Retrospective analysis of free temporoparietal fascial flap for defect reconstruction of the hand and the distal upper extremity

Introduction: Soft tissue reconstruction of the hand and distal upper extremity is challenging to preserve the function of the hand as good as possible. Therefore, a thin flap has been shown to be useful. In this retrospective study, we aimed to show the use of the free temporoparietal fascial flap in soft tissue reconstruction of the hand and distal upper extremity. Methods We analysed the outcome of free temporoparietal fascial flaps that were used between the years 2007and 2016 at our institution. Major and minor complications, defect location and donor site morbidity were the main fields of interest. Results: 14 patients received a free temporoparietal fascial flap for soft tissue reconstruction of the distal upper extremity. Minor complications were noted in three patients and major complications in two patients. Total flap necrosis occurred in one patient. Conclusion The free temporoparietal fascial flap is a useful tool in reconstructive surgery of the hand and the distal upper extremity with a low donor site morbidity and moderate rates of major and minor complications

Can systemically administered antibiotics be detected in wound tissues and surfaces under negative pressure wound therapy?

In this study, we evaluated a new aspect of negative pressure wound therapy (NPWT) as an analytical tool for pharmacokinetic studies. Twenty-one patients with soft tissue defects scheduled to receive NPWT were included in this study. Concomitant to NPWT, all patients received intravenous moxifloxacin (MX). At different time intervals, blood plasma levels of MX were sampled and compared with synchronous concentrations of MX in the exudate obtained from the NPWT drainage system. Serial measurements were performed upon initiation of the therapy as well as in the steady state (after 5 days). At steady state, wound tissue was obtained intraoperatively. High-performance liquid-chromatography (HPLC) was used for analysis. At 1 hour post-administration, the exudate/plasma levels (mg/L) were 1.92/3.07; at 12 hours, 0.80/1.14; at 24 hours, 0.26/0.43; and at 120 hours (steady state), 0.42/0.47. There was a correlation between exudate and plasma levels reaching approximately 0.75. Until now, methods for pharmacokinetic studies concerning interstitial fluid are difficult to apply in the clinical context. The presented method showed limitations, but we believe that, after methodological improvements, measurements of substances in the interstitial fluid by means of NPWT are feasible

Can systemically administered antibiotics be detected in wound tissues and surfaces under negative pressure wound therapy?

In this study, we evaluated a new aspect of negative pressure wound therapy (NPWT) as an analytical tool for pharmacokinetic studies. Twenty-one patients with soft tissue defects scheduled to receive NPWT were included in this study. Concomitant to NPWT, all patients received intravenous moxifloxacin (MX). At different time intervals, blood plasma levels of MX were sampled and compared with synchronous concentrations of MX in the exudate obtained from the NPWT drainage system. Serial measurements were performed upon initiation of the therapy as well as in the steady state (after 5 days). At steady state, wound tissue was obtained intraoperatively. High-performance liquid-chromatography (HPLC) was used for analysis. At 1 hour post-administration, the exudate/plasma levels (mg/L) were 1.92/3.07; at 12 hours, 0.80/1.14; at 24 hours, 0.26/0.43; and at 120 hours (steady state), 0.42/0.47. There was a correlation between exudate and plasma levels reaching approximately 0.75. Until now, methods for pharmacokinetic studies concerning interstitial fluid are difficult to apply in the clinical context. The presented method showed limitations, but we believe that, after methodological improvements, measurements of substances in the interstitial fluid by means of NPWT are feasible

Defect reconstruction of the trochanter major after necrotizing fasciitis and multiple operations using an arteriovenous loop and latissimus dorsi free flap

Necrotizing fasciitis (NF) is a severe soft tissue infection which has to be treated with a radical debridement as the key element. In the further course often large tissue defects occur, so that a long-term stable defect reconstruction plays a crucial role after any successful debridement. The reconstruction can include split skin grafting or local and free flaps. Here we present a case of a 41-year-old male patient with a NF in the trochanter major region after spondylodesis and spinal cord stimulation (SCS) device implantation. After multiple operations including local and free flaps we performed a defect reconstruction using an arteriovenous (AV) loop and subsequent free latissimus dorsi transplantation leading to no further operations. This complex reconstruction can be considered as the final stage of any reconstruction latter

Synchronous atypical fibroxanthoma and Bowen’s disease of the head and neck in an otherwise normal patient – a case report and review of literature [Simultanes Auftreten eines atypischen Fibroxanthoms und Plattenepithelkarzinoms im Kopf-Hals-Bereich – Fallbericht und Literaturübersicht]

[english] Although both atypical fibroxanthoma and squamous cell carcinoma arise on top of sun-damaged skin of the elderly, there is no evidence in literature reporting a synchronous presentation of primary lesions of both malignancies in the head and neck regions. We report a case of synchronous atypical fibroxanthoma and squamous cell carcinoma in situ (Bowen’s disease) of the head and neck in an otherwise normal old Caucasian male patient. We reviewed the literature for cases of head and neck atypical fibroxanthoma in association with other skin malignancies with an overview over the risk factors and modalities of treatment. We would like to raise the awareness for the concept of multiple synchronous primary malignant lesions and the importance to anticipate and differentiate between different pathologies in order to provide adequate investigations and treatment for the patient. <br>[german] Obwohl sowohl das atypische Fibroxanthom der Haut als auch das Plattenepithelkarzinom bei sonnengeschädigter Haut älterer Menschen gehäuft vorkommen, gibt es in der Literatur keine Beschreibung eines simultanen Auftretens beider Malignome als Primärläsionen im Kopf-Hals-Bereich. Aus diesem Grund möchten wir über einen Fall berichten, bei dem sowohl ein atypisches Fibroxanthom als auch ein Morbus Bowen (als in situ Variante des Plattenepithelkarzinoms) im Kopf-Hals-Bereich eines sonst gesunden 74-jährigen männlichen Patienten aufgetreten ist. Auf Grundlage der bestehenden Publikationen von Fällen mit atypischen Fibroxanthomen in Assoziation mit anderen Hautmalignomen, verglichen wir diese mit dem vorliegenden Fall, insbesondere in Hinblick auf die Risikofaktoren und das empfohlene Behandlungsregime. Ein simultanes Auftreten von mehreren primären Hauttumoren verschiedener Entität ist in einigen Fällen möglich und sollte daher insbesondere bei älteren Menschen deutlich häufiger in die Beurteilung und Diagnosestellung mit eingeschlossen werden. Ein Hauptaugenmerk sollte hierbei insbesondere auf die Differenzierung dieser verschiedenartigen Pathologien zu liegen kommen, um so eine inadäquate Therapie zu vermeiden

When free flaps are not the first choice: is the distally based peroneus brevis still an option for foot and ankle reconstruction in the era of microsurgery?

Aim: Soft tissue defects with or without exposed bones in the lower extremity, ankle and the foot-with or without bone defects or exposed hardware-often require coverage with vascularized flaps. Free flaps, which add healthy tissue especially to the lower extremity instead of further injuring a limb, are the first choice in high volume microsurgical centres. Nevertheless, in some instances pedicled flaps may have indications when free flaps are not suitable.Methods: The distally based peroneus brevis flap is harvested from the lateral compartment of the leg based on the distal perforating arterial supply and covered with split skin.Results: We performed a total of 69 peroneus flaps between 2003 and 2017. Minor flap necroses at the distal tip were noted in 8% of the peroneus brevis reconstructions. Total flap loss occurred in 1 peroneus flap. Defect etiology and patient age were not associated with surgical outcome.Conclusion: While nowadays the first choice of lower extremity reconstruction is an appropriate free flap solution, the peroneus brevis muscle flap can also be seen as a valuable tool to reconstruct small to medium sized defects at the ankle, distal tibia, and the heel with an acceptable donor site morbidity. Despite the easily available variety of free flaps to achieve this purpose, still proper indications remain where a local flap can be a viable option in the hand of experienced plastic surgeons. However, caution is advisable in patients with peripheral arterial occlusive disease or venous insufficiency

Reconstruction of composite defects of the scalp and neurocranium—a treatment algorithm from local flaps to combined AV loop free flap reconstruction

Abstract Background Reconstruction of cranial composite defects, including all layers of the scalp and the neurocranium, poses an interdisciplinary challenge. Especially after multiple previous operations and/or radiation therapy, sufficient reconstruction is often only possible using microsurgical free flap transplantation. The aim of this study was to analyze the therapy of interdisciplinary cases with composite defects including the scalp and neurocranium. Methods From 2009 to 2017, 23 patients with 18 free flaps and 10 pedicled/local flaps were analyzed. First choices for free flaps were muscle flaps followed by fasciocutaneous flaps. Results Except for four patients, a stable coverage could be reached in the first operation. Three of these patients received a local scalp rotation flap in the first operation and needed an additional free flap because the local flap was no longer sufficient for coverage after wound healing deficiency or tumor relapse. The superficial temporal artery or external carotid artery served as recipient vessels. In special cases, venous grafts or an arteriovenous loop (AV loop) were used as extensions for the recipient vessels. Conclusions In summary, an interdisciplinary approach with radical debridement of infected or necrotic tissue and the reconstruction of the dura mater are essential to reach a stable, long-lasting reconstructive result. Based on our experience, free flaps seem to be the first choice for patients after multiple previous operations and/or radiation therapy

Reconstruction of composite defects of the scalp and neurocranium-a treatment algorithm from local flaps to combined AV loop free flap reconstruction

Abstract Background Reconstruction of cranial composite defects, including all layers of the scalp and the neurocranium, poses an interdisciplinary challenge. Especially after multiple previous operations and/or radiation therapy, sufficient reconstruction is often only possible using microsurgical free flap transplantation. The aim of this study was to analyze the therapy of interdisciplinary cases with composite defects including the scalp and neurocranium. Methods From 2009 to 2017, 23 patients with 18 free flaps and 10 pedicled/local flaps were analyzed. First choices for free flaps were muscle flaps followed by fasciocutaneous flaps. Results Except for four patients, a stable coverage could be reached in the first operation. Three of these patients received a local scalp rotation flap in the first operation and needed an additional free flap because the local flap was no longer sufficient for coverage after wound healing deficiency or tumor relapse. The superficial temporal artery or external carotid artery served as recipient vessels. In special cases, venous grafts or an arteriovenous loop (AV loop) were used as extensions for the recipient vessels. Conclusions In summary, an interdisciplinary approach with radical debridement of infected or necrotic tissue and the reconstruction of the dura mater are essential to reach a stable, long-lasting reconstructive result. Based on our experience, free flaps seem to be the first choice for patients after multiple previous operations and/or radiation therapy