Necrotizing fasciitis and evisceration complicating an inferiorly based epigastric TRAM flap

Summary The rectus abdommis myocutaneous flap, based on the deep inferior epigastric vessels, is an excellent flap for reconstructing large wounds of the groin and perineum. However, wound infection in the donor site is a potential complication, even with thorough preparation of the recipient site. We present one such case in a diabetic patient who developed a necrotizing fasciitis and evisceration following transfer of an inferiorly based myocutaneous flap.     

上、下蒂横形腹直肌肌皮瓣乳房再造的解剖学研究

目的探讨上蒂横形腹直肌肌皮瓣乳房再造术后并发症产生的原因。方法对20侧成人尸体进行解剖观察。结果发现主要是由于上蒂术式切断了该肌皮瓣的主要供血动脉——腹壁下动脉,仅靠腹壁上、下动脉之间微薄的螺旋微动脉的吻合支供血,以致术后产生脂肪液化、边缘坏死等并发症。结论腹壁下动、静脉是中、下腹部横形腹直肌肌皮瓣的直接供血动脉及回流静脉,即下蒂优于上蒂。     

上、下蒂横形腹直肌肌皮瓣乳房再造的解剖学研究

目的探讨上蒂横形腹直肌肌皮瓣乳房再造术后并发症产生的原因。方法对２０侧成人尸体进行解剖观察。结果发现主要是由于上蒂术式切断了该肌皮瓣的主要供血动脉——腹壁下动脉，仅靠腹壁上、下动脉之间微薄的螺旋微动脉的吻合支供血，以致术后产生脂肪液化、边缘坏死等并发症。结论腹壁下动、静脉是中、下腹部横形腹直肌肌皮瓣的直接供血动脉及回流静脉，即下蒂优于上蒂。     

Necrotizing fasciitis of chest wall complicating empyema thoracis

Necrotizing fasciitis affecting the chest wall is a rare condition and carries high mortality. It spreads rapidly, requiring early diagnosis and immediate extensive surgical debridement. The case of a 32 year old man afflicted with this uncommon condition following tube thoracostomy for empyema thoracis is described and literature reviewed.     

Use of an inferiorly based rectus muscle flap in flank wound coverage.

An inferiorly based rectus island flap was used to repair a large infected hip wound resulting from treatment of a posteriorly dislocated-comminuted acetabular fracture. The muscle island flap (based on the inferior epigastric vessels) allowed an extended arc of rotation to cover this laterally located wound.     

V-Y advancement of the inferiorly based rectus abdominis musculocutaneous flap

We describe two cases in which a rectus abdominis musculocutaneous flap was used to reconstruct an ipsilateral groin defect by V to Y advancement. Cadaveric studies undertaken to investigate the likely versatility of this flap showed that it may be advanced to midthigh level. This range can be increased by division of the inguinal ligament and by partial reflection of the rectus abdominis muscle from the skin island. The operative technique and the merits and disadvantages of the flap are discussed. This variation is a useful alternative. It has a considerable excursion potential and may be cosmetically more acceptable than other transposition flaps.     

Necrotizing fasciitis: Diagnosis and management of an occult infective focus

Necrotizing fasciitis is a life-threatening, fulminant disease that is a diagnostic and therapeutic challenge. Presenting with a triad of findings including progressive erythema, severe dermatological edema and severe pain disproportionate to the physical findings, this disease is a surgical emergency. Delayed diagnosis and surgical debridement lead to higher mortality. Early extensive surgical debridement, aggressive antibiotic therapy, invasive monitoring and intensive care management determine the outcome in most cases. In patients who fail to demonstrate clinical improvement, profound sepsis and its sequela –systemic inflammatory response – have frequently been implicated. It is these patients that need to be carefully re-evaluated for ‘hidden’ foci of infection that may be the real cause of the patient’s decline. Once detected, these occult foci can be surgically debrided, resulting in dramatic improvement. Two illustrative cases, one with occult endo- and panophthalmitis and the other with an unusual involvement of deeper muscle planes and the nodal basin, demonstrate this point. This consumptive process gathers momentum at an alarming speed, hence, the treatment must be aggressive and prompt.     

Catheter ablation of the inferior epigastric artery. An conservative method for conditioning the pedicled TRAM flap

The pedicled transverse rectus abdominis musculocutaneous (TRAM) flap is a recognized, reliable method of autogenous tissue breast reconstruction after mastectomy. However, the blood supply to the distal part of the flap is often precarious after ligation of the the main feeder, the inferior epigastric artery (AEI), at time of the operation. We describe our clinical experience with a new technique to augment the superior blood stream (superior epigastric artery, AES) by selective embolization of the inferior epigastric artery some weeks prior to plastic surgery. One hundred and eleven embolization procedures were performed until now. Technique of crossover and ipsilateral epigastric spiral embolization is described, requiring minimal time and material as an in- or outpatient procedure. The anatomical situation of the m. rectus abdominis blood supply is discussed as well as possible complications of the procedure.     

Correction of high pelvic defects with the inferiorly based rectus abdominis myocutaneous flap

The two inferiorly based rectus abdominis myocutaneous flaps are the most versatile and accessible flaps for high pelvic defects. Their primary contribution is in the obliteration of the pelvic "deadspace." At the present time, these useful flaps are generally considered only for massive defects of the perineum, groin, and pelvis, but improved flap designs will enhance their usefulness for smaller defects.     

Anatomic and clinical study of rectus abdominis musculocutaneous flaps based on the superior epigastric system: ipsilateral pedicled TRAM flap as a safe alternative

This anatomic and clinical study supports the use of the ipsilateral transverse rectus abdominis musculocutaneous (TRAM) flap over the contralateral TRAM flap for breast reconstruction. The costomarginal artery was constant in these dissections and supplied a vascular pedicle to the rectus abdominis muscle. Radiologic studies confirmed the communications between the costomarginal artery and the deep epigastric system, the same as between the costomarginal artery and the musculophrenic and intercostal arteries. The results of the clinical series confirmed the costomarginal artery as an alternative or adjuvant vascular pedicle of the deep superior epigastric artery in cases of potential lesion of the latter. The lack of pedicle tension because of the shorter distance to be transposed allowed a greater versatility in flap shaping and positively affected its aesthetic result. This fact made the authors change from the contralateral to the ipsilateral pedicled TRAM flap as the first option for autologous breast reconstruction because of vascular security.     

Necrotizing fasciitis in an immunocompetent patient with multiple sites of involvement

Necrotizing fasciitis (NF) in an immunocompetent patient with multiple sites of involvement is very rare. We describe a case of E. coli associated necrotizing fasciitis in a middle aged female with three lesions of NF on her lower limbs at the time of presentation. She was managed with broad spectrum intravenous antibiotics, radical surgical debridements with skin grafting, and aggressive supportive care.     

Necrotizing fasciitis. A diagnostic and therapeutic challenge

A case of necrotizing fasciitis of the upper limb caused by group A streptococcal infection and a case with an abscess of the hand caused by staphylococcus aureus, are presented. The anatomo-pathological and clinical differences between the two different types of infection are underlined and stress is laid on the excruciating pain, the high temperature and the rapidly spreading inflammatory-necrotizing evolution of the first case. More than the anatomo-pathological findings of a necrotic area the authors consider more important, the rapidity and the severity of the infection, that can evolve into a toxic shock-like syndrome, and the microbiological isolation of the streptococcus type A. On the basis of personal experience and of an accurate review of the literature, a therapeutical protocol is proposed based on an aggressive surgical approach, prompt specific antibiotic treatment and daily control of the lesions.