Reconstruction of the perineum

Defects of the perineal area commonly occur following ablative procedures for gynecological, urological, and colorectal malignancies. A coordinated approach between the surgical oncologist and the reconstructive surgeon is necessary in order to achieve appropriate results in these patients. Consideration of both form and function is essential and must be planned for. A variety of reconstructive procedures, including skin grafts, local skin flaps, various myocutaneous and fasciocutaneous flaps and, in rare situations, free tissue transfers, are used in the closure of these wounds. An algorithm for the selection of these various procedures is presented so that uncomplicated wound healing can be achieved and functional results can be optimized. Semin. Surg. Oncol. 19:282-293, 2000.     

A regional approach to reconstruction of the upper lip

Treatment of upper lip wounds by second intention, full-thickness skin grafts, and local flaps is discussed. The location, size, depth, and type of closure for each defect in 200 cases involving defects of the upper lip are reviewed. The percentages of wounds treated by each modality were 20, 6, 74% for second intention, grafts, and local flaps, respectively. Of wound treatment by local flaps, 80% used advancement flaps, 10% used transposition flaps, and 10% used island-pedicle flaps. Advancement flaps, island-pedicle flaps, possible complications, and post-operative care are reviewed.     

Sarcoma metastases due to iatrogenic implantation.

AIM: To demonstrate the ability of extremity soft tissue sarcomas (STSs) to implant into tissues exposed during surgery. METHODS: We use two cases to illustrate that wounds created during surgery for STSs, including donor sites for skin grafts, pedicled and free flaps and blood vessels used in reconstruction, should be regarded as potential sites of quasi-local recurrence. CONCLUSIONS: This report reinforces the need for meticulous surgical technique and planning of procedures to avoid contamination of clean areas that might not be included in adjuvant radiotherapy fields. The cases also highlight the pivotal importance of the correct initial management of these uncommon tumours.     

Reconstruction of the nose with local flaps

The author presents the results of a study of 200 patients with surgical defects of the nose following excision of skin malignancies. The location, size, depth, and quality of the adjacent skin, the reconstruction choice, and the cosmetic result were recorded. Healing by second intention was most useful for wounds in concave areas. Full-thickness skin grafts were used for defects too large for local flaps, or for defects on the nasal tip or alar surface. Local flaps were the most useful choice for nasal reconstruction. Transposition flaps, in particular, were most useful for each cosmetic sub unit of the nose.     

Immediate repair of wounds following operations by Mohs' fresh-tissue technique.

With the introduction of the Mohs fresh-tissue technique, immediate repair of surgical wounds has become feasible in selected cases. In this article several case reports are presented to illustrate the use of primary closures, skin grafts, and flaps in an office facility.     

两种治疗足跟与足跖部皮肤恶性黑色素瘤手术的远期疗效评价

 目的　探讨手术治疗足跟与足跖部部皮肤恶性黑色素瘤的适宜方式。方法　对 1 994年以来收治的 1 2例足跟与足跖部皮肤恶性黑色素瘤患者在病灶彻底切除后 ,7例患者采用岛状皮瓣转移修复创面 ,5例患者采用全厚皮片移植修复创面。对其临床资料与随访结果进行回顾性总结和分析。结果　皮瓣修复组获得随访的 6例患者均存活 ,术区外形和功能恢复良好 ,局部无复发 ;皮片修复组 4例患者获得随访 ,其中 2例死亡 ,1例局部复发 ,1例发生全身转移 ,另外 2例存活 ,术区外形和功能尚满意。结论　在一定的广度和深度彻底切除足跟与足跖部皮肤恶性黑色素瘤是取得良好疗效的关键 ,其中切除深度更重要。     

面部皮肤恶性黑色素瘤整复治疗的临床观察

目的 探讨治疗面部皮肤恶性黑色素瘤切除后皮肤缺损的手术方法 ,并评价其临床疗效。方法 2007年2月至2014年3月本科收治9例面部皮肤恶性黑色素瘤,均采用手术扩大切除病灶;术中常规冰冻切片监测手术切缘,病灶切除后皮肤软组织缺损,分别采用游离皮片移植2例,邻近任意皮瓣6例,游离皮瓣1例,术后常规辅以免疫治疗。结果 9例皮片及皮瓣均成活,伤口Ⅰ期愈合。局部形态较好,术区平整,瘢痕不明显。9例患者获随访3个月~7年,死亡2例,其中1例因其他疾病术后2年死亡;其余病例外形良好,未见局部复发。结论 面部皮肤恶性黑色素瘤手术治疗联合术后辅助免疫治疗疗效肯定,皮瓣修复可取得较为理想的局部外形,术中常规冰冻切片是保证肿瘤根治的一项重要手段。     

术后放射治疗对口腔颌面部组织瓣修复的影响

目的研究术后放射治疗对口腔颌面部组织瓣修复的影响和组织瓣的放射治疗耐受性,为头颈部癌根治术组织缺损立即整复后行术后放射治疗提供临床依据。方法对１１４块口腔颌面部修复组织瓣进行术后放射治疗（４０００～７２００ｃＧｙ,４～７．５周）反应的近期和远期观察,并以放射野内相邻正常口腔粘膜或皮肤为自身对照。结果组织瓣的急性放射反应（包括红肿、糜烂或溃疡）的发生率明显低于相邻的正常组织（Ｐ＜０．０５）,且出现晚、程度轻,放射治疗后可完全消退;远期反应也不常见;不同类型修复组织瓣的放射治疗耐受性差异无显著意义;放射治疗后１１４块组织瓣中１１２块（９８．２％）全瓣成活。结论口腔颌面部修复组织瓣有良好的放射治疗耐受性,可安全接受全疗程的常规术后放射剂量照射。     

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.     

Anatomic rubber stamps of the face and body to document procedures in dermatologic surgery: one picture is worth a thousand words

Representations of the anatomic surface location of cutaneous lesions and the surgical procedures performed on these lesions can be transferred to the medical charts using simple anatomic rubber stamps (ARS) of the body. The technique is exemplified with symbols to represent surgical excision, chemical face peel, dermabrasion, micrographic surgery, and the harvesting of flaps and grafts. ARS are also useful in liposuction surgery, punch grafts for pitted facial scars, hair transplantation, sclerotherapy, laser surgery, and other cosmetic dermatologic procedures. ARS are particularly valuable in micrographic surgery for skin cancer because they help document the depth and breadth of cancer invasion and aid in the follow-up of recurrent skin cancer, especially when defects are reconstructed.     

Tolerance of tissue transfers to adjuvant radiation therapy in primary soft tissue sarcoma of the extremity

PURPOSE: Treatment of extremity sarcomas occasionally requires tissue transfer in the form of pedicle flaps, free flaps, or skin grafts to repair surgical defects. These tissues are often subject to radiation (RT) and are therefore at risk for wound breakdown requiring reoperation. This study reviews a single center's experience with tissue transfer and postoperative RT. METODS AND MATERIALS: Between 1983 and 2000, 43 adult patients (>16 years old) with primary high-grade soft tissue extremity sarcomas underwent limb-sparing surgery and reconstruction of their surgical defects, followed by adjuvant RT. The reconstructions were as follows: pedicle flaps (n = 14), free flaps (n = 10), skin grafts (n = 4), or a combination (n = 15). Postoperative external beam radiation therapy (EBRT) (median dose: 63 Gy) alone was given to 27 patients (63%). Adjuvant brachytherapy (BRT) was given to 16 patients (37%); BRT alone (median dose: 45 Gy) was given to 12 patients and combined with EBRT for 4 patients (EBRT: 45 Gy; BRT: 20 Gy). Comorbid conditions such as diabetes, hypertension, tobacco use, and obesity (calculated using body mass index >or=30) were present in 30 patients (70%). Tumor characteristics were as follows: 26 were >5 cm in size, 37 were deep, and 30 were in the lower extremity. The median follow-up time, calculated from the date of operation, was 32 months.Five of 43 patients suffered wound complications necessitating reoperation; however, 3 patients developed complications before initiation of RT and were therefore excluded from the analysis. Two of 43 patients (5%) required reoperation for wound complications after RT; 1 of these patients ultimately required amputation for necrosis. The 5-year overall wound reoperation rate was 6% (95% confidence interval: 0-14%). The influence of patient and tumor characteristics, as well as the type of RT, on the wound reoperation rates is as follows: BRT vs. EBRT (17% vs. 0%, p = 0.06); upper vs. lower extremity (0% vs. 8%, p = 0.41); 5 cm (8% vs. 4%, p = 0.9); comorbidity vs. no comorbidity (3% vs. 13%, p = 0.8); age 50 (8% vs. 4%, p = 0.8). CONCLUSION: Based on this review, most tissue transfers (95%) tolerated subsequent adjuvant radiation therapy well. Although more wound complications necessitating reoperation were seen in patients who received BRT, whether this is because of the inherent susceptibility of flaps and skin grafts to breakdown in the immediate postoperative period vs. the direct result of BRT needs further investigation.     

瘢痕癌的临床特点与治疗

目的：探讨瘢痕癌的临床特点与治疗方法。方法：回顾性分析近12年来18例瘢痕癌患的临床资料。结果：18例均属慢性瘢痕癌，其中溃疡型5例，菜花型13例；除1例头皮瘢痕癌外，其余患的移植皮片或皮瓣100％成活，2例截肢伤口一期愈合。8例患分别于术后4个月～6年获得随访，1例于术后6个月因颅内转移死亡，1例于术后5年死于其他疾病；1例足跟部瘢痕癌于术后4个月复发，并侵噬跟骨，行小腿中段截肢，其余5例局部无复发，功能外形良好。结论：病理检查结果是确定诊断与治疗方案的重要依据，手术仍是瘢痕癌的首选治疗。     

手术联合免疫疗法治疗皮肤恶性黑色素瘤的疗效分析

目的探讨采用手术联合免疫疗法治疗皮肤恶性黑色素瘤的临床疗效。方法1998年8月-2010年12月,对收治的34例皮肤MM患者按照无瘤技术在一定深度与广度完整切除肿瘤病灶,根据创面部位、大小、深度,遵照“宁近勿远,宁简勿繁”的原则,分别选择皮瓣或皮片修复创面;术后按照“扶正驱邪”理论,选择免疫治疗做为辅助治疗,并按期随访。结果14例采用18个皮瓣修复,皮瓣均100%成活,术区外形与功能良好;13例于术后7~132月得到随访,9例存活,4例死亡;存活者中最长1例已无瘤健康存活11年。18例皮片修复者中,7例皮片存活率为95%左右,经换药愈合;其余11例皮片成活率均为100%,术区外形与功能均良好;15例术后12~120月随访结果显示,9例存活,6例死亡。2例分别行掌指/跖趾关节离断术者,伤口一期愈合,现分别为手术后15月与24月,全身情况良好,局部无任何复发迹象。结论手术联合免疫治疗是目前治疗皮肤恶性黑色素瘤的良好方法。     

The plastic repair of extensive wound defects with vascularized flaps in treating tumors of the skin and soft tissues]

The study was concerned with comparison of the results of application of two procedures of plastic surgery using vascularized flaps for treatment of localized recurrent malignant tumors of the skin, soft tissues of the head, arms, legs and the trunk. According to one procedure (28 patients), large wound defects caused by extensive excision of tumor were treated using tissue flaps and microvascular anastomosis. In the other group of 10 patients, large defects were treated with skin-muscular flaps sitting on a fixed vascular-neural pedicle. But for these two procedures, some cases would not have been operated on at all due to considerable local extension of tumor.     

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。     

Treatment of extensive avulsions of skin and subcutaneous tissues

This article deals with the treatment of extensive avulsion injuries. Five out of twenty-eight cases of extensive avulsion injuries are presented and illustrated. All of these injuries were caused by machinery or automobile accidents and were encountered in the three-year period from 1972 to 1975. Etiology, pathology, and treatment with mechanical and chemical debridement, porcine skin grafts, fasciotomy, delayed primary closure, stamp or mesh skin grafts, and skin flaps are detailed and discussed.     

Reconstructive surgery of the pelvis after surgery for rectal cancer

The role of the reconstructive surgeon has increased with an increasingly aggressive surgical approach to locally advanced rectal carcinoma. Multiple options exist for pelvic floor reconstruction. Muscle and myocutaneous flaps for pelvic-floor reconstruction provide well vascularized tissues which may also serve as a biologic spacer. Flaps help to prevent post-radiation fistulae, small bowel obstruction, and pelvic sidewall adherence; flaps also may serve as a barrier to radiation injury. Often a more stable perineal wound closure is achieved. In cases that involve vaginal resection, flaps make neo-vaginal reconstruction possible. Pre-operative consultation with the reconstructive surgeon allows planning of complex, multi-disciplinary procedures, and facilitates patient understanding of the proposed procedure.     

Lower lip reconstruction after tumor resection; a single author's experience with various methods

BACKGROUND: Squamous cell carcinoma is the most frequently seen malignant tumor of the lower lip. The more tissue is lost from the lip after tumor resection, the more challenging is the reconstruction. Many methods have been described, but each has its own advantages and its disadvantages. The author presents through his own clinical experience with lower lip reconstruction at the NCI, an evaluation of the commonly practiced techniques. PATIENTS AND METHODS: Over a 3 year period from May 2002 till May 2005, 17 cases presented at the National Cancer Institute, Cairo University, with lower lip squamous cell carcinoma. The lesions involved various regions of the lower lip excluding the commissures. Following resection, the resulting defects ranged from 1 /3 of lip to total lip loss. The age of the patients ranged from 28 to 67 years and they were 13 males and 4 females. With regards to the reconstructive procedures used, Karapandzic technique (orbicularis oris myocutaneous flaps) was used in 7 patients, 3 of whom underwent secondary lower lip augmentation with upper lip switch flaps. Primary Abbe (Lip switch) flap reconstruction was used in two patients, while 2 other patients were reconstructed with bilateral fan flaps with vermilion reconstruction by mucosal advancement in one case and tongue flap in the other. The radial forearm free flap was used only in 2 cases, and direct wound closure was achieved in three cases. All patients were evaluated for early postoperative results emphasizing on flap viability and wound problems and for late results emphasizing on oral continence, microstomia, and aesthetic outcome, in addition to the usual oncological follow-up. RESULTS: All flaps used in this study survived completely including the 2 free flaps. In the early postoperative period, minor wound breakdown occurred in all three cases reconstructed by utilizing adjacent cheek skin flaps, but all wounds healed spontaneously. The latter three cases involved defects greater than 2 /3 of lower lip and one of them was previously irradiated. Those patients then suffered from occasional drooling of saliva. The best results in terms of oral continence and cosmetic outcome were achieved in those cases reconstructed with flaps utilizing residual lower lip or upper lip tissues (i.e; the Karapandzic technique (orbicularis oris myocutaneous flaps, and the Abbe (upper lip switch flaps). Nevertheless, microstomia developed in four patients primarily reconstructed with the Karapandzic technique in which defects were greater than one half of the lip. Only one of those patients tolerated her microstomia and required no further treatment. The remaining three patients showed marked improvement after augmenting the lower lip with bilateral paraphiltral lip switch flaps from upper lip in a second stage. The follow-up period ranged from 6 months to three years during which no patient had developed local recurrence or distant metastasis. CONCLUSION: Lower lip reconstruction aims to restore function and appearance with the best results obtained by utilizing residual normal lip tissues incorporating potentially innervated muscle fibers. With larger defects, reconstruction is less than optimal, but every effort should be taken to obtain an adequate sphincter function and lip continence to saliva, both of which are the most important goals to achieve in lip reconstruction.     

下颌骨缺损不同重建方法在口腔肿瘤中的应用

目的从各个方面分析下颌骨连续性缺损不同重建方法的效果.方法1973年4月～2003年7月,应用不同的方法进行下颌骨缺损的重建72例,分析不同方法的成功率、修复长度、并发症发生率、输血量、住院时间及手术时间.结果游离腓骨瓣2例失败(成功率92.5%),游离髂骨瓣2例失败(成功率90.0%),胸锁乳突肌锁骨瓣5例均成功,其他重建手段成功率较低.与游离髂骨瓣相比较,游离腓骨瓣提供骨组织最长22cm,并可携带皮瓣.结论游离骨瓣移植的成功率较高,游离腓骨皮瓣是一较理想的下颌骨重建组织瓣,其他骨瓣也有一定的应用价值.     

A new modified method for nasal lining: the Menick technique for folded lining

Traditional lining techniques such as prefabricated flaps, hinge-over flaps, or second local flaps for lining are thick, stiff, or poorly vascularized. Support grafts have traditionally been placed incompletely or secondarily. Intranasal lining flaps have revolutionized reconstruction but are complex, tedious, and destructive to the residual nose. More recently, the forehead skin has been transferred for cover as a full thickness flap in three stages. It has allowed the modification of the traditional folded flap technique for lining to permit a simple, efficient, and widely useful method of lining replacement for common defects. Thin, supple, vascular lining is combined with delayed primary cartilage grafts to provide excellent functional and cosmetic results.