Biomedical subjects
Publications and source records attributed to R L Walton.
Endorectal ileo-anal anastomosis has become a mainstay of continent bowel reconstruction after total colectomy. However, the procedure is often aborted because of lack of vessel length for the formation of the ileal pouch. The use of microsurgical techniques to lengthen mesenteric vessels and to allow completion of this valuable procedure is reported.
Soft tissue defects in the periolecranon region are difficult to manage by standard techniques such as closure by approximation, split-thickness skin grafting, or healing by secondary intention. We employed cadaver injections and dissections to study the vascular anatomy of the periolecranon region in search of a suitable local flap for coverage of periolecranon defects. This report details our experience in 31 patients with a one-stage technique for elbow coverage employing a proximally based forearm fasciocutaneous flap. Surgical techniques and clinical applications are discussed; a satisfactory long-term outcome is documented in 30 of 31 patients. The advantages of using this model fasciocutaneous flap include enhanced vascularity, sensibility, and ease of elevation.
Six posterior calf fascial free flaps were employed to reconstruct defects of the upper and lower extremities. One flap failed due to a constricting dressing. Two flaps sustained partial loss secondary to bleeding and hematoma formation. One flap dehisced at the distal suture line due to mobility of an underlying fracture. All surviving flaps eventually healed and resulted in stable, thin coverage. Donor-site morbidity has been minimal. Shortcomings of this flap model have been defined in the peculiarities of its thinness, diffuse vascular oozing, the extent of the vascular territory, and in postoperative monitoring. These problems are analyzed and recommendations for their resolution are presented. Fascia represents a unique tissue which offers an exciting new dimension in the reconstruction of certain defects--particularly those in which thinness is a desirable option. In the posterior calf model, the inclusion of fat represents an alternative modification that allows the surgeon to tailor the design to a variety of problems where fascia alone is too thin and a cutaneous flap is too thick. This concept may find its greatest application in wounds involving the hand or foot. We believe that this and other fascial flap prototypes may offer an ideal solution for reconstruction of major wounds of the extremities.
Four clinical cases are presented that represent our initial experience with a new fasciocutaneous free-flap unit. The territory of this flap incorporates the skin, fat, and fascia of the posterior calf region. Its design is based on the principle of the fasciocutaneous flap. Anatomic studies confirm that the blood supply to this flap is derived from a descending subfascial branch of the popliteal artery. The flap is well endowed with cutaneous sensory nerves, making it a potential neurosensory free flap. Our technique of flap design and elevation is presented, and potential advantages and disadvantages of this flap are discussed.
A free hair-bearing occipital scalp flap was employed for reconstruction of the upper lip in a young man who had sustained a close range shotgun blast to the face. The "moustache" free-flap provides an abundant source of hair-bearing scalp which has certain advantages over conventional techniques of repair. It is a one-stage operation, involves minimal donor site morbidity and uses hair-bearing scalp which is not usually affected by male-pattern baldness.
The authors present their successful experience with an attractive alternative to the latissimus dorsi and gracilis muscle flaps for lower extremity reconstruction--the free rectus abdominis muscle flap. The muscle flap has a dual blood supply, but the longer pedicle length and larger vessel diameter of the inferior epigastric vascular pedicle favor its use for free-tissue transfer. Surgical anatomy, technique, indications, and potential complications are outlined.
A case of Aspergillus niger fungal colonization associated with bilateral inflatable silicone mammary implants is reported. Painful fibrous capsular contractures without clinical evidence of infection or inflammation characterized the presenting symptoms. Operative findings included a cheesy-white exudate that surrounded the implants and turbid fluid within the implants. All specimens yielded a heavy growth of Aspergillus niger. Special stains of the fibrous capsules were negative for fungal invasion. The etiology and pathogenesis of Aspergillus colonization in this patient are postulated.
In a laboratory model, quantitative skin-surface fluorescence has been used to reliably measure skin perfusion in ischemic random flaps and to predict viability. The method is reproducible and allows investigators to sequentially monitor soft-tissue perfusion using a fluorescent indicator. It is superior to the conventional fluorescein test (Wood's lamp method), which allows only a single subjective assessment within a 24-hour period.
Our initial experience with the lower rectus abdominis procedure for breast reconstruction in 19 patients is presented. Anatomic considerations, surgical technique, and results are reviewed. Errors in flap design and execution resulted in a disproportionately high complication rate, which improved following certain technical refinements. The lower rectus flap has proved to be an alternative to conventional techniques of breast reconstruction. As more experience is gained with this flap, its particular role in the reconstructive armamentarium will be more clearly defined.
A case report of hypertensive leg ulcer and its management is described. The diagnosis of hypertensive leg ulcer is primarily based upon clinical findings after other etiologies have been excluded. Microscopic arteriolar changes associated with hypertensive disease do not necessarily preclude the development of hypertensive ulcers. Therapy of these ulcers is based upon a sound understanding of their pathophysiology--control of systemic hypertension, possible enhancement of local tissue perfusion, atraumatic debridement, and skin graft closure.
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A new flap of the buttock and posterior thigh has been developed for closure of wounds of the perineal and postsacral regions. Flap anatomy and operation technique are described. Five patients with difficult wounds were selected to demonstrate the versatility and range of this flap. In 40 patients under 65 years of age with a variety of buttock and perineal wounds, there have been no appreciable wound-healing problems with use of this flap.
Degloving injuries of the extremities and torso occur with relative frequency and are associated with a high morbidity and mortality. The common aim of all surgical approaches is to reestablish skin coverage over the injured area, but therapies differ in both technique and results. This survey evaluates the management and results of 21 patients sustaining degloving injury of at least 2/3 the circumference of the torso or an extremity. Initial surgical techniques which employ application of the skin as a full- or split-thickness graft were contrasted with those in which salvage of the entire flap with its subcutaneous tissue was attempted. The results suggest that immediate use of the degloved skin as a full-or split-thickness skin graft gives the most satisfactory coverage to the denuded areas. Other important features in management include frequent observation and immobilization of the extremity postoperatively, and use of mesh grafts when necessary to cover large areas. Recent emphasis on the blood supply of the skin underscores the importance of its circulation as the determinant of flap survival. Daily observation until the flap becomes fixed is mandatory. Primary reattachment of the full-or split-thickness flap by suture or use of compression dressings without grafting is unsuccessful and should be abandoned as an acceptable approach to this problem.
The standard approach to loss of substantial amounts of calvarium and dura is replacement of the dura with pathches, usually of biologic material such as fascia. We question the need for such patches and offer experimental and clinical evidence to support a different approach. Treatment of large calvarium and dural defects in 20 rats divided in two groups showed no difference in dural regeneration between animals repaired with patches and those repaired with the scalp flap only onlay on the brain. An illustrative clinical case confirms the observations. The scalp flap only onlay repair of cranial defects involving the dura provides a reasonable means for reconstruction. (1) In experimental animals there appeared to be no histologic difference between dura repaired by autogenous patch and that repaired by the scalp flap only onlay. (2) Clinically, well-nourished galea effects an ideal onlay repair of the dura. Secondary reconstruction of the bony calvarium can be performed utilizing a modified crane technique. (3) The procedure is simple in design, requires no donor sites, and certainly has application in cases other than trauma.
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Explore the source record for details and available documents.
Explore the source record for details and available documents.