect locations included the big toe (2 cases), metatarsophalangeal joint (5 cases), dorsal finger (2 cases) and volar finger (1 case). Flaps were raised based on proximal peroneal perforator vessels without sacrificing the peroneal artery. The first dorsal metatarsal artery (5 cases) and digital artery (5 cases) were dissected as recipient vessels. The flap sizes varied from 2.5 x 2 cm to 9 x 5 cm. All of flaps were survival after surgery. One flap suffered from venous thrombosis and was successfully salvaged by performing a venous thrombectomy and vein graft. The donor sites were all primarily closed with minimal morbidities. Follow-up observations were conducted for 7 to 20 months, and all patients had good functional recovery with satisfying cosmetic results. Perforators arising from the peroneal artery in the proximal lateral leg can be used to design small, pliable fasciocutaneous flaps. Although the pedicle is short, the vessel diameter is adequate for microvascular anastomosis to the distal foot and hand recipient vessels. The free PPAP flap may be a good option for reconstructing distal hand and foot defects. © 2014 Wiley Periodicals, Inc.
Kelahmetoglu, Osman; Van Landuyt, Koenraad; Yagmur, Caglayan; Sommeling, Casper E; Keles, Musa K; Tayfur, Volkan; Simsek, Tekin; Demirtas, Yener; Guneren, Ethem
We present a new surgical modification to allow propeller perforator flaps to cover pressure sores at various locations. We used a propeller perforator flap concept based on the detection of newly formed perforator vessels located 1 cm from the wound margin and stimulated by the chronic inflammation process. Between January 2009 and January 2017, 33 wound edge-based propeller perforator flaps were used to cover pressure sores at various locations in 28 patients. In four cases more than one flap was used on the same patient. The patients comprised 18 males and 10 females with a mean age of 41·25 (range, 16-70) years. All patients underwent follow-up for 0-12 months. The mean follow-up duration was 5·03 months. Venous congestion was observed in three flaps that were rotated by 180° (9·1%). However, there was a significant difference between flaps rotated by 90° and 180° according to the complication rate (P = 0·034). Out of 33 flaps, 29 flaps healed uneventfully. Patients were able to sit and lie on their flaps three weeks after surgery. In our study, we were able to obtain satisfying final results using these novel flaps. © 2017 Medicalhelplines.com Inc and John Wiley & Sons Ltd.
Colen, David L; Yeh, Jiun-Ting; Colen, Lawrence B
Neuropathic symptoms after median nerve repair at the wrist or secondary to refractory carpal tunnel syndrome may become debilitating. These symptoms develop because of perineural adhesions, intraneural fibrosis, and fixation of the nerve to the transverse carpal ligament after surgery, and often require neurolysis. Interposition of vascularized soft tissue over the median nerve at the time of neurolysis prevents recurrence of such adhesions. The synovial flap, fashioned from the synovial lining of the flexor tendon sheath, is an ideal tissue for this purpose. Previous authors have described the surgical technique of the synovial flap, but the anatomical basis and design of the flap have not been previously discussed. Twenty fresh cadaver upper extremities were injected with Microfil to analyze the arterial anatomy, flap dimensions, and arc of rotation of the flexor tendon synovium mobilized as a flap suitable for coverage of the median nerve at the wrist. The authors determined that both radial and ulnar-based flaps are clinically useful for providing coverage in the wrist and distal forearm. This flap was used in 18 patients with complicated median nerve lesions in this region. All patients had an uncomplicated postoperative course. Of 13 patients treated for posttraumatic median nerve neuromas, all but two had significant resolution of symptoms. When used as a vascularized flap, the flexor tendon synovium provides adequate protection of the median nerve. Flap dimensions and vascularity of this tissue make it an ideal local flap option when performing reoperative surgery on the median nerve.
Feng, L.J.; Price, D.C.; Mathes, S.J.; Hohn, D.
Two aspects of the inflammatory response to infection--blood flow alteration and leukocyte mobilization--are investigated in the canine model. The elevation of paired musculocutaneous (MC) and random pattern (RP) flaps allowed comparison of healing flaps with significant differences in blood flow (lower in random pattern flaps) and resistance to infection (greater in musculocutaneous flaps). Blood flow changes as determined by radioactive xenon washout were compared in normal skin and distal flap skin both after elevation and following bacterial inoculation. Simultaneous use of In-111 labeled leukocytes allowed determination of leukocyte mobilization and subsequent localization in response to flap infection. Blood flow significantly improved in the musculocutaneous flap in response to infection. Although total leukocyte mobilization in the random pattern flap was greater, the leukocytes in the musculocutaneous flap were localized around the site of bacterial inoculation within the dermis. Differences in the dynamic blood flow and leukocyte mobilization may, in part, explain the greater reliability of musculocutaneous flaps when transposed in the presence of infection
Dast, Sandy; Havet, Eric; Dessena, Lidia; Abdulshakoor, Abeer; Alharbi, Mohammed; Vaucher, Richard; Herlin, Christian; Sinna, Raphael
The concept of extended thoracodorsal artery perforator (TDAP) flap was described in 2015 for breast reconstruction. Our anatomical study aims to identify the territories vascularised by the thoracodorsal artery perforator via the deep muscular fascial network. The second goal was to define the volume of the extended TDAP flap. Ten extended TDAP flaps were dissected on 5 fresh human cadavers. Around the classical skin paddle of a TDAP flap, the dissections were performed in a subfascial level, including the muscular fascia and the adipose tissue compartments to increase the volume of the flap. After injection of methylene blue in the thoracodorsal artery, we measured the length and width, the surface and the volume of the coloured flap. The mean sizes of the extended TDAP flap were 24.9 cm × 20.1 cm. The mean surface of the total vascularization zone was 441 cm 2 . The mean volume of the vascularized flap was 193 ml. The thoracodorsal artery perforator via the deep muscular fascial network allows us to harvest a flap of 25 cm × 20 cm with a mean surface of 441 cm² and a mean volume of 193 ml. The extended TDAP flap is a credible option in breast reconstruction.
Full Text Available Background It can be difficult to select an appropriate flap for various defects on the hand. Although defects of the hand usually must be covered with a skin flap, some defects require a flap with rich blood supply and adequate additive soft tissue volume. The authors present their experience with the anconeus muscle free flap in the reconstruction of various defects and the release of scar contractures of the hand. Methods Ten patients underwent reconstruction of the finger or release of the first web space using the anconeus muscle free flap from May 1998 to October 2013. Adequate bed preparations with thorough debridement or contracture release were performed. The entire anconeus muscle, located at the elbow superficially, was harvested, with the posterior recurrent interosseous artery as a pedicle. The defects were covered with a uniformly trimmed anconeus muscle free flap. Additional debulking of the flap and skin coverage using a split-thickness skin graft were performed 3 weeks after the first operation. Results The average flap size was 18.7 cm2 (range, 13.5–30 cm2. All flaps survived without significant complications. Vein grafts for overcoming a short pedicle were necessary in 4 cases. Conclusions The anconeus muscle free flap can be considered a reliable reconstructive option for small defects on the hand or contracture release of the web space, because it has relatively consistent anatomy, provides robust blood supply within the same operative field, and leads to no functional loss at the donor site.
Adani, R; Marcuzzi, A; Busa, R; Pancaldi, G; Bathia, A; Caroli, A
The authors discuss the indications for homodigital island flap with a reverse vascular pedicle. This flap is based on the anastomoses between the radial and ulnar digital arteries. These anastomotic branches lie between the posterior wall of the tendon sheath and the periosteum to form an arch and are named the "digitopalmar arches". The vascularization of the reverse homodigital island flap is derived by using the middle transverse palmar arch. This flap was performed successfully in 14 patients involving 15 fingers to resurface amputation of the distal phalanx. In 6 cases the flap was used as an "artery" flap, and in 9 cases as a "sensitive" homodigital island flap. The pedicle in these cases was neurovascular also containing the digital nerve. The sensitivity of the flap was obtained by neurorraphy between the transposed digital nerve of the flap and the receiving digital nerve of the recipient finger. This technique achieves cover of the tactile pad in one operative stage and provides well vascularized skin allowing early mobilization. Sensation of the flap can be restored rapidly when neurorraphy of the transposed digital nerve is performed.
Goldie, Stephen J; Almasharqah, Riyadh; Fogg, Quentin A; Anderson, William
Reconstruction of the perineum is required following oncological resections. Plastic surgical techniques can be used to restore the aesthetics and function of the perineum. The gracilis myocutaneous flap provides a substantial skin paddle, with minimal donor site morbidity. The flap is pedicled on a perforator from the medial circumflex femoral artery, giving it limited reach across the perineum. Tunnelling the flap under the adductor longus muscle may free up more of the arterial pedicle, increasing its reach. On three female cadavers, bilateral gracilis flaps were raised in the standard surgical manner, giving six flaps in total. With the flaps pedicled across the perineum, the distance from the tip of each flap was measured to the anterior superior iliac spine (ASIS). The flaps were then tunnelled under the adductor longus muscle. The distances to the ASIS were measured again. The average pedicle length was greater than 7 cm. Tunnelling the flap under the adductor longus muscle increased the reach by more than 4 cm on average. Cadaveric dissection has shown that tunnelling of the flap in a novel way increase its reach across the perineum. This additional flexibility improves its use clinically and is of benefit to plastic surgeons operating in perineal reconstruction. Copyright © 2016 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Şen, Hilmi; Oruç, Melike; Işik, Veysel Murat; Sadiç, Murat; Sayar, Hamide; Çitil, Rana; Korkmaz, Meliha; Koçer, Uğur
Necrosis of random pattern flaps caused by inadequate blood flow, especially in the distal part of the flap is one of the biggest challenges in reconstructive surgery. Various agents have been used to prevent flap ischemia. In this study, we used omeprazole, which is a potent inhibitor of gastric acidity to increase flap viability. In this study, 35 Wistar-Albino type rats which were divided into 5 equal groups were used. Random-pattern dorsal skin flaps were raised in all groups at seventh day of the study. Group 1 was accepted as control group, and the rats in this group was only given distilled water intraperitoneally for 14 days. Group 2 and group 3 received 10 and 40 mg/kg omeprazole daily for 14 days, respectively. Group 4 and group 5 were given distilled water for the first 7 days and then after the operations they received 10 and 40 mg/kg omeprazole daily for 7 days, respectively. Survival rates of the flaps were examined seventh day after elevation of the flaps by digital imaging and scintigraphy. After assessment of the amount of necrosis, number of vascular structures were counted histopathologically. Percentage of flap necrosis was found to be less in all omeprazole received groups. On digital imaging, percentages of flap necrosis in the study groups were statistically significantly lower than that of the control group (P 0.05).In the histopathologic specimens, it was detected that the mean number of vessels in proximal (a) and distal (c) portions of the flap in the study groups showed a significant increase when compared with the control group (P usage of medications increasing gastrin during flap surgeries can be thought as a positive contributor. In this sense, this study showed that parenteral administration of omeprazole in skin flap surgery increases flap viability possibly by increasing gastrin levels.
Gong, Xu; Cui, Jianli; Jiang, Ziping; Lu, Laijin; Li, Xiucun
Few clinical retrospective studies have reported the risk factors of pedicled flap necrosis in hand soft tissue reconstruction. The aim of this study was to identify non-technical risk factors associated with pedicled flap perioperative necrosis in hand soft tissue reconstruction via a multivariate logistic regression analysis. For patients with hand soft tissue reconstruction, we carefully reviewed hospital records and identified 163 patients who met the inclusion criteria. The characteristics of these patients, flap transfer procedures and postoperative complications were recorded. Eleven predictors were identified. The correlations between pedicled flap necrosis and risk factors were analysed using a logistic regression model. Of 163 skin flaps, 125 flaps survived completely without any complications. The pedicled flap necrosis rate in hands was 11.04%, which included partial flap necrosis (7.36%) and total flap necrosis (3.68%). Soft tissue defects in fingers were noted in 68.10% of all cases. The logistic regression analysis indicated that the soft tissue defect site (P = 0.046, odds ratio (OR) = 0.079, confidence interval (CI) (0.006, 0.959)), flap size (P = 0.020, OR = 1.024, CI (1.004, 1.045)) and postoperative wound infection (P < 0.001, OR = 17.407, CI (3.821, 79.303)) were statistically significant risk factors for pedicled flap necrosis of the hand. Soft tissue defect site, flap size and postoperative wound infection were risk factors associated with pedicled flap necrosis in hand soft tissue defect reconstruction. © 2017 Royal Australasian College of Surgeons.
Park, Sung Woo; Oh, Tae Suk; Eom, Jin Sup; Sun, Yoon Chi; Suh, Hyun Suk; Hong, Joon Pio
The reconstruction of the posterior trunk remains to be a challenge as defects can be extensive, with deep dead space, and fixation devices exposed. Our goal was to achieve a tension-free closure for complex defects on the posterior trunk. From August 2006 to May 2013, 18 cases were reconstructed with multiple flaps combining perforator(s) and local skin flaps. The reconstructions were performed using freestyle approach. Starting with propeller flap(s) in single or multilobed design and sequentially in conjunction with adjacent random pattern flaps such as fitting puzzle. All defects achieved tensionless primary closure. The final appearance resembled a jigsaw puzzle-like appearance. The average size of defect was 139.6 cm(2) (range, 36-345 cm(2)). A total of 26 perforator flaps were used in addition to 19 random pattern flaps for 18 cases. In all cases, a single perforator was used for each propeller flap. The defect and the donor site all achieved tension-free closure. The reconstruction was 100% successful without flap loss. One case of late infection was noted at 12 months after surgery. Using multiple lobe designed propeller flaps in conjunction with random pattern flaps in a freestyle approach, resembling putting a jigsaw puzzle together, we can achieve a tension-free closure by distributing the