Revascularization of ischemic bronchial anastomoses by an intercostal pedicle flap

Ischemia of the donor bronchus, perfused solely by retrograde collaterals from the pulmonary circulation, is an important factor in the impaired healing of the bronchial anastomosis of transplanted lungs. The healing of two experimental models of bronchial anastomotic ischemia, the bronchial segmental autograft and the postpneumonectomy bronchial autograft, was assessed in dogs. The application of a polytetrafluoroethylene wrap to the bronchial segmental autograft and the application of an intercostal pedicle flap to the postpneumonectomy bronchial autograft, with and without concomitant administration of corticosteroids, were also studied to elucidate factors that affect bronchial anastomotic healing. The bronchial segmental autograft healed normally without stricture, but isolation of this autograft from the mediastinum and lung by the polytetrafluoroethylene wrap resulted in necrosis of the autograft. All dogs that had a postpneumonectomy bronchial autograft died of bronchopleural fistulas due to autograft necrosis. Application of an intercostal pedicle flap to the autograft resulted in healing in all animals. Arteriography and Microfil injection demonstrated revascularization of the postpneumonectomy bronchial autograft by the pedicled intercostal artery. Several conclusions can be drawn: With the lung in situ the bronchial segmental autograft survives, probably as a free composite graft. In contrast, the postpneumonectomy bronchial autograft is an excellent model of bronchial anastomotic ischemia. The intercostal pedicle flap is a reliable method for providing neovascularity and mechanical reinforcement to an ischemic bronchial anastomosis. Its effect on bronchial anastomotic healing was not diminished by administration of corticosteroids. The intercostal pedicle flap may be useful in preventing bronchial anastomotic complications in clinical lung transplantation.     

Clinical application of V-Y flap with subcutaneous pedicle]

From March 1987 to October 1989, 27 wounds in 27 cases have been repaired successfully by a V-Y flap with a subcutaneous pedicle beside the flap. Results were satisfactory. 16 cases of them have been followed-up for 2 months to 2 years, and the appearance has been satisfactory. It seems that V-Y flap with subcutaneous pedicle possesses the following advantages: (1) the advancing distance is large; (2) it has a wide range of application; (3) there is little damage to the blood supply and sensation of the flap.     

Autogenous nerve pedicle graft in the forearm

We report our experience during a 15-year period with three patients who had severe segmental loss of more than 10 cm of both the median and ulnar nerves in the arm and forearm. The procedure was described by St. Clair Strange and by Silverstone in 1947. A modification of the procedure was used in our three patients. In two patients, the proximal stumps of the median and ulnar nerves were sutured together in the proximal forearm. The ulnar nerve was transected high in the axilla, leaving its blood supply intact. Several months later the ulnar nerve was transposed distally, and a juncture with the distal median nerve was created. The third patient had a significant segmental loss in the arm of both the median and ulnar nerves. The distal stumps of the median and ulnar nerves were sutured together, and at a later stage the ulnar nerve was transposed proximally and sutured to the median nerve in the axilla. In all three patients, an advancing Tinel sign was observed. Subjectively, all three patients believed there was a definite improvement in sensibility. Objective testing was, however, less convincing. This operation has limited applicability but definitely has a place in situations where direct sutures or nerve grafting are impossible.     

Treatment of postoperative mediastinitis using an omental pedicle flap]

Four patients with postoperative mediastinitis who were treated by omentopexy at the Fukuoka University Hospital between 1989 and 1990. Three of the 4 patients healed successfully, another one died of multiple organ failure 83 days after surgery. All patients were received coronary artery bypass surgery harvesting a left internal thoracic artery for ischemic heart disease. Three patients had diabetes mellitus, one patient had renal failure preoperatively. Recognition of mediastinitis was made by sternal wound purulent discharge and sternal dehiscence. Culture of the discharge fluid yielded methicillin-resistant Staphylococcus aureus in three, and Enterococcus cloacae in one. Irrigation with popidone-iodine or blonopol were ineffective. Thus, the wound was treated with debridement and omentopexy with an omental pedicle flap, respectively. Postoperative course after omentopexy were excellent, had no complications. We conclude that the omentopexy is useful in the treatment of postoperative refractory anterior mediastinitis.     

Bronchoplastic procedures for bronchial carcinoma

In a 22-year period from 1962 to 1984, 51 patients with malignant lung disease had a sleeve resection performed. In 33% of the patients, pneumonectomy was contraindicated because of limited lung function. The operative mortality was 8%. Six per cent of the patients developed complications after the operation. The 5-year survival of the total group of patients was 30%. Patients with lesions classified as stage 1 and stage 2 had the best prognosis, with a 5- and 10-year survival of 43.5% and 27%, respectively. In patients classified as stage 3 and stage 4, the 5- and 10-year survival was 20%. A postoperative measurement of regional ventilation and perfusion indicated that the function of the remaining lung was presumably undisturbed by the operation. Also, the vital capacity and FEV 1 were only minimally reduced as a result of the operation. The amount of functional lung tissue spared by the operation compared to pneumonectomy was estimated to 39%. Because of these functional results and the promising 5-year survival figures, we suggest that sleeve lobectomy should be the operation of choice for tumors localized to the upper lobe orifice involving the main bronchus.     

蒂部减张皮瓣在远端蒂皮瓣中的应用

目的探讨蒂部减张皮瓣处理方法对远端蒂皮瓣成活及外观的影响。方法 2009年10月-2011年2月,采用蒂部减张皮瓣的方法利用远端蒂皮瓣移位修复四肢皮肤软组织缺损27例。男19例,女8例;年龄17～58岁,平均31.5岁。致伤原因:交通事故伤14例,机器绞伤9例,外科感染3例,肿瘤切除后1例。缺损部位:胫骨下段7例,踝关节12例,足部5例,手掌2例,手背1例。伤后至入院时间1～19 h,平均10 h。创面范围5.2 cm×3.8 cm～14.0 cm×5.8 cm。远端蒂皮瓣切取范围5.5 cm×4.5 cm～14.5 cm×6.5 cm。供区直接缝合6例,游离植皮21例。结果术后蒂部减张皮瓣均顺利成活。3例术后7 d远端蒂皮瓣发生部分坏死,经换药后1例行游离植皮,2例切除坏死皮缘后直接缝合后愈合;其余皮瓣均顺利成活,创面Ⅰ期愈合。供区切口均Ⅰ期愈合,植皮均成活。术后26例获随访,随访时间6～12个月,平均7.5个月。皮瓣质地、外观均良好。结论应用蒂部减张皮瓣可促进远端蒂皮瓣成活,并改善修复后外观。     

A subcutaneous pedicle flap for perineal reconstruction

The application of the subcutaneous pedicle flap for perineal defects is presented. We recognize from clinical experience that the perineal area has a sufficient subcutaneous vascular network from internal and external pudendar arteries. We found that the subcutaneous pedicle flaps can be used safely in the perineal area the same as the facial area. The perineal defect that reaches to the vaginal orifice or anus needs to be reconstructed three dimensionally, not flat. The subcutaneous pedicle flap with vertical pedicle can produce natural shape and depth of the perineum.     

Experimental study of an axial vascularized pedicle flap induced in rats]

The authors report an experimental study about induced flaps in rats. The aim of this study is to determine that neoangiogenesis can be formed from surgically introduced pedicle. Two main groups were studied: in the first one the arteriovenous pedicle was be anastomased at its distal end, in the other, an arteriovenous loop was created microsurgically. In both groups we obtained good results and the flaps stayed alive. Neoangiogenesis from the surgically introduced axial pedicle was observed. The prospects in human pathology are interesting to consider, for the surgeon might be liberated from the narrow anatomic limits imposed by vascular territories, by creating a suitable flap anywhere in the body.     

The osteocutaneous pedicle forearm flap

Two patients treated by an osteocutaneous radial island flap with retrograde blood flow are described. Rotation of the flap and its distal vascular pedicle by nearly 180 degrees caused no impairment of the arterial flow, but it may interfere with the venous return through the radial veins, as observed in one of our cases. Therefore, it is safer to include in the skin flap an additional vein, suturing it to a superficial vein in the recipient zone, thus ensuring normal venous flow to the flap as well. The purpose of this paper is to present two patients treated by the use of an osteocutaneous radial artery forearm flap.     

Abbe flap on mucosal pedicle

A difficult secondary bilateral cleft lip deformity with nasal distortion was treated with eight local flaps specifically designed for this case. One of these was an Abbe flap in which the coronary vessel in the pedicle was inadvertently divided. The judgment in handling this flap and its fate as a composite lip flap based on a narrow mucosal pedicle is reported.