[show abstract][hide abstract] ABSTRACT: The indication for microvascular free tissue transfer is usually exposure of vital structures, bone defect, or loss of function.
Radical debridement and control of infection is a prerequisite for any kind of reconstructive procedure. This is especially
true for untidy wounds in industrial or agricultural settings; in these, one should not hesitate to debride any tissue which
is not obviously viable. Aggressive surgical debridement should be performed before flap coverage. Some organisms, however,
fail to be eradicated by mechanical debridement as they are particularly pathogenic or embedded in the tissues. Perforator
flaps are currently recommended for soft tissue coverage of the upper limb, for their pliability and the low morbidity of
the donor site. A case of traumatic deglovement injury of an upper arm is presented. After free flap coverage, it was complicated
by a rare and highly pathogenic fungal infection. Successful soft tissue reconstruction obtained with a chimeric free flap
was compromised by an expanding fungal infection ultimately leading to limb amputation.
European Journal of Plastic Surgery 04/2012; 31(4):187-191.
[show abstract][hide abstract] ABSTRACT: Methods to improve operative outcomes in deep inferior epigastric artery perforator flap surgery have previously focussed on operative technique and postoperative-course modification. Recently, preoperative imaging has become capable of mapping the entire course of perforating vessels, including those vessels as small as 0.3 mm, enabling 'virtual surgery' to be performed preoperatively. This has been shown to facilitate faster and safer surgery. The recent 'Navarra' meeting classified current imaging modalities and discussed the current status of imaging modalities for this role. This article discusses the current expectations and optimal techniques for achieving these outcomes through the available imaging modalities: Doppler ultrasound, colour Doppler (duplex) ultrasound, computed tomography angiography (CTA) and magnetic resonance angiography (MRA). Features of imaging that are of importance to the surgeon are explored, and a consensus statement has been developed that describes exactly what the current imaging modalities should aim to deliver to the surgeon prior to operating, as well as the benefits and pitfalls of each of these modalities. The techniques described herein permit the radiologist and the surgeon to perform virtual surgery together, preoperatively.
Journal of Plastic Reconstructive & Aesthetic Surgery 12/2008; 63(2):289-97. · 1.44 Impact Factor
[show abstract][hide abstract] ABSTRACT: Release and reconstruction of axillary scar contractures can be challenging due to the specific anatomic site and contouring of the axillary region. Pliable and unscarred skin coverage of resulting defects after scar release is needed which enhances the postoperative recovery and revalidation. When traditional donor regions of fasciocutaneous flaps are involved in the scarred area, options are few. We describe the design and versatility of an inframammary extended lateral intercostal artery perforator (LICAP) flap to reconstruct an axillary defect after wide scar release and debridement. The postoperative recovery was uneventful with restoration of the range of motion of the shoulder joint.
Journal of Plastic Reconstructive & Aesthetic Surgery 09/2008; 61(12):e7-11. · 1.44 Impact Factor
[show abstract][hide abstract] ABSTRACT: Perforator flaps are widely used in our unit for breast reconstruction. They provide ample tissue with minimal donor site morbidity together with long lasting aesthetic results. Increasing number of patients may have liposuction procedure which may jeopardise areas such as the abdomen and the buttock which are the donor sites for perforator-free flaps in breast reconstruction. Therefore, liposuction has been considered as a relative contraindication of raising perforator flaps. Six patients who had previous liposuction of the donor sites underwent autologous breast reconstruction with perforator-free flaps. Colour Duplex imaging was obtained in all cases preoperatively in order to evaluate the blood supply to the flap and to map the perforators. There were five deep inferior epigastric artery flaps (DIEP) and one superior gluteal artery perforator (SGAP) flap used. Total flap survival was obtained in all cases. Postoperative course was uneventful. Our results showed that raising perforator flaps after liposuction of the donor sites is possible. Preoperative radiological evaluation of the perforators is mandatory for such difficult cases.
Journal of Plastic Reconstructive & Aesthetic Surgery 02/2006; 59(10):1031-6. · 1.44 Impact Factor
[show abstract][hide abstract] ABSTRACT: Since its original description more than 25years ago, the radial forearm flap is universally considered as the golden standard for phallic reconstruction in female-to-male (FTM) transsexuals. Despite a supposedly worldwide use by many major gender teams, there is a relative paucity in the literature of large series of radial forearm phalloplasties. Moreover, although considered as an easy and reliable flap, the radial forearm has been reported to present more problems in penile reconstruction than when used in other areas (e.g. head and neck). In most publications, the reported complication rates are excessively high, and have discouraged surgeons as well as patients to continue with this kind of surgery. This article presents a review of 81 consecutive radial forearm phalloplasty procedures, performed by the same surgical team between 1992 and 2000. A detailed description is given of the immediate postoperative results, in addition to the findings on long-term follow-up. We specifically report on our experience and our current approach with: the operative sequence, preparation and position of the patient, choice and design of the flap, reconstruction of the fixed part of the urethra and vaginectomy, the recipient vessels and nerves, recommendations for re-exploration, handling of urinary tract complications, reconstruction of the scrotum, implantation of the penile stiffener and later follow-up. Special emphasis is put on the different refinements in technique, which have been made over this 8-year period to improve phalloplasty results both functionally and cosmetically.
European Journal of Plastic Surgery 09/2005; 28(3):206-212.
[show abstract][hide abstract] ABSTRACT: Nine cases of massive soft-tissue loss of the foot were reconstructed by means of a compound (chimera) thoracodorsal artery perforator (TAP) flap, which reconstituted the different functional units (dorsum, heel, instep, weight-bearing surface). In each case, the flap consisted of a skin component isolated on its perforator in combination with a portion of latissimus dorsi muscle and/or serratus fascia, all pedicled on the thoracodorsal vessels. The pedicle length allows up to 4-6 cm of independent mobility of the skin island. The mobility of the various flap components allows the various functional units of the foot to be reconstructed without relying on multiple flaps or anastomoses. The pedicle length was sufficient to be able to perform the anastomosis out of the zone of injury. In some cases the skin island was harvested along with intercostal nerve branches, this gave us the potential to develop a sensate flap. The indications and advantages of this reconstructive method are discussed.
British Journal of Plastic Surgery 05/2005; 58(3):371-8. · 1.29 Impact Factor
[show abstract][hide abstract] ABSTRACT: Classical skin free flaps are rarely used to cover large skin defects of the upper extremity because of the limited donor size. Muscle flaps with a skin graft are preferred because they provide a large amount of cover and a good blood supply. A case report is presented in which a double skin flap was used to cover a large defect (408cm) extending from the lateral humeral condyle to the dorsal aspect of the hand. A free lateral arm flap from the contra–lateral arm was successfully used in conjunction with a pedicled reversed lateral arm flap from the injured limb. We suggest that skin flaps should be considered for cover of skin defects. The lateral arm flap, which is a versatile flap, offers thin, pliable and sensate skin with minimal donor site morbidity.
European Journal of Plastic Surgery 04/2004; 27(2):86-89.
[show abstract][hide abstract] ABSTRACT: The pyramidalis muscle is introduced as a new small muscle free flap, with description of its anatomy, the surgical technique and the clinical results in five different cases in which this flap was used to treat small recalcitrant wounds in the foot/ankle region. The pyramidalis muscle can be an alternative option in selective cases to reduce donor site morbidity as compared with more traditional free flaps.
British Journal of Plastic Surgery 10/2003; 56(6):585-92. · 1.29 Impact Factor
[show abstract][hide abstract] ABSTRACT: To create a neovagina and an endocervival canal in two patients with vaginal aplasia and a functioning uterus.
Technique and instrumentations.
A 31-year-old woman with vaginal aplasia and a double noncommunicating uterus (classified as Mayer-Rokitansky-Kuster-Hauser syndrome) and a 19-year-old woman with partial vaginal aplasia and a functional uterus.
Creation of a neovagina by using the bilateral pudendal thigh fasciocutaneous flap procedure and laparotomy to establish uterovaginal continuity.
Clinical follow-up evaluation of restoration of outflow of menstrual blood and coital satisfaction.
Uterovaginal continuity was established in both patients, resulting in normal menstruation. Granulomatous polyps occurred in one patient, and stenosis at the site of anastomosis occurred in the other patient; these conditions were successfully managed. Unimpeded menstrual flow continued after 1 year of follow-up in one patient and 3 years of follow-up in the other patient.
Bilateral fasciocutaneous pudendal thigh flaps permit vaginal reconstruction and a uterovaginal connection in patients with vaginal agenesis and a functional uterus. The main advantages of this technique are that postoperative dilatation is not necessary, sensation is maintained, and the resulting scar is inconspicuous. The main disadvantage is the presence of some sebaceous vaginal secretion and hair in the vaginal lining; the latter can be managed by preoperative and postoperative laser depilation.
Fertility and Sterility 10/2003; 80(3):607-11. · 4.17 Impact Factor
[show abstract][hide abstract] ABSTRACT: For more than 150 years, iodine has been used for the prevention of infection and for the treatment of wounds. Nowadays a large amount of published evidence is available and, although it is generally in support of the use of iodine product, it is confused by being a mixture of laboratory, animals and human studies, often using different preparations. This makes interpretation and comparison difficult. After new developments and publications, the role of iodine in antisepsis and in wound management needs to be reevaluated. We mainly focused our review on the following problems: the role of the newly developed formulations of iodine preparations, its antimicrobial activity, the possibility of impairing the wound healing process, the role of iodine in the problem of growing resistance against antibiotics and antiseptics. New formulations seem to keep the same clinical efficacy, avoiding the problem of toxicity; it seems that the antibacterial activity of iodine is superior compared to other products and, in contrast with antibiotics and other antiseptics, it seems to have no resistance problem. It seems that povidone-iodine has all the characteristics to become the first choice antiseptic in wound treatment.
[show abstract][hide abstract] ABSTRACT: Ball lightning is a rare physical phenomenon, which is not yet completely explained. It is similar to lightning but with different, peculiar characteristics. It can be considered a mix of fire and electricity, concentrated in a fireball with a diameter of 20-cm that most commonly appears suddenly, even in indoor conditions, during a thunderstorm. It moves quickly for several meters, can change direction, and ultimately disappears. During a great storm, a 28-year-old man and his 5-year-old daughter sustained burn wounds after ball lightning came from the outdoors through a chimney. These two patients demonstrated signs of fire and electrical injuries. The father, who lost consciousness, sustained superficial second-degree burn wounds bilaterally on the zygomatic area and deep second-degree burn wounds on his right hand (total body surface area, 4%). His daughter demonstrated superficial second-degree burn wounds on the left part of the face and deep second-degree and third-degree burn wounds (total body surface area, 30%) on the left neck, both upper arms, and the back. In this article, the authors report the first two cases of burn injuries resulting from ball lightning contact indoors. The literature on this rare phenomenon is reviewed to elucidate the nature of ball lightning. Emphasis is placed on the nature of injuries after ball lightning contact, the therapy used, and the long-term complications.
Annals of Plastic Surgery 06/2003; 50(5):541-4. · 1.38 Impact Factor
[show abstract][hide abstract] ABSTRACT: A transsexual patient has the constant and persistent conviction that he or she belongs to the opposite sex, thus creating a deeply seated gender identity conflict. With psychotherapy being unsuccessful, it has been proven that in carefully selected patients, gender reassignment or adjusting the body to the mind (both with hormones and surgery) is the best way to normalize their lives. Optimal treatment of these patients requires the multidisciplinary approach of a gender team with the input of several specialties. Such a team consists of a nucleus of physicians who sees the patient more frequently: the psychiatrist, the endocrinologist, the plastic surgeon, the gynecologist and the urologist and a more peripheral group that sees the patients more incidentally: the psychologist, the otorhinolaryngologist, the dermatologist, the speech therapist, the lawyer, the nurse and the social worker. Between 1987 and 1999, a total of 71 male-to-female (MTF) and 54 female-to-male transsexuals have undergone gender confirming surgery in our hospital. This article gives a review and an update on the different surgical procedures as well as on the outcome in our patient population. The results in this series of patients clearly demonstrate that a close cooperation of the different surgical specialties, within our multidisciplinary gender team, is the key to success in treating transsexual patients.
[show abstract][hide abstract] ABSTRACT: This article reports a clinical study investigating the role of polarised-light therapy in the conservative treatment of deep dermal burn wounds. In 22 out of 67 patients with deep dermal burn wounds, clinical evaluation revealed only a very limited potential for spontaneous healing, and, despite the fact that the majority of the surgeons (four out of six) would have recommended surgery, these patients were treated conservatively with polarised-light therapy (400-2000 nm, 40 m W cm(-2), 2.4 J cm(-2)) until complete closure. Evaluation by a panel of four surgeons, all experts in burn surgery, revealed that conservative treatment of these deep dermal wounds with polarised-light irradiation resulted in a significantly shorter healing time, with almost no hypertrophic scarring, and optimal aesthetic and functional results at long-term follow-up. No extension of the hospital stay was required. Polarised-light therapy may be a valuable way of avoiding surgery in patients with deep dermal burns.
British Journal of Plastic Surgery 08/2002; 55(5):420-6. · 1.29 Impact Factor
[show abstract][hide abstract] ABSTRACT: A microsurgical pseudoaneurysm is a very rare complication after free flap surgery. The authors report a case of a free thoracodorsal artery perforator flap transferred to a degloving wound on the dorsum of the foot and ankle. The patient developed pedicle thrombosis caused by a septic pseudoaneurysm, which was treated by conservative means. Sufficient vascularization developed within 15 days after surgery and the flap survived completely. This is in sharp contrast to other reported cases of pseudoaneurysm formation, all of which were treated surgically and resulted in flap failure, except in one case. A critical review of the literature is presented and the factors influencing flap survival are discussed.
Annals of Plastic Surgery 10/2001; 47(3):332-5. · 1.38 Impact Factor