Supraclavicular flap in head and neck reconstruction: experience in 50 consecutive patients.

The supraclavicular flap (SCF) is a fasciocutaneous flap used to cover head, oral, and neck region defects after tumor resection. Its main vascular supply is the supraclavicular artery and accompanying veins and it can be harvested as a vascularised pedicled flap. The SCF serves as an excellent outer skin cover as well as a good inner mucosal lining after oral cavity and head-neck tumor resections. The flap has a wide arc of rotation and matches the skin colour and texture of the face and neck. Between March 2006 and March 2011, the pedicled supraclavicular flap was used for reconstruction in 50 consecutive patients after head and neck tumor resections and certain benign conditions in a tertiary university hospital setting. The flaps were tunnelized under the neck skin to cover the external cervicofacial defects or passed medial to the mandible to give an inner epithelial lining after the oral cavity and oropharyngeal tumor excision. Forty-four of the 50 patients had 100% flap survival with excellent wound healing. All the flaps were harvested in less than 1 h. There were four cases of distal tip desquamation and two patients had complete flap necrosis. Distal flap desquamation was observed in SCFs used for resurfacing the external skin defects after oral cavity tumor ablation and needed only conservative treatment measures. Total flap failure was encountered in two patients who had failed in previous chemoradiotherapy for squamous cell cancer of the floor of mouth and tonsil, respectively, and the SCF was used in mucosal defect closure after tumor ablation. The benefits of a pedicled fasciocutaneous supraclavicular flap are clear; it is thin, reliable, easy, and quick to harvest. In head, face and neck reconstructions, it is a good alternative to free fasciocutaneous flaps, regional pedicled myocutaneous flaps, and the deltopectoral flap.

Second primary squamous cell carcinoma arising in cutaneous flap reconstructions of two head and neck cancer patients.

Early complications of myocutaneous flap transfers following surgical eradication of head and neck tumors have been extensively described. However, knowledge concerning long-term complications of these techniques remains limited. We report the cases of two patients with a prior history of squamous cell carcinoma of the head and neck (HNSCC), who developed a second primary SCC on the cutaneous surface of their flaps, years after reconstruction. Interestingly, it seems that the well-known risk of a second primary SCC in patients with previous head and neck carcinoma also applies to foreign tissues implanted within the area at risk. Given the important expansion of these interventions, this type of complication may become more frequent in the future. Therefore, long-term follow-up of patients previously treated for HNSCC not only requires careful evaluation of the normal mucosa of the upper aero-digestive tract, but also of the cutaneous surface of the flap used for reconstruction.

Free microvascular iliac crest flap for extensive talar necrosis--case report with a 16-year long-term follow up.

Atraumatic osteonecrosis of the talus can be extremely painful and lead to significant functional impairment. Although clinical, radiographic, and demographic characteristics of atraumatic osteonecrosis of the talus have been well documented, the diagnosis is frequently missed or delayed; the most common causes are use of corticosteroids and the presence of immune disorders. Operative treatment of large osteochondral lesions of the talus is difficult because the blood supply is poor in the talar dome. Microvascular reconstruction of the talar dome with iliac crest autografts is a complex but functionally excellent therapeutic option. We present a 48-year-old man, who developed an extensive atraumatic avascular necrosis of the talar dome without collapse. Except for insulin dependent diabetes mellitus no further comorbidities were known. A microvascular iliac crest bone flap was inserted into the talus. A follow-up 16 years postoperatively showed a clinically as well as radiographically stable reconstruction of the talar dome and an excellent mobility of the ankle joint. The AOFAS hindfoot scale had improved from initially 33 points to 100 on the last follow-up. Free microvascular bony reconstruction of the talar dome should not only be considered in younger patients but also for middle aged active patients, since our follow-up shows an excellent long term result. Early reconstruction can prevent collapse of the talar bone.

Secret scar free gracilis flap.

The gracilis free flap is a workhorse in plastic surgery. We present a modified technique that relies on a single horizontal thigh-lift-type approach, which (1) gives wide pedicle exposure, (2) provides material for skin grafting, and (3) allows for distal flap transection without an additional incision. Eighteen gracilis free flaps were performed from 2007 to 2009 for lower extremity reconstruction. Complete flap survival was observed in 17 patients with one partial necrosis distally. Our approach allowed access to divide the distal gracilis tendon without a second incision in all cases. The mean scar length was 16 ± 3 cm and no hypertrophic scars were observed. In 15 patients, no visible scar was observed in the upright position, and in three patients, the scar was visible dorsally (2 ± 1 cm). No sensory deficits were observed 6 months postoperatively. In addition, the split-thickness skin graft harvested from the skin paddle was sufficient to cover all defects.

The temporoparietal fascia flap: a versatile tool in head and neck reconstruction.

PURPOSE OF REVIEW: The article reviews recent significant advances and current applications of the temporoparietal fascia flap (TPFF) in head and neck surgery. RECENT FINDINGS: The recent literature describes a wide span of new applications of the TPFF in many areas. Significant developments and refinements in the reconstruction of orbitomaxillary composite defects and orbital exenteration cavities are reported. The TPFF combined with alloplastic framework is gaining in importance in external ear reconstruction. Innovative prefabricated skin or soft-tissue grafts based on the TPFF are used to restore facial contour or in the reconstruction of complex facial defects. The free TPFF finds a role in laryngotracheal reconstruction as a vascular carrier to support cartilage grafts. SUMMARY: Owing to its reliability and unequalled structural properties, the TPFF still plays a central role in facial reconstruction. Future investigation will likely incorporate the free TPFF as a vascular carrier of bioengineered tissues, such as cartilage and mucosa, for various head and neck indications.

Real-time full field laser Doppler imaging.

We present a full field laser Doppler imaging instrument, which enables real-time in vivo assessment of blood flow in dermal tissue and skin. This instrument monitors the blood perfusion in an area of about 50 cm(2) with 480 × 480 pixels per frame at a rate of 12-14 frames per second. Smaller frames can be monitored at much higher frame rates. We recorded the microcirculation in healthy skin before, during and after arterial occlusion. In initial clinical case studies, we imaged the microcirculation in burned skin and monitored the recovery of blood flow in a skin flap during reconstructive surgery indicating the high potential of LDI for clinical applications. Small animal imaging in mouse ears clearly revealed the network of blood vessels and the corresponding blood perfusion.

Psoriasis triggered by toll-like receptor 7 agonist imiquimod in the presence of dermal plasmacytoid dendritic cell precursors.

BACKGROUND: It has been proposed that the innate immune system plays a central role in driving the autoimmune T-cell cascade leading to psoriasis; however, there is no direct evidence for this. OBSERVATIONS: We observed aggravation and spreading of a psoriatic plaque when treated topically with the toll-like receptor (TLR) 7 agonist imiquimod. The exacerbation of psoriasis was accompanied by a massive induction of lesional type I interferon activity, detected by MxA expression after imiquimod therapy. Since imiquimod induces large amounts of type I interferon production from TLR7-expressing plasmacytoid dendritic cell precursors (PDCs), the natural interferon-producing cells of the peripheral blood, we asked whether PDCs are present in psoriatic skin. We identified high numbers of PDCs in psoriatic skin lesions (up to 16% of the total dermal infiltrate) based on their coexpression of BDCA2 and CD123. By contrast, PDCs were present at very low levels in atopic dermatitis and not detected in normal human skin. CONCLUSIONS: This study shows that psoriasis can be driven by the innate immune system through TLR ligation. Furthermore, our finding that large numbers of PDCs infiltrate psoriatic skin suggests a role of lesional PDCs as type I interferon-producing targets for the TLR7 agonist imiquimod.

Bone propeller flap: a staged procedure.

The ideal reconstruction technique for complex defects of the lower limb consists of replacing tissue with similar tissue in an attempt to achieve a good functional result. A 23-year-old white male sustained a crush injury with a grade IIIB open ankle dislocation. After open reduction and fixation, the patient developed severe osteomyelitis at the tibiotalar joint requiring a staged and radical debridement with a substantial combined soft tissue and bony defect over the distal tibia, fibula, and talus area. The reconstructive approach consisted of a modified model of the propeller flap, implementing the spare part concept in a 2-stage procedure using a prefabricated and vascularized "double-barrel" fibular graft. At 17 months postoperatively, a plain radiograph showed bony union with complete and stable coverage of the soft tissue defect. The patient was fully weightbearing. In conclusion, there is evidence to suggest that the established concept of a soft tissue propeller flap can be implemented on bone.

Evaluation of respiratory and dermal occupational exposures to monoethanolamine during cleaning

Professional cleaning is a basic service occupation with a wide variety of tasks carried out in all kind of different sectors and workplaces by a large workforce. One important risk for cleaning workers is the exposure to chemical substances that are present in cleaning products.Monoethanolamine was found to be often present in cleaning products such as general purpose cleaners, bathroom cleaners, floor cleaners and kitchen cleaners. Monoethanolamine can injure the skin, and exposure to monoethanolamine was associated to asthma even when the air concentrations were low. It is a strong irritant and known to be involved in sensitizing mechanisms. It is very likely that the use of cleaning products containing monoethanolamine gives rise to respiratory and dermal exposures. Therefore there is a need to further investigate the exposures to monoethanolamine for both, respiratory and dermal exposure.The determination of monoethanolamine has traditionally been difficult and analytical methods available are little adapted for occupational exposure assessments. For monoethanolamine air concentrations, a sampling and analytical method was already available and could be used. However, a method to analyses samples for skin exposure assessments as well as samples of skin permeation experiments was missing. Therefore one main objective of this master thesis was to search an already developed and described analytical method for the measurement of monoethanolamine in water solutions, and to set it up in the laboratory. Monoethanolamine was analyzed after a derivatisation reaction with o-pthtaldialdehyde. The derivated fluorescing monoethanolamine was then separated with high performance liquid chromatography and detection took place with a fluorescent detector. The method was found to be suitable for qualitative and quantitative analysis of monoethanolamine. An exposure assessment was conducted in the cleaning sector to measure the respiratory and dermal exposures to monoethanolamine during floor cleaning. Stationary air samples (n=36) were collected in 8 companies and samples for dermal exposures (n=12) were collected in two companies. Air concentrations (Mean = 0.18 mg/m3, Standard Deviation = 0.23 mg/m3, geometric Mean = 0.09 mg/m3, Geometric Standard Deviation = 3.50) detected were mostly below 1/10 of the Swiss 8h time weighted average occupational exposure limit. Factors that influenced the measured monoethanolamine air concentrations were room size, ventilation system and the concentration of monoethanolamine in the cleaning product and amount of monoethanolamine used. Measured skin exposures ranged from 0.6 to 128.4 mg/sample. Some cleaning workers that participated in the skin exposure assessment did not use gloves and had direct contact with the solutions containing the cleaning product and monoethanolamine. During the entire sampling campaign, cleaning workers mostly did not use gloves. Cleaning workers are at risk to be regularly exposed to low air concentrations of monoethanolamine. This exposure may be problematic if a worker suffers from allergic reactions (e.g. Asthma). In that case a substitution of the cleaning product may be a good prevention measure as several different cleaning products are available for similar cleaning tasks. Currently there are no occupational exposure limits to compare the skin exposures that were found. To prevent skin exposures, adaptations of the cleaning techniques and the use of gloves should be considered. The simultaneous skin and airborne exposures might accelerate adverse health effects. Overall the risks caused by exposures to monoethanolamine are considered as low to moderate when the cleaning products are used correctly. Whenever possible, skin exposures should be avoided. Further research should consider especially the dermal exposure routes, as very high exposures might occur by skin contact with cleaning products. Dermatitis but also sensitization might be caused by skin exposures. In addition, new biomedical insights are needed to better understand the risks of the dermal exposure. Therefore skin permeability experiments should be considered.

Removal of unusual, large high-velocity metallic maxillary sinus foreign bodies by a modified free bone flap technique.

Metallic foreign bodies are rarely found in the maxillary sinus, and usually they have a dental origin.Potential complications related to foreign bodies include recurrent sinusitis, rhinolith formation, cutaneous fistula,chemical poisoning, facial neuralgic pain and even malignancies.Two main surgical approaches are currently used for the removal of foreign bodies in the maxillary sinus: the bone flap and the endoscopic sinus techniques. We are reporting two unusual cases of large high-velocity foreign bodies removed by a modified maxillary lateral antrotomy,with free bone flap repositioning and fixation with a titanium miniplate.

Local shockwave-application prevents flap necrosis

Objective: Local shockwave-application (SW) has shown to improve healing of various tissues and decrease necrosis of flaps. Though, there is no data about the optimal time-point of SW-application with regard to induction of ischemia (i.e. flap elevation) and subsequent effect on flap survival. Therefore we compared 2 shock-wave protocols in a model of persistent ischemia and investigated underlying mechanisms. Methods: 18 C57BL/6-mice equipped with a skinfold chamber containing a musculocutaneous flap were assigned to 3 experimental groups: 1. One session of 500 SWimpulses at 0·15 mJ/mm2 applied 24 hrs before (preconditioning) or 2. Applied 30 min after flap elevation (treatment). 3. Untreated flaps (control). Tissue necrosis,microhemodynamics, inflammation, apoptosis and angiogenesis were assessed by intravital epi-fluorescence microscopy over 10 days. Results: SW significantly reduced flap necrosis independent from the application time-point (preconditioning: 29 ± 7%; treatment: 25 ± 7% vs. control: 47 ± 2%; d10, p<0·05). This was associated with an early increase of functional capillary density (preconditioning: 236 ± 39 cm/cm2; treatment: 211 ± 33 cm/cm2 vs. control: 141 ± 7 cm/cm2; day1, p<0·05). Arteriolar diameter, red blood cell velocity and blood flow were comparable between the 3 experimental groups. SW-application significantly decreased the ischemiainduced inflammatory response (apoptotic cell death and leukocyte-endothelial interaction: (p<0·05)). Sprouts indicating angiogenesis were observed from day 7 only after SW-application. Conclusions: SW protects ischemically challenged musculocutaneous tissue. Interestingly, postoperative SW-application is as efficient as preoperative SWapplication. The protective effect induced by mechanical stress might be based on an early recruitment of ''sleeping capillaries'' maintaining nutritive perfusion and an anti-inflammatory effect within the ischemically jeopardized tissue. SWapplication provides a non-invasive alternative to local thermic and systemic pre-treatment of endangered tissues.

Periodontal health and esthetic results in impacted teeth exposed by apically positioned flap technique

Objectives: This study evaluates the periodontal health status and the esthetic results of teeth subjected to orthodontic traction, after their exposure by an apically positioned flap. Study design: Fifteen patients were included in the study, ages between 11 and 28 years old. The fenestrated teeth and their homologous contralateral normally erupted teeth, used as control, were evaluated. Results: Statistically significant differences were found in the position of the gingival margin (p = 0.005), with an average distance between cemento-enamel junction (CEJ) and gingival margin of 2.47 mm (SD 1.19) in control teeth and of 1 mm (SD 1.31) in the operated teeth, and in the depth of palatal probing (p = 0.031), with 2.1 mm (SD 0.9) for the experimental teeth and 1.7 mm (SD 0.8) for the control teeth. The gingival index, the bleeding during probing and the probing depth did not show statistically significant differences. The patient"s subjective esthetic evaluation was more favorable for the control teeth in most of the cases. Conclusions: The surgical approach for the impacted teeth by means of the apically positioned flap resulted to be a predictable technique allowing the maintenance of the periodontal health on a long-term basis.

The Combined Pedicled Anterolateral Thigh and Vastus Lateralis Flap as Filler for Complex Perineal Defects.

Extensive defects of the pelvis and genitoperineal region are a reconstructive challenge. We discuss a consecutive series of 25 reconstructions with the pedicled anterolateral thigh (ALT) flap including muscle part of the vastus lateralis (VL) in 23 patients from October 1999 to September 2012.Only surface defects larger than 100 cm and reconstructions by composite ALT + VL were included in this retrospective analysis. Of the 23 patients, 19 underwent oncologic resection, whereas 4 cases presented Fournier gangrene. Three patients did not reach 6 months of follow-up and were excluded from further data analysis. Among the remaining 20 patients (22 reconstructions), average follow-up period was 14 months (range, 10-18 months). Patient's average age was 60 years. Average size of the defect was 182 cm.Postoperative complications included 1 (4.5%) flap necrosis out of 22 raised flaps, 1 partial flap necrosis after venous congestion, and 2 cases where a complementary reconstructive procedure was performed due to remaining defect or partial flap failure. In 6 cases, peripheral wound dehiscence (27%) was treated by debridement followed by split-thickness skin graft or advancement local flaps. Defect size was significantly related to postoperative complications and increased hospital stay, especially in those patients who underwent preoperative radiotherapy. At the end of the follow-up period, a long-term and satisfactory coverage was obtained in all patients without functional deficits.This consecutive series of composite ALT + VL flap shows that, in case of extended defects, the flap provides an excellent and adjustable muscle mass, is reliable with minimal donor-site morbidity, and can even be designed as a sensate flap.