Large, deep high-grade extremity sarcomas: when is a myocutaneous flap reconstruction necessary?

The surgical treatment of large, deep high-grade extremity soft tissue sarcomas frequently produces a significant tissue defect. In addition, the management of the surgical wound is often further complicated by preoperative radiation or adjuvant therapies. The use of either pedicled or free myocutaneous flaps allows for more rapid and predictable wound healing in this situation. Myocutaneous flaps provide well-vascularized coverage of lost tissue volume, exposed vital structures, and prosthetic reconstruction materials. When harvested from unirradiated sites, flap coverage can overcome the detrimental effects of radiation therapy and chemotherapy on postoperative wound healing. Reconstruction of the soft tissue defect may also improve patient satisfaction with aesthetic issues. The use of innervated myocutaneous flaps can even address the functionality of the extremity following resection of major muscle groups. Myocutaneous flaps are an extremely versatile option for reconstruction in the treatment of large, deep high-grade extremity soft tissue sarcomas.     

Cultured allogenic keratinocyte grafts in the management of wound healing: prognostic factors

Cultured allografts derived from neonatal foreskin provide a potent stimulus to wound healing in a wide variety of wounds. Their application is a simple outpatient procedure involving no discomfort for the patient. In contrast to autografting, no biopsy is necessary, and growth of newborn keratinocytes in cultures is more rapid than that of adult cells. Use of cultured allogeneic cells offers immediate graft availability and the possibility of stockpiling and preserving the graft for future use. Cultured epidermal allografts may be valuable in accelerating healing by second intention in surgical wounds, as well as being a helpful addition to chronic ulcer management. In venous disease, the outcome is at least comparable to other forms of skin grafting. Ulcers due to connective tissue disorders fared less well and deep chronic ulcers (down to fascia or tendon) were not significantly improved by cultured allograft application. Surprisingly, patient age did not influence outcome.     

骶会阴部难治性创面的修复--附28例报道

目的探讨修复骶会阴区各种原因造成的难以愈合的组织缺损创面的方法。方法28例患者因骶会阴部位肿瘤切除手术、褥创、外伤、电烧伤、放射损伤造成骶会阴部久治不愈的创面和复杂的组织缺损,在全身综合治疗的基础上,用皮瓣、肌皮瓣、大网膜等移植修复。结果28例皮瓣肌皮瓣均成活良好,无一例坏死。2例患者在住院治疗后期因肿瘤复发转移死亡。其余26例中有11例创面一期愈合,占全部病例的39.3%;6例又做了1次、2例做了2次扩创缝合手术后创面愈合;6例形成慢性小创面或窦道经较长时间换药愈合,1例慢性窦道和直肠残段相通难以愈合。结论皮瓣肌皮瓣以及大网膜移植可以有效治愈骶会阴部位难治性创面。     

Primary and secondary reconstruction after surgery of the irradiated pelvis using a gracilis muscle flap transposition.

INTRODUCTION: The aim of this study is to describe our experience with reconstruction of pelvic defects after surgery for previously irradiated malignancies using a gracilis muscle flap transposition. PATIENTS AND METHODS: Between 1993 and 2002, 25 patients were treated by primary (n=7) or secondary reconstruction (n=18) using a gracilis muscle transfer. All patients were previously irradiated with a median dosage of 50 Gy. RESULTS: Direct reconstruction following resection of the tumour was accompanied with minor complications in three patients and without major complications. Median time to complete healing of the donor site and perineal defect was 11 and 46 days, respectively. Reconstruction of persistent perineal infections resulted in minor complications at the donor site (n=3) and at the perineal wound (n=11). Three patients experienced a major complication. Median time to complete healing of the donor site and perineal defect was, respectively, 17 and 190 days. Necrosis of the gracilis muscle flaps was not observed. CONCLUSION: Direct reconstruction with a gracilis transfer resulted in primary wound healing with low morbidity, hereby preventing potentially disabling persistent defects. After debridement of persistent wounds, indirect reconstruction with gracilis muscle resulted in the majority of patients in healing of the defects with acceptable morbidity.     

皮肤恶性肿瘤组织缺损修复重建策略专家共识(2020)

外科手术是皮肤恶性肿瘤主要的治疗方式,局部软组织缺损的修复重建是治疗的重点和难点,可能严重影响外科手术的彻底性、修复的完整性和外观的美容性。皮肤肿瘤软组织缺损皮瓣修复重建的最终目标是在确保手术切除外科边界的前提下,通过皮瓣修复局部软组织缺损,尽量达到修复缺损、重建组织功能、外观美容化的目标,提高皮肤肿瘤的外科手术效果和临床预后。目前皮肤恶性肿瘤的缺损修复重建治疗涉及多个专业,技术规范性差、修复方式不尽统一,外科手术水平参差不齐,导致最终皮肤肿瘤外科临床预后仍有待提高。为促进皮肤恶性肿瘤组织缺损修复重建治疗的规范化进程,中国抗癌协会皮肤肿瘤专业委员会牵头组织国内多名从事皮肤肿瘤外科工作的专家共同讨论,形成皮肤恶性肿瘤组织缺损修复重建策略专家共识。针对皮肤恶性肿瘤的外科切除原则,对组织缺损修复重建治疗的适应证评估、修复方式选择、术后并发症的预防与处理、术后随访提出规范化治疗策略推荐,旨在提高全国皮肤恶性肿瘤外科修复重建诊疗水平。     

Free muscle transfer with split thickness skin graft coverage in head and neck reconstructive surgery

Sixteen patients (eight females and eight males) who underwent microsurgical free tissue transfers for head and neck reconstruction are reviewed. In this series, the flap reconstruction was completed on eleven patients with extra-oral defects and five with intra-oral defects. Split thickness skin graft coverage was used in all cases. The rectus abdominis free muscle flap was used in nine patients and the latissimus dorsi free muscle flap in seven patients. The choice of tissue reconstruction was decided by the size of the surgical defect. There were no failures of the tissue transfers and skin grafts. In skilled hands, free tissue transfer provides a reliable method of head and neck reconstruction, with a low incidence of recipient and donor site complications. In extra-oral defects, coverage of free muscle transfer with split thickness skin grafts, results in a better colour match than musculocutaneous flaps, and complements the appearance and pliability of the free muscle flap.     

The purse-string suture in facial reconstruction.

Mohs surgical defects in 26 patients were reconstructed utilizing a purse-string suture and a full-thickness graft. The placement of the purse-string suture decreased the surface area of the wound an average of 53%. A full-thickness graft was then placed in the remaining defect. This technique enabled us to repair large wounds of the facial region with a relatively small full-thickness graft. There were no complications in our series. The resultant areas were cosmetically acceptable and resistant to trauma.     

Reconstructive approaches in soft tissue sarcoma.

Plastic surgical techniques continue to evolve to deal with problem wounds following soft tissue sarcoma resection. Important advances in how tissue is transferred have allowed most wounds to be closed following extirpation; the emphasis is now placed on refining these transfers while minimizing donor site injury. Reconstructive microsurgery has emerged as a frequently preferred way to resurface wounds after sarcoma resection, particularly in patients who have received radiotherapy or previous surgery. Free flaps provide well-vascularized tissue to fill dead space, cover exposed vital structures, and provide structural support and contour. These procedures demonstrate a high success rate of over 90% and often can ensure a healed wound in a single-stage operation. Creative use of the versatile rectus abdominis or latissimus dorsi myocutaneous flaps can reconstruct the majority of breast, extremity, and head and neck soft tissue defects. Endoscopic harvest of muscle flaps has minimized donor morbidity and scarring. The use of "fillet flaps" is an important concept that spares a patient donor site. Composite free flaps, including bone, are routinely used to rebuild the mandible or other bony structures. The future holds great promise for sarcoma reconstruction because tissue engineering is rapidly closing in on techniques that can duplicate tissues in the laboratory for ultimate use in reconstruction, thus sparing the donor site from disease.     

A multivariate analysis of factors affecting wound-healing time

For post-Mohs surgical defects of the head and neck, the width of the defect is the best predictor of the length of that time it will take the wound to heal. This conclusion is based on a multivariate analysis, testing the effect of the following factors on wound-healing time: (1) age, (2) sex, (3) sound location, (4) wound width, (5) wound length, and (6) wound length X wound width. After accounting for wound width, none of the other factors significantly influenced the rate of wound healing. The 64 wounds evaluated were dressed daily with one of five bandages. When compared with the controls, and after correcting for wound width, each of the test bandages shortened wound-healing time. Among the treatment groups, no significant differences were found in the cultures or in the appearance of the wounds.     

Flap reconstruction and interstitial brachytherapy in nonextremity soft tissue sarcoma

Radiotherapy is an integral component of management of high-grade soft tissue sarcomas. Interstitial brachytherapy is used to deliver a boost or radical dose with several advantages over external beam radiotherapy. There has always been a concern to use brachytherapy with flap reconstruction of skin defects after wide excision. We preset our initial experience with interstitial brachytherapy in two patients of recurrent high-grade non-extremity sarcomas treated with surgical excision and soft tissue reconstruction of surgical defect.     

Vaginal reconstruction: an algorithm approach to defect classification and flap reconstruction

Vaginal defects from oncologic resection present a complex array of reconstructive challenges. Increased use of adjuvant radiation and chemotherapy demands uncomplicated wound healing. As patients are being diagnosed at earlier stages of disease and at younger ages, maintenance of sexual function and body image are fundamental goals. This review provides an algorithm approach to defect classification and flap reconstruction. Carefully appreciation of the specific defect facilitates flap choice. There are two basic defect types partial (Type I) and circumferential defects (Type II) 1. These defect types can be further subclassified. Type IA defects are partial and involve the anterior and/or lateral wall. Type IB defects are also partial, but involve the posterior vaginal wall. Type IIA defects are circumferential, involving the upper two-thirds of the vagina. Type IIB defects represent circumferential, total vaginal resection, most commonly following pelvic exenteration. Using this method of defect classification, three pedicled flaps can be used to successfully reconstruct the majority of defects: the Singapore (or pudendal thigh) flap, the rectus flap, and the gracilis flap. With appropriate flap choice and a multidisciplinary approach to patient care, rapid wound healing, restoration of the pelvic floor, and re-establishment of sexual function may be most reliably achieved.     

头面部皮肤恶性肿瘤切除与整形修复

目的:回顾性分析和总结头面部皮肤恶性肿瘤手术和修复的临床经验。方法:扩大切除头面部皮肤恶性肿瘤44例,对47处缺损分别采用直接拉拢缝合、游离植皮、各种邻近皮瓣、皮肤软组织扩张术、游离大网膜 皮片移植等方法修复。结果:因皮瓣下血肿致延期愈合1例,大网膜坏死而重新植皮1例,面神经麻痹2例,部分皮片坏死2例,其余的病例均Ⅰ期愈合。结论:术后缺损的修复方法应根据患者的具体情况而定,其中以邻近随意皮瓣的效果较好。     

The use of artificial dermis for surgical defects in the treatment of oral premalignant lesions

BACKGROUND: This study investigated the application of an artificial dermis as a substitute for split-thickness skin graft in an oral mucosal defect after excision of a premalignant lesion. METHODS: We examined a total of 125 sites repaired with artificial dermis in 84 patients. Forty-one of 84 patients had two different defects and 43 had a single defect. Of 84 patients, there were 52 oral leukoplakia and 32 oral submucous fibrosis. RESULTS: Most patients chewed betel nuts (97.6%). Most of the premalignant lesions were located in the buccal mucosa (94%). The overall success rate was 100% without any or partial graft loss. The minor wound oozing occurred in three grafts (2.4%). No patient had an immunologic reaction or experienced with significant pain. CONCLUSIONS: Therefore, an artificial dermis may be an alterative to a split-thickness skin graft for patients with oral mucosal defects after removal of premalignant lesions.     

Delayed grafting of midline forehead flap donor defect: utilization of residual flap tissue

The use of a midline forehead flap often creates a secondary defect that is difficult to close primarily. When the pedicle is detached, the residual flap tissue can be utilized as a delayed full-thickness skin graft. This technique combines two surgical principles: delayed grafting and the use of adjacent residual flap pedicle skin that would normally be discarded.     

Wound complications following pre-operative radiotherapy for soft tissue sarcoma.

AIMS: We analysed wound complications in 43 patients with soft tissue sarcoma who were treated with combined pre-operative radiotherapy and surgery. METHODS: All patients received the same protocol of pre-operative radiotherapy at our institution. RESULTS: Thirty-six (84%) patients developed acute skin toxicity following radiotherapy. After wide local excision, 15 patients required primary soft tissue reconstruction with vascularized muscle transfer and four patients underwent free skin flap to enable wound closure as part of their primary surgery. Nineteen patients (44%) developed post-operative wound complications including 10 (23%) patients who required an additional surgical procedure. Four (27%) patients developed flap necrosis in a group of 15 who underwent primary vascularized soft tissue transfer. All required a second vascularized muscular flap. One elderly patient, who had grade 3 acute radiation skin toxicity, had an arterial graft and total hip arthroplasty for a femoral artery aneurysm and an avascular necrosis of the hip, respectively. In our series, age (> or = 40 years) was the only impact factor influencing wound complication after surgery following radiotherapy (P=0.06). CONCLUSIONS: Site of tumour, radiation field size, surgical resection volume, grade of acute radiation toxicity, co-morbidity, and smoking were not demonstrated to have predictive value in wound complication following pre-operative radiotherapy. Although previous papers suggested that vascularized soft tissue transfer could be useful reducing wound morbidity, our results could not confirm this.     

Epithelial stem cells, wound healing and cancer

It is well established that tissue repair depends on stem cells and that chronic wounds predispose to tumour formation. However, the association between stem cells, wound healing and cancer is poorly understood. Lineage tracing has now shown how stem cells are mobilized to repair skin wounds and how they contribute to skin tumour development. The signalling pathways, including WNT and Hedgehog, that control stem cell behaviour during wound healing are also implicated in tumour formation. Furthermore, tumorigenesis and wound repair both depend on communication between epithelial cells, mesenchymal cells and bone marrow-derived cells. These studies suggest ways to harness stem cells for wound repair while minimizing cancer risk.     

Therapie des Rezidivs beim Vulva- und Vaginalkarzinom

Objective

In this retrospective analysis,186 patient cases of recurrent vulvar or vaginal carcinoma were examined regarding pretreatment, surgical therapy, plastic reconstruction, and postoperative disease course.

Results

Therapy was individualized according to tumor status using the complete spectrum of surgical interventions. Plastic reconstruction led to improvements with respect to operability, wound healing, and survival. For minor defects, local (fasciocutaneous) flaps proved to be reliable operative techniques. In cases exhibiting larger wounds, the use of regional (myocutaneous) flaps produced satisfactory results. For posterior defects, gluteal thigh flaps were the safest procedures, whereas for anterior defects, flaps from the rectus abdominis muscle proved to be most successful.

Conclusion

Our analysis shows that individualized reconstructive surgery leads to good local control and satisfactory patient outcome in patients with recurrent vulvar cancer. Surgical procedures for recurrent vulvar carcinoma require the same principles of radicality as for primary tumors. To an even greater extent than for primary therapy, plastic surgery enlarges the spectrum of feasible surgical alternatives, especially after radiotherapy.     

足底部恶性黑色素瘤切除术后两种修复方法临床疗效观察

目的：比较足底部皮肤恶性黑色素瘤切除术后两种修复方法的疗效。方法：回顾性分析2006年7月~2014年2月我院收治31例足底部皮肤恶性黑色素瘤患者临床病理资料,其中男14例,女17例。临床分期：I期2例,Ⅱ期9例,Ⅲ期20例。手术均行距肿瘤边缘2cm的广泛切除＋腹股沟淋巴结清扫术；足底肿瘤切除术后缺损以两种方式修复,A组（11例）：直接从同侧腹股沟切口取全厚皮片修复或皮瓣修复＋取同侧腹股沟全厚皮片修复供皮瓣区。 B组（20例）：直接取同侧大腿中厚皮片植皮修复或皮瓣修复＋取同侧大腿中厚皮片修复供皮瓣区；比较两组患者的手术时间、术中出血量、术中淋巴结清扫数目、住院时间、住院费用、腹股沟伤口并发症及足底局部复发情况等方面的差异。结果：术后足底缺损区植皮或皮瓣完全成活,肿瘤均无局部复发。两种方法在住院时间、住院费用及腹股沟伤口术后并发症方面差异有统计学意义（p0．05）。结论：与从同侧大腿取中厚皮片修复相比,从腹股沟切口直接取全厚皮片修复减少手术伤口,并发症少,住院时间短,住院费用低,是一种较理想的修复方法。     

A synthetic skin substitute as a temporary dressing in Mohs surgery

Epigard (Synthes, Paoli, PA), a synthetic skin substitute, is useful in the temporary covering of surgical wounds. The dressing adheres to the wound bed, provides hemostasis, and aids neovascularization. When removed after 2-3 days, the surgeon has a wound ready to accept a graft.     

Celecoxib can prevent tumor growth and distant metastasis in postoperative setting

Much evidence suggests that an inflammatory condition provides a microenvironment favorable for tumor growth. One of the main components in the healing wound is the induction of cyclooxygenase-2 (COX-2) and prostaglandins, and many solid tumors have been known to overexpress COX-2. The present study investigated the relationship between surgical wounds and tumor growth and the roles of COX-2 and inflammatory reaction in this microenvironment. We created surgical wounds in syngeneic mice for the implantation of SCC VII murine cancer cell line. Accelerated tumor growth and increased angiogenesis by surgical wounds were clearly observed in C3H/HeJ mice with SCC VII tumor. The COX-2 expression of peritumoral tissues and leukocyte infiltration partly explained the accelerated tumor growth, especially in the early phase after surgical wounding. Celecoxib had a significantly suppressive effect on tumor growth, angiogenesis, and metastasis in tumor-implanted mice with surgical wounds. This tumor-suppressive action of celecoxib did not show any noticeable side effects on the late wound healing and on the gastrointestinal tracts. Prophylactic use of the drug can be advocated in many clinical situations, such as residual tumors or contamination of surgical fields by tumor cells.