Gluteal necrosis following pelvic fracture and bilateral internal iliac embolization: Reconstruction using a transposition flap based on the lumbar artery perforators

INTRODUCTIONThe use of bilateral internal iliac artery embolization to control hemorrhage associated with pelvic fractures is a life saving intervention. Gluteal necrosis is a rare but potentially fatal complication of this procedure. Following debridement, reconstruction can present a considerable challenge due to the compromised vascularity of local tissue.PRESENTATION OF CASEA 17 year old girl suffered an open book pelvic fracture following a road traffic accident. In order to stop profuse bleeding, bilateral internal iliac artery embolization was performed. This procedure was complicated by the development of right sided gluteal necrosis. Following extensive debridement, a transposition flap based on the lumbar artery perforators was performed to cover the soft tissue defect.DISCUSSIONGluteal necrosis occurs in approximately 3% of cases following internal iliac artery embolization. Following complete excision of the devitalised tissue reconstructive surgery is necessary. Local flaps are suboptimal options when the integument supplied by branches of the internal iliac arteries has been compromised following embolization. Furthermore, the use of a free flap is restricted by the lack of a readily accessible undamaged recipient vessel. In the present case a transposition flap based on the lumbar artery perforators facilitated robust reconstruction of the buttock region.CONCLUSIONTo avoid sepsis, it is imperative that gluteal necrosis following internal iliac artery embolization is recognized and promptly debrided. A transposition flap based on the lumbar artery perforators is a good option for subsequent soft tissue coverage, which avoids use of tissue supplied by the branches of the internal iliac arteries.     

Incisional lumbar hernia after the use of a lumbar artery perforator flap for breast reconstruction

Abstract

Autologous breast reconstruction with a perforator flap has become increasingly popular. The free lumbar artery perforator (LAP) flap has been described as a good alternative for autologous breast reconstruction. The LAP flap is a perforator flap based on a single pedicle. This flap is easy to harvest, with minimal donor-site morbidity. We present a case of a lumbar incisional hernia after LAP flap breast reconstruction in a 53-year-old patient. The patient had been treated with a bilateral mastectomy for cancer. Secondary breast reconstruction was performed with a bilateral DIEP flap. Reoperation was necessary because of a failed DIEP flap at the left side. Reconstruction was performed with a free LAP flap. The patient was referred for a right lumbar incisional hernia at the donor-site of the LAP flap. Open repair was performed with a retroperitoneal mesh. The thoracolumbar fascia was closed in with a running suture. Lumbar artery perforator is a perforator flap based on a single pedicle. Although it does not sacrifice any muscle and seems to be associated with minimal donor-site morbidity, we present the first report of a lumbar incisional hernia repair after LAP flap breast reconstruction treated using an open retroperitoneal mesh repair.     

带第四腰动脉蒂髂骨瓣植骨治疗腰椎不稳

目的：探讨应用带第四腰动脉蒂植骨治疗腰椎不稳的手术方法和适应症。方法：本组腰椎不稳病人16例,将带第四腰动脉蒂髂骨瓣用松质骨螺丝钉固定于需融合节段腰椎的椎弓根,对侧椎板或横突间植骨融合。／结果：术后随访8个月至6年,平均2．8年,根据李稔生的疗效评价标准：优13例,良2例,可1例,结论：应用带第四腰动脉蒂髂骨瓣植骨融合治疗腰椎不稳手术简单,临床效果好。     

拇指软组织缺损的本体皮瓣修复

目的探讨应用拇指本体皮瓣对拇指软组织缺损修复的有效方法。方法应用三种不同的拇指本体皮瓣,即Hueston皮瓣,Moberg皮瓣及拇指尺背侧动脉逆行皮瓣修复10例拇指软组织缺损的患者。结果皮瓣全部成活,外形修复理想,受创拇指的长度得到保留,拇指感觉存在。结论对于拇指软组织缺损,尤其合并多指损伤时,应用同指本体皮瓣,完成对裸露骨组织的覆盖,可避免受创拇指有效长度的进一步缩短和恢复理想的感觉,操作简单、手术效果满意。     

Reconstruction of floor of mouth defects by the facial artery musculo-mucosal flap following cancer ablation

BACKGROUND: The purpose of this study is to review our experience with the use of the facial artery musculo-mucosal (FAMM) flap for floor of mouth (FOM) reconstruction following cancer ablation to assess its reliability, associated complications, and functional results. METHODS: This was a retrospective analysis of 61 FAMM flaps performed for FOM reconstruction from 1997 to 2006. RESULTS: No total flap loss was observed. Fifteen cases of partial flap necrosis occurred, with 2 of them requiring revision surgery. We encountered 8 other complications, with 4 of them requiring revision surgery for an overall rate of revision surgery of 10% (6/61). The majority of patients resumed to a regular diet (85%), and speech was considered as functional and/or understandable by the surgeon in 93% of the patients. Dental restoration was successful for 83% (24/29) of the patients. CONCLUSION: The FAMM flap is well suited for FOM reconstruction because it is reliable, has few significant complications, and allows preservation of oral function.     

Distal internal iliac artery embolization: a procedure to avoid

OBJECTIVES: Internal iliac artery (IIA) coil embolization as an adjunct to endovascular stent grafting (ESG) is common practice for treating abdominal aortic aneurysm (AAA) in patients with a substantially enlarged common iliac artery requiring extension of the stent-graft limb into the external iliac artery. The literature describing pelvic ischemia in association with IIA coil embolization contains conflicting reports of symptom severity. We studied IIA occlusion outcome as a function of coil placement in the IIA. METHODS: From August 1997 to March 2002, 20 patients with AAA underwent ESG with unilateral IIA coil embolization. Coils were placed proximal to the first branch of the IIA in 8 patients and distal to the first branch in 12 patients. Symptoms of pelvic ischemia and mid-term outcome were studied. RESULTS: Patients included 18 men and 2 women with mean age of 70(1/2) years (range, 53-86 years). Mean diameter of AAA was 54.4 mm (range, 38-80 mm), and of common iliac artery was 24.2 mm (range, 15-48 mm). Ten patients (50%) had new onset of symptoms of pelvic ischemia after endograft procedures: 1 of 8 patients (13%) with proximal IIA embolization had buttock claudication, and 9 of 12 patients (75%) with distal IIA embolization had pelvic ischemic symptoms, including buttock claudication in 8 and impotence in 1 (P =.02, Fisher exact test). No colonic ischemia occurred in this series. At 12-month follow-up, 4 patients with distal IIA embolization were symptom-free. At further follow-up to 24 months, 4 patients remained significantly limited with symptoms of claudication. CONCLUSIONS: A significantly higher incidence of symptoms of pelvic ischemia occurred with more distal placement of coils for IIA embolization. Failure to control for extent of coil placement may account for the apparently conflicting results in published studies. IIA coil embolization should be performed as proximal as possible to prevent interference with pelvic collateral circulation.     

带旋髂深动脉髂骨瓣与腓肠神经营养血管皮瓣修复跟骨及软组织缺损

目的探讨带旋髂深动脉髂骨瓣、腓肠神经营养血管皮瓣修复跟骨及软组织缺损的临床疗效。方法采用游离带旋髂深动脉髂骨瓣联合腓肠神经营养血管皮瓣修复6例跟骨及软组织缺损患者。结果 6例皮瓣骨瓣全部成活。3例皮瓣发生部分边缘性坏死,经换药后创面愈合;1例因跟腱修复失败,二期行踝关节融合术。患者均获得6~20个月随访。术后小腿及足部均有良好外形及部分感觉,部分患者经锻炼后恢复承重功能。结论以带旋髂深动脉髂骨瓣联合腓肠神经营养血管皮瓣修复跟骨及软组织缺损可行,临床疗效满意。     

吻合血管的逆行游离耳前皮瓣移植修复鼻部分缺损

目的旨在设计以颞浅动脉远端为蒂的逆行游离耳前皮瓣进行吻合血管的移植一期修复鼻部分缺损。方法本组共3例,1例为鼻尖缺损,1例为右侧鼻翼缺损,1例为鼻尖缺损、右侧鼻翼完全缺损及左侧鼻翼不完全缺损。术中将游离逆行耳前皮瓣的颞浅动、静脉分别与鼻唇沟部面动、静脉吻合,其中1例急诊患者颞浅静脉是与下睑伤口的一条静脉吻合。结果逆行游离耳前皮瓣大小范围为3.0 cm×2.5 cm~6 cm×2 cm,血管蒂长5~6 cm。3例患者皮瓣均成活,再造的鼻尖、鼻翼外形逼真,皮肤色泽、质地与鼻部皮肤接近。耳前供区切口隐蔽不遗留明显瘢痕。结论耳前皮瓣皮肤颜色、质地与鼻部接近,皮瓣血管蒂长,不需要血管移植,可通过显微外科技术一期修复鼻部分缺损,该皮瓣也可用于面部其他皮肤缺损的修复。     

指掌横支血管蒂指掌侧皮瓣修复指端缺损

目的 探讨一种新的对指端组织缺损的皮瓣修复方法.方法 以指动脉的掌横支为血管蒂,设计指掌侧皮瓣,逆行转移覆盖指端缺损创面.结果 临床应用11例12指,1指皮瓣坏死,11指皮瓣全部成活,外形满意.结论 这是一种新的、对指端提供了良好的指脂垫和感觉功能的手术方法且操作简单.     

Reconstruction of hard palate defects using a facial artery musculomucosal flap

The facial artery musculomucosal flap (FAMM) is usually used in reconstruction of defects in oral cavity, most frequent being the mouth floor. This flap has many advantages from its surgical procedure, its great reliability, its mucous tissue origin, its usable surface, its large axis of rotation and the little of after-effects of the donor site. The hard palate defects with bucconasal communication can raise difficulties of reconstruction. We show, by a case report, the many advantages of FAMM flap in these reconstructions.     

Reconstruction of intraoral defects using facial artery musculomucosal flap.

The facial artery musculomucosal flap, technically a combination of the nasolabial flap and the buccal mucosal flap, has been a reliable, versatile flap, either superiorly or inferiorly based for reconstruction of a wide variety of postcancer excision intraoral mucosal defects including defects of the palate, alveolus, lips and floor of mouth. We have used it 17 times in 16 patients with no failures and one flap with terminal necrosis. Almost all flaps developed venous congestion which settled on its own by conservative management.     

旋肩胛血管横支岛状皮瓣修复严重腋窝瘢痕挛缩畸形

目的 探讨应用旋肩胛血管横支岛状皮瓣修复严重腋窝瘢痕挛缩畸形的可行性.方法 对12例患者共15侧严重腋窝瘢痕挛缩畸形采用旋肩胛血管横支为蒂的岛状皮瓣修复,皮瓣面积12 cm×5 cm至20 cm×10 cm,旋转180°覆盖创面,供瓣区直接拉拢缝合.结果 所有皮瓣全部成活,挛缩腋窝得到了基本纠正,8例患者随访1～3年,腋窝外观满意,肩关节功能良好.结论 旋肩胛血管横支岛状皮瓣是修复严重腋窝瘢痕挛缩的良好方法,特别适合于女性或不适宜选用旋肩胛血管降支或升支形成旋肩胛皮瓣的患者.     

胸廓内动脉穿支皮瓣及背阔肌Kiss皮瓣在乳腺肿瘤切除术后胸壁缺损中的应用

目的探讨对侧胸廓内动脉穿支皮瓣及背阔肌Kiss皮瓣修复乳腺肿瘤切除术后胸壁软组织缺损的临床效果。方法回顾性分析大连医科大学附属第一医院2018年1月至2019年5月收治的6例乳腺肿瘤患者的临床资料,均为女性,年龄46~73岁,平均55.5岁,其中5例为局部晚期乳腺癌,1例为晚期乳腺癌。病程4个月至5年,中位时间20.1个月。4例患者行术前化疗。术中切除原发病灶后,局部皮肤软组织缺损范围达10 cm×15 cm^21 cm×31 cm,单独采取对侧胸廓内动脉穿支皮瓣或联合带蒂背阔肌Kiss皮瓣修复胸壁缺损,供区直接拉拢缝合,1例患者对侧乳房体积较大,同期行乳房缩小和乳房成形术。术后进行随访,观察皮瓣情况,以及肿瘤是否复发。结果6例胸廓内动脉穿支皮瓣切取范围为5 cm×12 cm^10 cm×23 cm,其中3例联合带蒂背阔肌Kiss皮瓣进行修复,两叶皮瓣每叶面积范围为5 cm×15 cm^7 cm×18 cm,6例患者皮瓣均成活,其中5例创面一期愈合,1例背部供区因张力稍大,出现皮下积液,经换药、引流后切口延期愈合。术后随访1~17个月,平均7.5个月,术区皮肤平整,皮瓣外观良好,对肩关节及腰部活动无影响,肿瘤均无局部复发,供区仅遗留线状瘢痕。结论应用对侧胸廓内动脉穿支皮瓣及背阔肌Kiss皮瓣修复乳腺肿瘤切除后巨大胸壁软组织缺损,无需血管吻合,手术简单,术后恢复快,并发症少,效果较好。     

Scrotal reconstruction using a superficial circumflex iliac artery perforator flap following Fournier's gangrene

Fournier's gangrene is a type of necrotising fasciitis around the scrotum and perineum. Because of its aggressive nature, patients should be treated with broad‐spectrum antibiotics and emergency, radical debridement during the acute phase. After recovering from the acute phase, reconstruction of the scrotal and perineal soft tissue defects is needed and is often challenging. Traditionally, various reconstruction methods have been used, including skin grafts, fasciocutaneous flaps and musculocutaneous flaps, each with its pros and cons. We successfully covered a wide scrotal defect using a superficial circumflex iliac artery perforator flap, which has not been previously reported for this indication. The design and operative technique are introduced in this study.     

A case of ischias as a complication of internal iliac artery embolization

A case of severe right radicular ischias following embolization is reported. Gelfoam powder and pledgets were used for right internal iliac artery embolization in the case of intractable bladder cancer hemorrhage. It is supposed that previous radiotherapy and fine embolic material may be the contributing factors to this complication.