Modified Purse-String Closure for Reconstruction of Moderate/Large Surgical Defects of the Face

Background.  Large surgical defects of the face can often be difficult to repair. Extensive adjacent tissue transfer may be necessary and may result in significant scars and possible flap compromise. Often there may be less donor tissue available than is necessary to achieve closure. The alternative is a split-thickness skin graft, which often has a poor cosmetic outcome with poor color match and contour irregularities.
Objective.  A novel approach to closing large surgical defects of the face is described. This relies on a combination of side-to-side bilateral advancement and circumferential tissue recruitment utilizing the purse-string suture.
Methods.  Report of illustrated cases.
Results.  A 3.5 × 5.5 cm preauricular cheek defect, which could not be closed primarily side-to-side, was successfully completely closed in a curvilinear fashion by implementing both side-to-side bilateral advancement and circumferential tissue recruitment. A 3.8 × 5.5 cm cheek defect and a 6.0 × 8.0 cm temple defect were significantly decreased by using the modified purse-string closure. Healing by second intention in these two cases provided an excellent cosmetic result.
Conclusion.  The use of the purse-string closure utilizing circumferential tissue recruitment in combination with side-to-side bilateral adjacent tissue transfer allows seemingly large facial defects to be closed or significantly reduced in size. Such closure is evident even in cases where poor skin laxity and size of the defect would not appear to allow this. The modified purse string closure can result in an excellent cosmetic outcome.     

Stellate Purse-String Closure

BACKGROUND: There are fundamental concepts we use in managing surgical defects. Whether planning a primary closure or a local flap, we frequently modify the basic design to maximize aesthetic outcomes, taking into consideration a number of factors including the location of the defect and tissue availability. OBJECTIVE: We describe the stellate modified purse-string closure, a novel flap modification. METHOD: Report of an illustrated case. RESULT: A patient with vertex scalp defect was reconstructed using the stellate purse-string flap. CONCLUSION: Certain modifications of commonly used reconstructive techniques can be utilized in specific situations to enhance cosmesis. Advantages of this modification are discussed.     

Revisiting the Purse-String Closure: Some New Methods and Modifications

BACKGROUND: Surgical wounds resulting from the extirpation of cutaneous malignancies can be repaired in a number of ways. One alternative, which has been used extensively in our practice, is the purse-string closure. This method of closure offers distinct advantages in the proper setting over traditional methods of closure. OBJECTIVE: Over the years, our approach to this procedure has evolved, and we have integrated a number of new modifications that are presented later here. METHODS: A report of three illustrative cases is given. RESULTS: Three cases are presented that illustrate some new modifications to the purse-string closure. CONCLUSION: The purse-string closure, which uses circumferential tissue advancement, can be used to close a wide range of surgical wounds. This method also frequently offers the advantage of an excellent cosmetic outcome.     

Nasolabial V-Y Advancement for Closure of the Midface Defects

BACKGROUND: V-Y subcutaneous advancement flaps receive an excellent blood supply from subcutaneous tissue and are ideal for use on the face. Also it is advantageous cosmetically compared to other local flaps. OBJECTIVE: Nasolabial V-Y advancement flaps are very useful in closing defects of the midface region after tumor resection. METHODS: Our experience with nasolabial V-Y flaps in 22 patients is reported. The average defect size was 2.4 cm x 3.2 cm. RESULTS: Minor flap necrosis occurred in one patient and simple lower eyelid ectropion in another. CONCLUSION: Nasolabial V-Y advancement flap is a simple and satisfactory alternative for closing relatively large defects in the midface when compared with other methods such as skin graft and rotation or transposition flaps. It is easy to design, reliable, and offers good cosmetic results.     

应用肋间后动脉穿支皮瓣修复微囊型淋巴管畸形切除后的大面积缺损

目的 探讨微囊型淋巴管畸形（LMs）手术切除的可行性,并对肋间后动脉穿支（LICAP）皮瓣修复微囊型LMs切除后的大面积缺损的有效性进行评价。方法 2009年1月至2012年12月,对8例13-22岁腋胸侧壁微囊型LMs患者,应用MRI和B超确定病变切除的范围和层次,对彻底切除后均遗留的腋窝、胸侧壁皮肤组织缺损,应用LICAP皮瓣进行修复,7位患者皮瓣供区直接缝合,1位患者供区植皮覆盖。结果 应用LICAP皮瓣可成功修复所有微囊型LMs切除术造成的组织缺损。术后随访1-3年,皮瓣形态良好,B超和MRI证实无复发微囊腔出现,皮瓣供区无功能受损。结论 超声和MRI可为手术彻底切除病灶作精确定位并进行手术后评估。微囊型LMs手术切除术后遗留组织缺损可应用LICAP皮瓣获得良好的组织覆盖和修复,术后受区外形良好,供区无功能损伤。     

Complete Closure by Purse-String Suture After Mohs Micrographic Surgery on Thin, Sun-Damaged Skin

BACKGROUND: The purse-string suture technique is useful for partial closure of surgical defects. OBJECTIVE: We demonstrated that 100% closure can often be obtained on surgical defects of the thin skin on the upper extremities. METHODS: Standard purse-string suture techniques were used to close surgical defects on the upper extremities. RESULTS: 100% closure of surgical defects on upper extremities was demonstrated. CONCLUSIONS: Purse-string suture technique is useful for repairs of surgical defects on the upper extremities when the skin is very thin but not recommended when the skin is thick.     

骨段输送治疗下肢大段骨缺损

目的　总结骨段输送技术治疗大段骨缺损、骨感染及皮肤缺损的体会。方法　应用骨段输送治疗严重创伤或骨肿瘤术后大段骨缺损 9例 ,其中 6例伴有骨感染和皮肤缺损。结果　 9例骨缺损全部治愈 ,恢复了肢体持重功能。 1例儿童 2年后胫骨出现过生长。结论　骨段输送技术是治疗下肢大段骨缺损简单而有效的新方法。软组织创面可在骨段输送中逐渐缩小并闭合 ,骨骼感染可在骨段输送中逐渐被控制并伴随骨连接而愈合     

Neutrophil Response to Replantation of Large Human Extremities

Abstract Background: Polymorphonuclear leukocytes (PMN) play a pivotal pathogenic role in ischemia/reperfusion injury of various tissues. The aim of the present study was to investigate the effect of replantation of large extremities on the function of circulating PMN in human patients. Patients and Methods: PMN were isolated from whole blood up to 90 min after vessel repair and reperfusion. PMN superoxide anion production was measured by a cytochrome C reduction assay. Ten patients with amputations of the leg (n = 2), lower leg (n = 5), upper arm (n = 2), forearm (n = 1), and three subtotal amputations of the lower leg with severe vessel damage were enrolled. Results: In four of six reamputated patients, total time of limb ischemia exceeded 5 h and PMN superoxide production was substantially increased at 60 min after reperfusion. With successful replantation, time of ischemia was < 5 h and PMN superoxide production did not further increase during reperfusion. Conclusion: The neutrophil response to replantation of large extremities is associated with the time of ischemia which may be involved in multiorgan dysfunction syndrome observed in some of these patients.     

经胸超声心动图在房间隔缺损封堵术中的应用

目的讨论经胸超声心动图在房间隔缺损(atrial septal defect,ASD)封堵术中的临床价值。方法 35例ASD适合介入封堵的病人,术前应用彩超多切面、多角度观察房间隔缺损大小、残留边缘的情况及所选封堵器的型号,术中术后监测封堵器放置情况及房水平是否存在残余分流及封堵器是否影响周围结构功能。结果 35例ASD患者全部一次封堵成功。封堵器直径与经胸超声心动图判断的直径相关系数r=0.94,P<0.05。结论经胸超声心动图在ASD封堵术中能准确估测ASD直径、指导封堵过程、监测有无并发症发生,在ASD封堵术中具有重要指导作用。     

游离股前外侧皮瓣修复四肢大面积软组织缺损

目的总结游离股前外侧皮瓣修复四肢大面积软组织缺损的经验。方法拟采用游离股前外侧皮瓣修复四肢软组织缺损65例,急诊手术38例,二期手术27例,其中单纯皮瓣57例,带部分股外侧肌皮瓣7例,因血管变异1例改游离股前内侧皮瓣。结果根据顾玉东[1]等分型,本组股前外侧皮瓣动脉支Ⅰ型4例(6.2%),Ⅱ型51例(78.5%),Ⅲ型8例(12.3%),高位皮支1例(1.5%),有1例因为血管变异改为股前内侧皮瓣。同侧移植51块,对侧移植13块,皮瓣面积(6 cm×11 cm)~(15 cm×32 cm),平均10.27 cm×19.82 cm。64例术后平均随访12(6~24)个月,皮瓣全部存活。感觉恢复达S3级者7例,达S2级者48例,达S1级或稍差者9例。无皮神经的皮瓣恢复了保护性感觉,基本上达S1级。按皮瓣功能7项检查指标进行评定,优14例,良38例,可7例,差5例,优良率为81.2%。结论股前外侧皮瓣是修复四肢大面积软组织缺损比较理想的皮瓣。     

Nasalis Flap and Graft Repair Provides Reliable Closure for Denuded Defects of the Nose

BACKGROUND: Skin cancer surgery involving the nasal tip and dorsum sometimes results in exposure of underlying bone or cartilage. We describe a simple method of providing a vascular bed for the defect using the superficial nasalis musculoaponeurotic system (SNAS) of the nose, which allows full-thickness skin graft reconstruction of the defect and an acceptable cosmetic outcome. OBJECTIVE: The utility of nasalis flaps to provide a vascular bed for grafting has not been specifically addressed in the dermatology literature. Our experience with 26 SNAS flaps is outlined to demonstrate the utility of this closure in the appropriate situations. METHODS: A discussion of the relevant anatomy is followed by an outline of the surgical technique. Results: SNAS flaps provide a reliable vascular bed and contour for defects of the bridge and distal nose. Complications have been few. CONCLUSIONS: The SNAS flap and graft are simple to perform and provide a reliable alternative to interpolated nasolabial or forehead flaps when the defect exposes significant bare cartilage or bone.