Thigh Grafts: A Preferable Alternative to Catheters when Upper Extremity Access Sites are Exhausted

Hemodialysis patients with failed upper extremity (arm) access sites comprise 5–10% of the dialysis population. In these patients, arm vessels are either unsuitable for access placement due to trauma or peripheral vascular disease, or have been exhausted following dialysis usage. Synthetic grafts in the lower extremity (thigh) would benefit these patients, but surgeons are often reluctant to place them, due to concerns of infection and vascular complications. As a result, these patients receive tunneled central venous catheters as their permanent dialysis access. Recent studies have shown, however, that survival and complication rates of thigh grafts are similar to arm grafts and fistulas. Moreover, thigh grafts have lower infection and mortality rates than catheters and provide higher blood flows and dialysis adequacy. In this editorial we argue that thigh grafts are the better option in patients who have lost all arm access sites; they should be placed in preference to tunneled central venous catheters.     

Anterolateral thigh flap for breast reconstruction: review of the literature and case reports

More women than ever before are undergoing mastectomies secondary to increased awareness and screening. This has also caused a corresponding increase in the number of breast reconstructions requested each year. The demand for improved results has fueled recent advances in new techniques. Aside from implant reconstruction, the methods now being employed are related to autogenous donations and reconstruction. Currently, the most commonly used techniques for autogenous breast reconstruction are the DIEP (deep inferior epigastric perforator) and TRAM (transverse rectus abdominis myocutaneous) flaps from the lower abdomen. The anterolateral thigh flap is a type of perforator flap usually described for use in head and neck reconstruction. The authors have discovered this flap's utility as an alternative in autogenous breast reconstruction when the abdomen is not available as a donor site. A review of the literature reveals a dearth of experience in using the anterolateral thigh flap for breast reconstruction. The article reviews the literature with regard to current uses of the anterolateral thigh flap, and then reports three case studies which highlight the thigh flap as an excellent alternative for breast reconstruction in selected patients.     

Limb Contouring after Massive Weight Loss: Functional Rather than Aesthetic Improvement

Background  After massive weight loss, both upper and lower limbs show a similar deformity which consists of redundancy and ptosis of the cutaneous mantle. Many disturbances are associated with this abnormality, which can be treated surgically. A retrospective review of limb-contouring procedures after massive weight loss is presented. Methods  Thigh lift and arm lift procedures are described. All surgeries of upper and lower limbs contouring performed between 2003 and 2006 are reviewed with regard to quantity of tissue removed, comorbidities, complications and patients’ satisfaction, which was surveyed through a questionnaire exploring functional and esthetic results (maximum score 3). Results  Among 48 bilateral limb-contouring procedures, medial thigh lifts were 35 (73%) and brachioplasties were 13 (27%). Mean age was 46 and average body mass index variation was 20 kg/m². The most frequent comorbidity was gallstones (28%). In 46% of the whole group of patients, there was no complication to mention. The most frequent complication was acute anaemia in both procedures (43% in thigh lift and 54% in arm lift). Mean quantity of adipose–dermoid tissue removed was 766 g in thigh lift and 463 g in arm lift. In case of surgery combined with liposuction, the average aspirated volume was 1,933 ml (thighs) and 1,117 ml (arms). Patients’ satisfaction was 2.7 for thighs and 2.6 for arms, as average. Conclusion  The rate of complications in limb contouring after weight loss is higher than the analogue esthetic procedures. Nevertheless, due to the rehabilitative significance of limb surgery after weight loss, this step is to be included as fundamental in obese patients’ surgical therapy. Data partially presented at the XVI Conference of the Italian Society of Obesity Surgery (Capri, May 14–16, 2008).     

Uterine prolapse in a young nulligravida with scleroderma and premature ovarian failure

We report a case of pelvic organ prolapse quantification (POPQ) stage III uterine prolapse in a 25-year-old nulligravida. Premature ovarian failure was diagnosed after 1 year of amenorrhea. Localized scleroderma was noticed on her thigh and lower back. We discuss the possible role of scleroderma and ovarian failure on the occurrence of uterine prolapse in light of the literature.     

A new cause for iatrogenic lesion of the ulnar nerve at the arm: contraceptive hormonal implant. Report of two cases

The authors describe two cases of iatrogenic lesions of the ulnar nerve at the arm level after insertion of contraceptive hormonal implants. The presence of only a thin subcutaneous fat layer on the medial side of the arm in slim women, exposes the ulnar nerve to danger during the insertion or withdrawal of the implant. We therefore advise the insertion of such implants on the medial side of the thigh in slim women. We equally recommend that withdrawal of non-tangible devices implanted on the medial side of the arm or in case of neurologic symptoms, even transitory, be done by a trained microsurgeon.     

Dinamap arm and thigh arterial pressure measurement

Two automatic arterial pressure monitors (Model 1846 P) were used in 30 patients to measure arterial pressures and heart rates in the thigh and arm. Significant differences were found in thigh-arm systolic (p less than 0.001) and diastolic pressures (p less than 0.05). Arm pressures could be predicted from leg pressures and correction factors are suggested. Mean pressures in the thigh approximated more closely to the calculated mean pressures than in the arm. These differences were of little clinical importance.     

Posterior Scrotal Artery Flap to Cover a Groin Defect: A New Technique

Commonly, a groin defect is reconstructed with flaps from ipsilateral thigh or lower abdomen. Here we present a case report of use of a pedicled flap from the posterior scrotum based on posterior scrotal artery to cover a groin defect exposing femoral vessels. Posterior scrotal artery, to best of our knowledge, has not been described in the literature to cover a groin defect.     

Intramuscular myxoma

Myxomas of the skeletal muscle are uncommon mesenchymal tumours. About one hundred such tumours have been reported in the world literature so far. In the present paper, we report a case of myxoma which occurred in the thigh muscles, with brief review of pertinent literature.     

A case of sarcoidosis occurring within an extensive burns scar.

Scarring from burn injuries can result in cosmetic and functional deformities. In addition, late complications can also occur presenting as other pathology developing within the scarred tissue. We report a unique case of cutaneous sarcoidosis developing within a burns scar in an adult male who sustained a burns injury to his torso, right arm and thigh.     

The effects of epidural and general anesthesia on tissue oxygenation

The risk of wound infections is inversely related to subcutaneous tissue oxygen tension. General anesthesia increases local blood flow by direct vasodilation and central inhibition of thermoregulatory vasoconstriction. Epidural anesthesia can increase perfusion in blocked regions by decreasing sympathetic tone. We therefore tested the hypothesis that epidural anesthesia increases tissue oxygen tension in awake and anesthetized subjects. Fifteen healthy volunteers underwent epidural, general, and combined epidural and general anesthesia. Subcutaneous tissue oxygen tension was measured using tonometers in the lateral upper arm and the lateral thigh. Epidural anesthesia to a T10 level was maintained with 0.75% mepivacaine. General anesthesia was maintained with 1.5% sevoflurane in 30% oxygen; 30% inspired oxygen was given via a sealed facemask during baseline and epidural anesthesia. Baseline subcutaneous tissue oxygen tensions for arm and thigh were 57 +/- 11 and 54 +/- 8 mm Hg, respectively. Epidural anesthesia significantly increased tissue oxygenation in the thigh by 9 mm Hg, to 63 +/- 7 mm Hg, without increasing arm oxygenation. Tissue oxygenation in the arm and thigh were similar during general anesthesia alone, 58 +/- 11 and 63 +/- 12 mm Hg. Arm oxygenation remained unchanged with the addition of epidural anesthesia; however, thigh subcutaneous oxygen partial pressure increased 8 +/- 3 mm Hg, from 63 +/- 12 to 71 +/- 9 mm Hg. Although epidural anesthesia increased tissue oxygenation significantly with and without general anesthesia, the magnitude of this increase might be of marginal clinical importance in regard to surgical wound infections. IMPLICATIONS: Epidural anesthesia significantly increased subcutaneous tissue oxygenation in the thigh both with and without general anesthesia. Although each increase was statistically significant, previous work suggests that the magnitude of these changes is unlikely to markedly reduce the risk of surgical wound infection.     

Severe radiation-induced injury after cardiac catheter ablation: a case requiring free anterolateral thigh flap and vastus lateralis muscle flap reconstruction on the upper arm.

Although cases of radiation-induced skin injury after fluoroscopically-guided procedures have been reported since 1996, diagnosis and treatment of such injury remain difficult. We present the case of a patient who complained of two ulcers, one on his right arm and one on his back, and limited motion of the right elbow joint after repeated cardiac radiofrequency catheter ablations. After resection of the skin ulcer on the patient's arm and of degenerated tissue in the distal part of the triceps brachii muscle, a combined free flap incorporating an anterolateral thigh flap and vastus lateralis muscle flap was transplanted. In the present case, this combined flap was very useful for simultaneous reconstruction of the muscle and skin defects under and over the tendon because the muscle flap and skin flap could be arranged separately.     

Extrusion of a Raimondi peritoneal catheter from the thigh

A case of extrusion of a peritoneal shunt catheter from the thigh is reported. The literature is reviewed and the frequent involvement of Raimondi catheters in extrusion is discussed.     

The prefabricated gracilis muscle flap with full-thickness skin graft and delay for urethral channel reconstruction

Fasciocutaneous free flaps are commonly used in reconstruction of the lower extremity. The purpose of this study was to compare preferences in donor-site scar location among 3 flaps capable of covering a wound that is 4 to 6 cm wide with primary closure of the donor-site. The locations chosen were the lateral arm, the anterolateral thigh, and the proximal lateral calf. Survey participants were presented a hypothetical scenario of a trauma patient with an open anterior tibial wound, requiring free flap reconstruction. In an internet-based survey, respondents were asked to take on the role of the patient and to rate the 3 donor-site scar locations with a visual analog scale and rank them in order of preference. One hundred ninety-eight respondents (mean age 24.7 ± 2.9 years, 49.1% men) responded to the survey, and 171 were included. The anterolateral thigh was the most preferred donor site (88.9% ranked first, rated 8.24 ± 1.86), followed by the proximal lateral calf (8.7% ranked first, rated 5.03 ± 1.96), and the lateral arm was last (2.3% ranked first, rated 2.18 ± 1.62). Survey participants clearly preferred the anterolateral thigh as a donor site. This preference may be related to the ability to conceal the scar under clothing, whereas the proximal lateral calf could keep scars in a smaller topographical area of the body. When other aspects of the reconstruction are equal, it may be important for the surgeon and patient to discuss the goals of concealing the donor-site scar versus keeping the wound and reconstruction-related scars in a smaller topographical area of the body.     

Late bacterial granuloma at an intrathecal drug delivery catheter

Summary In the case reported, neurological complaints were pain and dysaesthesiae in the lower back and thigh, as well as paresis of the ileopsoas muscle. MRI of the lumbar spine showed an intradural-extramedullary mass at the level of L1 homogeneously enhancing with gadolinium. This mass was situated at the tip of an intrathecal catheter implanted 11 years before for a morphine trial infusion as therapy for phantom pain after amputation of the right arm. Now, removal of the catheter was performed. Cultures of lumbar CSF and the catheter tip demonstrated coagulase negative staphylococcus. Antibiotic medication with cephalosporines was given for 6 weeks. After removal of the catheter, the patient was free of pain and he progressively regained full neurological function. Although most catheter-associated granulomas reported so far were sterile in nature, bacterial infection should still be considered even years after catheter placement.     

Simulation of compartment syndrome by rupture of the deep femoral artery from blunt trauma

Life-threatening hemorrhage of the femoral vasculature from a blunt injury to the thigh without femoral fracture has not been emphasized in the medical literature. Two cases of massive hemorrhage from the deep femoral system resulted from blunt injury to the thigh without femoral fracture. In the first case, a diagnosis of compartment syndrome was based on muscle swelling from the blunt trauma. A fasciotomy uncovered life-threatening bleeding. In the second case, which had a similar history and clinical symptoms, a vascular injury was suspected and an arteriogram was done. Disruption of the deep femoral arterial system was detected, and fluoroscopic embolization controlled the bleeding. A routine fasciotomy was then done. Both patients appeared clinically to have a thigh compartment syndrome, presumably based on injury from the crushed muscle. They both had normal arterial pulsations distal to the injured thigh. The only feature that suggested a vascular injury was a need for transfusion for hemodynamic support in excess of apparent blood loss. Arteriography, with embolization if necessary, is advised for all cases of suspected thigh compartment syndrome in which there is an unexplained need for hemodynamic support by transfusion.     

股前外侧皮瓣移植在小儿下肢大面积软组织缺损中的临床应用

目的探讨股前外侧皮瓣移植治疗小儿复杂创伤性大面积软组织缺损的可行性和临床疗效观察。方法应用股前外侧皮瓣游离移植治疗小儿下肢大面积软组织缺损11例,包括小腿1例、踝后伴跟腱缺损3例、足部7例。结果 10例皮瓣顺利成活,1例出现静脉危象,探查处理后成活;供区植皮全部成活。术后随访3~24个月,皮瓣质地柔软,外形良好,4例吻合皮神经后恢复保护性感觉。结论股前外侧皮瓣移植治疗小儿下肢大面积软组织缺损,可明显提高保肢成功率,缩短治疗周期,最大限度恢复患肢功能,临床疗效满意。     

We Underutilize the Leg Graft

Once hemodialysis patients have exhausted all option for a permanent vascular access in both upper extremities, they are often relegated at many dialysis centers to permanent catheter dependence with all its attendant complications, including infections, frequent dysfunction, and central vein stenosis. This commentary makes the case that thigh grafts are a far superior alternative to dialysis catheters in many of these patients. Technical graft failure may occur in some patients due to severe femoral artery calcification, but screening for calcification by ultrasound or computerized tomography can reduce the likelihood of a technical failure. Placement of a thigh graft may lead to critical lower extremity ischemia, but preoperative screening for peripheral vascular disease should minimize this possibility. Thigh grafts have comparable secondary patency to that obtained with upper extremity grafts. Finally, although the risk of infection is somewhat higher for thigh grafts than upper extremity grafts, it is still much lower than the risk of catheter‐related bacteremia. In summary, thigh grafts should be used much more frequently in patients without an option for an upper extremity access.     

Ischemic bowel as a late sequela of abdominal compartment syndrome secondary to severe burn injury

Abdominal compartment syndrome (ACS) is a known complication of the large-volume resuscitation that burn patients receive. Bowel ischemia has been theorized to occur in ACS but has yet to be described in the literature. The authors report an occurrence of late bowel obstruction related to ACS-associated bowel ischemia in a burn patient.A four-year-old previously well girl sustained 70% total body surface area burns with inhalation injury. The areas injured were the anterior neck, circumferential torso from neck to waist, left arm, left thigh and two-thirds of her right thigh. Fluid resuscitation was initially administered using the modified Parkland formula. Her transfer to the regional burn unit from a local hospital was complicated by early septic shock from a line infection, which increased her resuscitation fluid requirements. Infection ultimately led to multiple instances of ACS. Intervention with percutaneous drainage led to immediate improvement; however, the episodes of ACS resulted in a late small bowel obstruction secondary to stricture, requiring a laparotomy and bowel resection.     

Isolated thigh claudication as a result of fibromuscular dysplasia of the deep femoral artery.

Isolated thigh claudication as a result of fibromuscular dysplasia of the deep femoral artery has not previously been reported. This case report describes a patient with fibromuscular dysplasia of the carotid arteries in whom progressive unilateral thigh claudication developed despite normal femoral pulses. Deep femoral artery occlusion caused by fibromuscular dysplasia was successfully treated by common femoral to distal deep femoral artery bypass. Fibromuscular dysplasia of the infrainguinal arteries is rare but should be included as a possible cause of lower extremity ischemic symptoms.