Role of vitreoretinal surgery in maximizing treatment outcome following complications after proton therapy for uveal melanoma.

L'utilisation de faisceaux de protons accélérés dans le traitement des mélanomes de l'uvée a été utilisée pour la première fois en Suisse (et par ailleurs en Europe) en 1984. Depuis, la protonthérapie a constamment évolué avec des logiciels toujours plus performants et précis pour devenir à l'heure actuelle le traitement de référence pour ce type de tumeurs. Ainsi, jusqu'à ce jour, l'Institut Paul Scherrer à Villigen a traité plus de 7000 cas de tumeurs oculaires. Mais la protonthérapie, aussi efficace soit-elle avec un taux de guérison de plus de 98%, comporte malheureusement un certain nom bre d'effets secondaires et indésirables pouvant parfois mener le patient jusqu'à l'énucléation secondai re. De la simple dermatite actinique à l'hémorragie intravitréenne massive, les complications induites sont pour la plupart bien connues et documentées mais leurs prises en charge, notamment sur un organe préalablement irradié diffèrent. Alors que nous avons beaucoup de recul sur la protonthérapie, la gestion de ses complications reste propre à chaque centre de soin et n'est que très peu documentée. Les complications majeures de la protonthérapie qui ont nécessité une prise en charge par le chirurgien vitrorétinien représentent souvent un défi majeur. Bien que rares, puisqu'elles ne représentent que 2% de notre collectif, celles-ci peuvent avoir de lourdes conséquences. Pa r exemple, une hémorragie intravitréenne massive, complication la plus fréquente dans notre série, compromet l'observation de la tumeur au fond d'oeil et empêche le bon suivi oncologique. La chirurgie vitrorétinienne a alors pour mission, de restaurer la transparence des milieux, élément indispensable à l'ophtalmologue pour le suivi clinique, iconographique et radiologique des mélanomes de l'uvée. Secondairement, cette chirurgie permet parfois d'augmenter l'acuité visuelle de l'oeil malade. La chirurgie vitrorétinienne est un précieux atout pour l'oncologue et permet d'éviter une énucléation secondaire. Elle participe ainsi à la prise en charge globale du patient atteint de mélanome de l'uvée.

The Smartcanula: a new tool for remote access perfusion in limited access cardiac surgery.

Devices for venous cannulation have seen significant progress over time: the original, rigid steel cannulas have evolved toward flexible plastic cannulas with wire support that prevents kinking, very thin walled wire wound cannulas allowing for percutaneous application, and all sorts of combinations. In contrast to all these rectilinear venous cannula designs, which present the same cross-sectional area over their entire intravascular path, the smartcanula concept of "collapsed insertion and expansion in situ" is the logical next step for venous access. Automatically adjusting cross-sectional area up to a pre-determined diameter or the vessel lumen provides optimal flow and ease of use for both, insertion and removal. Smartcanula performance was assessed in a small series of patients (76 +/- 17 kg) undergoing redo procedures. The calculated target pump flow (2.4 L/min/m2) was 4.42 +/- 61 L/ min. Mean pump flow achieved during cardiopulmonary bypass was 4.84 +/- 87 L/min or 110% of the target. Reduced atrial chatter, kink resistance in situ, and improved blood drainage despite smaller access orifice size, are the most striking advantages of this new device. The benefits of smart cannulation are obvious in remote cannulation for limited access cardiac surgery, but there are many other cannula applications where space is an issue, and that is where smart cannulation is most effective.

The results of surgery, with or without radiotherapy, for primary spinal myxopapillary ependymoma: a retrospective study from the rare cancer network.

PURPOSE: The aim of this study was to assess the outcome of patients with primary spinal myxopapillary ependymoma (MPE). MATERIALS AND METHODS: Data from a series of 85 (35 females, 50 males) patients with spinal MPE were collected in this retrospective multicenter study. Thirty-eight (45%) underwent surgery only and 47 (55%) received postoperative radiotherapy (RT). Median administered radiation dose was 50.4 Gy (range, 22.2-59.4). Median follow-up of the surviving patients was 60.0 months (range, 0.2-316.6). RESULTS: The 5-year progression-free survival (PFS) was 50.4% and 74.8% for surgery only and surgery with postoperative low- (<50.4 Gy) or high-dose (>or=50.4 Gy) RT, respectively. Treatment failure was observed in 24 (28%) patients. Fifteen patients presented treatment failure at the primary site only, whereas 2 and 1 patients presented with brain and distant spinal failure only. Three and 2 patients with local failure presented with concomitant spinal distant seeding and brain failure, respectively. One patient failed simultaneously in the brain and spine. Age greater than 36 years (p = 0.01), absence of neurologic symptoms at diagnosis (p = 0.01), tumor size >or=25 mm (p = 0.04), and postoperative high-dose RT (p = 0.05) were variables predictive of improved PFS on univariate analysis. In multivariate analysis, only postoperative high-dose RT was independent predictors of PFS (p = 0.04). CONCLUSIONS: The observed pattern of failure was mainly local, but one fifth of the patients presented with a concomitant spinal or brain component. Postoperative high-dose RT appears to significantly reduce the rate of tumor progression.

Fissures du labrum glénoïdal postérieur et lésions associées de l'épaule: une étude en arthroscanner [Fissures of the posterior labrum and associated lesions: CT arthrogram evaluation]

PURPOSE: To describe osseous, chondral and tendinous lesions associated with fissures of the posterior labrum. To better understand the pathological processes leading to fissure of the posterior labrum. Materials and methods. Retrospective study of 43 CT arthrograms performed in 43 patients that showed a fissure of the posterior labrum. The following associated lesions were noted: osseous and chondral remodeling of the humeral head and/or glenoid and articular surface fissures of the rotator cuff. Based on type of associated lesions, patients were separated into one of four pathological subgroups: posterior instability, posterosuperior or internal impingement, anterior instability and isolated fissure of the posterior labrum. RESULTS: Sixteen patients (37.2%) of patients showed posterior instability, 12 (27.9%) showed lesions of internal impingement, and 11 (25.6%) showed lesions of anterior instability. Only 4 patients (9.3%) had an isolated fissure of the posterior labrum. CONCLUSION: Posterior instability, internal impingement and anterior instability are the main pathologies leading to fissure of the posterior labrum, which seldom occurs in isolation. Evaluation of these associated lesions allows understanding of the underlying pathological processes leading to fissure of the posterior labrum.

Pseudophakic Retinal Detachment Surgery by 23 G Vitrectomy using Slit-Lamp and Non-Contact 90 D Lens.

Background: The purpose of this study is to report the anatomic and functional results of primary 23 G vitrectomy using slit-lamp and non-contact 90 D lens for the treatment of pseudophakic rhegmatogenous retinal detachment. Patients and Methods: Pseudophakic eyes were operated by 23 G vitrectomy using slit-lamp and non-contact 90 D lens, internal subretinal fluid drainage, cryopexy and internal gas tamponade. The preoperative and postoperative characteristics were analysed. Main outcome measures were anatomic success rates after initial surgical intervention and after reoperation for primary failures, visual outcome at the last follow-up visit, and complications. Results: 46 pseudophakic eyes were included in this retrospective study (October 2013- January 2014). In 40 cases, sulfur hexafluoride 23 % gastamponade was used, silicone oil in 6 cases (13 %). The retina was reattached successfully after a single surgery in 44 eyes (96 %). Recurrence of retinal detachment occurred in 2 eyes. Final anatomic reattachment was obtained in 100 % after a second operation. Silicone oil was removed in all eyes. Visual acuity improved significantly from logMAR 0 (IQR 0 - 0.9) to logMAR 0 (IQR 0 - 0.2) (p < 0.005). Conclusions: Primary 23 G vitrectomy using slit-lamp and non contact 90 D lens for the treatment of pseudophakic rhegmatogenous retinal detachment provides a high anatomic and functional success rate and is associated with few complications.

Correction of pectus excavatum combined with open heart surgery in a patient with Marfan's syndrome.

We report a patient with Marfan's syndrome and pectus excavatum who underwent open heart surgery with simultaneous correction of the sternal malformation. Permanent internal stabilization, achieved by bilateral overlapping of the bevelled ends of the lowest ribs and reinforced with sternal closure wires offered a maintained postoperative chest wall stability, avoided the potential postoperative complications of cardiac compression, and improved the aesthetic appearance of the anterior chest wall. The increased risk of bleeding due to extensive dissection was minimized by postponing the repair of pectus excavatum to when protamin is administered after termination of cardiopulmonary bypass.

A novel technique using echocardiography to evaluate venous cannula performance perioperatively in CPB cardiac surgery.

OBJECTIVE: Transthoracic echocardiography (TTE) has been used clinically to disobstruct venous drainage cannula and to optimise placement of venous cannulae in the vena cava but it has never been used to evaluate performance capabilities. Also, little progress has been made in venous cannula design in order to optimise venous return to the heart lung machine. We designed a self-expandable Smartcanula (SC) and analysed its performance capability using echocardiography. METHODS: An epicardial echocardiography probe was placed over the SC or control cannula (CTRL) and a Doppler image was obtained. Mean (V(m)) and maximum (V(max)) velocities, flow and diameter were obtained. Also, pressure drop (DeltaP(CPB)) was obtained between the central venous pressure and inlet to venous reservoir. LDH and Free Hb were also compared in 30 patients. Comparison was made between the two groups using the student's t-test with statistical significance established when p<0.05. RESULTS: Age for the SC and CC groups were 61.6+/-17.6 years and 64.6+/-13.1 years, respectively. Weight was 70.3+/-11.6 kg and 72.8+/-14.4 kg, respectively. BSA was 1.80+/-0.2 m(2) and 1.82+/-0.2 m(2), respectively. CPB times were 114+/-53 min and 108+/-44 min, respectively. Cross-clamp time was 59+/-15 min and 76+/-29 min, respectively (p=NS). Free-Hb was 568+/-142 U/l versus 549+/-271 U/l post-CPB for the SC and CC, respectively (p=NS). LDH was 335+/-73 mg/l versus 354+/-116 mg/l for the SC and CC, respectively (p=NS). V(m) was 89+/-10 cm/s (SC) versus 63+/-3 cm/s (CC), V(max) was 139+/-23 cm/s (SC) versus 93+/-11 cm/s (CC) (both p<0.01). DeltaP(CPB) was 30+/-10 mmHg (SC) versus 43+/-13 mmHg (CC) (p<0.05). A Bland-Altman test showed good agreement between the two devices used concerning flow rate calculations between CPB and TTE (bias 300 ml+/-700 ml standard deviation). CONCLUSIONS: This novel Smartcanula design, due to its self-expanding principle, provides superior flow characteristics compared to classic two stage venous cannula used for adult CPB surgery. No detrimental effects were observed concerning blood damage. Echocardiography was effective in analysing venous cannula performance and velocity patterns.

Delayed referral and gram-negative organisms increase the conversion thoracotomy rate in patients undergoing video-assisted thoracoscopic surgery for empyema

BACKGROUND: The role of video-assisted thoracoscopic surgery in the treatment of pleural empyema was assessed in a consecutive series of 328 patients between 1992 and 2002. An analysis of the predicting factors for conversion thoracotomy in presumed stage II empyema was performed. METHODS: Empyema stage III with pleural thickening and signs of restriction on computer tomography imaging was treated by open decortication, whereas a thoracoscopic debridement was attempted in presumed stage II disease. Conversion thoracotomy was liberally used during thoracoscopy if stage III disease was found at surgery. Predictive factors for conversion thoracotomy were calculated in a multivariate analysis among several variables such as age, sex, time interval between onset of symptoms and surgery, involved microorganisms, and underlying cause of empyema. RESULTS: Of the 328 patients surgically treated for stage II and III empyema, 150 underwent primary open decortication for presumed stage III disease. One hundred seventy-eight patients with presumed stage II empyema underwent a video-assisted thoracoscopic approach. Of these 178 patients, thoracoscopic debridement was successful in 99 of 178 patients (56%), and conversion thoracotomy and open decortication was judged necessary in 79 of 178 patients (44%). The conversion thoracotomy rate was higher in parapneumonic empyema (55%) as compared with posttraumatic (32%) or postoperative (29%) empyema; however, delayed referral (p < 0.0001) and gram-negative microorganisms (p < 0.01) were the only significant predictors for conversion thoracotomy in a multivariate analysis. CONCLUSIONS: Video-assisted thoracoscopic debridement offers an elegant, minimally invasive approach in a number of patients with presumed stage II empyema. However, to achieve a high success rate with the video-assisted thoracoscopic approach, early referral of the patients to surgery is required. Conversion thoracotomy should be liberally used in case of chronicity, especially after delayed referral (> 2 weeks) and in the presence of gram-negative organisms.

Les sinusites d'origine dentaire: diagnostic et prise en charge [Diagnosis and management of sinusitis of odontogenic origin]

Les sinusites maxillaires sont des infections fréquentes de la sphère ORL. On retrouve une étiologie dentaire dans environ 10% des cas. L'extension des infections dentaires dans le sinus maxillaire est possible en raison de la proximité des racines des dents postérieures avec le bas fond sinusien. Une source odontogène doit être suspectée chez les patients ayant une anamnèse de douleur ou d'infection dentaires, de soins dentaires récents et qui présentent une sinusite unilatérale prolongée ou résistant à un traitement conservateur habituel. Les infections d'origine dentaire possèdent une flore bactérienne mixte. Le diagnostic et la prise en charge nécessitent un bilan radiologique précis. Le traitement doit prendre en charge conjointement la cause dentaire et la sinusite. Un geste chirurgical peut être indiqué dans un deuxième temps afin de restaurer la fonction sinusienne. Maxillary sinusitis are common infections. A dental origin is found in about 10% of the cases. The roots of the posterior maxillary teeth are adjacent to the sinus floor. Extensions of dental infections are therefore possible to the sinus. An odontogenic source should be considered in patients with a history of dental pain or recent oral surgery and those with extended unilateral sinusitis or unilateral sinusitis resistant to conventional treatment. Maxillary sinusitis of dental origin are polymicrobial infections. Conventional radiographs and CT-scans are required for the diagnosis and proper management. Dental treatments to remove the underlying cause combined with oral antibiotics to treat the infection are required. Endoscopic or open surgery may be necessary to complete the treatment and restore adequate sinusal function.

High prevalence of unsuspected abdominal aortic aneurysms in patients hospitalised for surgical coronary revascularisation.

OBJECTIVES: Prevalence of abdominal aortic aneurysms (AAA) is not exactly known among patients with coronary artery disease (CAD) who are considered for surgical revascularisation. We evaluated the value of screening AAA among coronary patients admitted in our cardiovascular surgery unit. METHODS: Over a 24-month period, an abdominal echography was proposed to male patients aged 60 or more while hospitalised for surgical coronary revascularisation. Patients with previous investigation of the aorta were excluded. The aorta was considered aneurysmal when the anterior-posterior diameter was of 30 mm or more. RESULTS: Three hundred and ninety-five consecutive patients all accepted a proposed abdominal echographic screening for AAA. Forty unsuspected AAA were detected (10.1%). The mean diameter was 38.9 +/- 1.3 mm. Four AAA were larger than 50 mm and considered for surgery after the CABG procedure. Surveillance was proposed to the other 36, especially the 10 patients with an AAA larger than 40 mm. Patients with AAA were significantly older than those without AAA (71.3 +/- 0.8 vs. 69.4 +/- 0.3 years, P<0.05). Smoking history (P<0.05) and hypertension (P<0.05) were also associated more frequently with AAA. More than 16% of the patients being smokers and suffering hypertension presented with unsuspected AAA. CONCLUSIONS: In-hospital screening of AAA is very efficient among patients with coronary artery disease. Therefore, patients with CAD may be considered for routine AAA screening.

Introducing a new MRI classification of lumbar spinal stenosis based on cross-sectional morphology of the dural sac : 37

Introduction: Measures of the degree of lumbar spinal stenosis (LSS) such as antero-posterior diameter of the canal, and dural sac cross sectional area vary, and do not correlate with symptoms or results of surgery. We created a grading system, comprised of seven categories, based on the morphology of the dural sac and its contents as seen on T2 axial images. The categories take into account the ratio of rootlet/ CSF content. Grade A indicates no significant compression, grade D is equivalent to a total myelograhic block. We compared this classification with commonly used criteria of severity of stenosis. Methods: Fifty T2 axial MRI images taken at disc level from 27 symptomatic LSS patients undergoing decompressive surgery were classified twice by two radiologists and three spinal surgeons working at different institutions and countries. Dural sac cross-sectional surface area and AP diameter of the canal were measured both at disc and pedicle level from DICOM images using OsiriX software. Intraand inter-observer reliability were assessed using Cohen's, Fleiss' kappa statistics, and t test. Results: For the morphological grading the average intra-and inter observer kappas were 0.76 and 0.69+, respectively, for physicians working in the study originating country. Combining all observers the kappa values were 0.57 ± 0.19. and 0.44 ± 0.19, respectively. AP diameter and dural sac cross-sectional area measurements showed no statistically significant differences between observers. No correlation between morphological grading and AP diameter or dural sac crosssectional areawas observed in 13 (26%) and 8 cases (16%), respectively. Discussion: The proposed morphological grading relies on the identification of the dural sac and CSF better seen on full MRI series. This was not available to the external observers, which might explain the lower overall kappa values. Since no specific measurement tools are needed the grading suits everyday clinical practice and favours communication of degree of stenosis between practising physicians. The absence of a strict correlation with the dural sac surface suggests that measuring the surface alone might be insufficient in defining LSS as it is essentially a mismatch between the spinal canal and its contents. This grading is now adopted in our unit and further studies concentrating on relation between morphology, clinical symptoms and surgical results are underway.

Investigations of a thermosensitive gel to temporarily occlude crural arteries in femoro-distal bypass surgery

L'artériopathie oblitérante des membres inférieurs (AOMI) est une pathologie de plus en plus fréquemment rencontrée en raison du vieillissement le la population et de l'augmentation de la prévalence du diabète. Les patients souffrant d'AOMI se manifestant par une ichémie critique du membre nécessitent un geste de revascularisation, afin que le risque d'amputation, acte fortement morbide, soit diminué. La revascularisation par voie endovasculaire est de nos jours la technique de premier choix mais en cas d'occlusion longue des artères jambières, une approche chirurgicale avec confection d'un pontage ne peut être évitée. La technique nécessite alors, lors de la confection de l'anastomose, de l'occlusion temporaire de l'artère en amont et en aval de rartériotomie, ce qui est réalisé traditionnellement à l'aide de clamps ou cathéters intravasculaires. Ces instruments présentent différents inconvénients reconnus - efficacité médiocre au vu d'artères fortement calcifiées et induction de lésions endothéliales notamment. Un nouveau type d'instrument est apparu sur le marché après approbation de la FDA, sous forme d'un gel thermosensible qui constitue un bouchon occlusif une fois injecté dans l'artère et se dissout spontanément après quelques minutes. Ce gel ayant été expérimenté avec succès en chirurgie cardiovasculaire chez des animaux, nous avons voulu évaluer l'efficacité et l'innocuité de son utilisation lors de la réalisation de pontages fémoro-jambier dans une cohorte de vingt patients. Différents paramètres opératoires ont été notés tels que le volume de gel injecté, les temps d'occlusion efficace et de confection d'anastomose ainsi que la qualité de l'occlusion vasculaire obtenue. Une artériographie per-opératoire a été réalisée de manière systématique à la recherche d'emboles de gel résiduel. Les taux de perméabilité primaire, de sauvetage de membre et de survie à 6 mois ont été rapportés. Les résultats sont satisfaisants puisque la qualité d'occlusion a été jugée bonne à excellente dans la totalité des cas sans qu'aucun instrument d'occlusion supplémentaire n'ait dû être employé et que le temps d'occlusion dépassait légèrement le temps nécessaire à la confection de l'anastomose. L'artériographie des deux premiers cas seulement a révélé la présence d'emboles distaux, avant que nous corrigions notre technique pour obtenir une dissolution instantanée du gel. Nous avons obtenu à 6 mois un taux de perméabilité primaire de 75% avec un taux de sauvetage de membre à 87.5%, le taux de mortalité à 30 jours étant de 10% - sans relation avec le gel. En conclusion, nous avons montré que l'utilisation de ce gel comme instrument d'occlusion vasculaire temporaire est sûre et efficace lors de la chirurgie de pontage fémoro-jambier. L'hypothèse qu'il pourrait être moins délétère pour l'endothélium et contribuer ainsi à une amélioration du taux de perméabilité des pontages distaux mériterait d'être testée dans le cadre d'une étude randomisée multicentrique.

Neonatal Minimally Invasive Surgery for Congenital Diaphragmatic Hernias: a multicenter study using thoracoscopy or laparoscopy.

BACKGROUND: Minimally invasive surgery (MIS) for late-presenting congenital diaphragmatic hernia (CDH) has been described previously, but few neonatal cases of CDH have been reported. This study aimed to report the multicenter experience of these rare cases and to compare the laparoscopic and thoracoscopic approaches. METHODS: Using MIS procedures, 30 patients (16 boys and 14 girls) from nine centers underwent surgery for CDH within the first month of life, 26 before day 5. Only one patient had associated malformations. There were 10 preterm patients (32-36 weeks of gestational age). Their weight at birth ranged from 1,800 to 3,800 g, with three patients weighing less than 2,600 g. Of the 30 patients, 18 were intubated at birth. RESULTS: The MIS procedures were performed in 18 cases by a thoracoscopic approach and in 12 cases by a laparoscopic approach. No severe complication was observed. For 20 patients, reduction of the intrathoracic contents was achieved easily with 15 thoracoscopies and 5 laparoscopies. In six cases, the reduction was difficult, proving to be impossible for the four remaining patients: one treated with thoracoscopy and three with laparoscopy. The reasons for the inability to reduce the thoracic contents were difficulty of liver mobilization (1 left CDH and 2 right CDH) and the presence of a dilated stomach in the thorax. Reductions were easier for cases of wide diaphragmatic defects using thoracoscopy. There were 10 conversions (5 laparoscopies and 5 thoracoscopies). The reported reasons for conversion were inability to reduce (n = 4), need for a patch (n = 5), lack of adequate vision (n = 4), narrow working space (n = 1), associated bowel malrotation (n = 1), and an anesthetic problem (n = 1). Five defects were too large for direct closure and had to be closed with a patch. Four required conversion, with one performed through video-assisted thoracic surgery. The recurrences were detected after two primer thoracoscopic closures, one of which was managed by successful reoperation using thoracoscopy. CONCLUSIONS: In the neonatal period, CDH can be safely closed using MIS procedures. The overall success rate in this study was 67%. The indication for MIS is not related to weeks of gestational age, to weight at birth (if >2,600 g), or to the extent of the immediate neonatal care. Patients with no associated anomaly who are hemodynamically stabilized can benefit from MIS procedures. Reduction of the herniated organs is easier using thoracoscopy. Right CDH, liver lobe herniation, and the need for a patch closure are the most frequent reasons for conversion.

Sustained release of nanosized complexes of polyethylenimine and anti-TGF-beta 2 oligonucleotide improves the outcome of glaucoma surgery.

The purpose of this study was to design microspheres combining sustained delivery and enhanced intracellular penetration for ocular administration of antisense oligonucleotides. Nanosized complexes of antisense TGF-beta2 phosphorothioate oligonucleotides (PS-ODN) with polyethylenimine (PEI), and naked PS-ODN were encapsulated into poly(lactide-co-glycolide) microspheres prepared by the double-emulsion solvent evaporation method. The PS-ODN was introduced either naked or complexed in the inner aqueous phase of the first emulsion. We observed a marked influence of microsphere composition on porosity, size distribution and PS-ODN encapsulation efficiency. Mainly, the presence of PEI induced the formation of large pores observed onto microsphere surface. Introduction of NaCl in the outer aqueous phase increased the encapsulation efficiency and reduced microsphere porosity. In vitro release kinetic of PS-ODN was also investigated. Clearly, the higher the porosity, the faster was the release and the higher was the burst effect. Using an analytical solution of Fick's second law of diffusion, it was shown that the early phase of PS-ODN and PS-ODN-PEI complex release was primarily controlled by pure diffusion, irrespectively of the type of microsphere. Finally, microspheres containing antisense TGF-beta2 nanosized complexes were shown, after subconjunctival administration to rabbit, to significantly increase intracellular penetration of ODN in conjunctival cells and subsequently to improve bleb survival in a rabbit experimental model of filtering surgery. These results open up interesting prospective for the local controlled delivery of genetic material into the eye.

Tip anchor flap in decubital surgery.

Anchoring a flap remains a key procedure in decubital surgery because a flap needs to be stable against shearing forces. This allows an early mobilization and undisturbed primary wound healing. This study evaluated a uniform group of eight paraplegic patients with sacral decubital ulcers and covered the lesions using gluteal rotation flaps with a deepithelialized tip to anchor the flap subcutaneously on the contralateral ischial tuber. Initial wound healing and recurrence after one year were evaluated. All but one flap showed uneventful wound healing, and all the flaps presented without any signs of recurrence or instability. The authors suggest that sufficient anchoring using a deepithelialized part of the flap helps to integrate and stabilize sacral rotation flaps.