Full-Thickness Skin Grafts for Coverage of the Pedicle in Partial Second Toe Pulp Free Flap

Pedicle coverage during free flap reconstruction of the digit commonly presents complicated issues. As the finger is a cylindrical unit with small volume, it is difficult to secure ample soft tissue for relaxed coverage of the pedicle. We have applied full-thickness skin grafts (FTSGs) to loosely cover the pedicle of the free flap of the fingertip and report preliminary results. Seven patients who received free toe pulp flap and FTSG for soft tissue coverage of the pedicle were analyzed. Intraoperative parameters collected were defect, flap and graft area size and donor site. Patients were observed postoperatively for up to 2 months for graft take, necrosis, digit contour, and donor site complications. The average area of the free flap was 2.39±1.03 cm² and the average graft area was 1.37±1.06 cm². The FTSG survived without sloughing or necrosis in six patients. Early epithelial sloughing with dermis take was noted in one patient who healed with dressings. The pedicle and graft portion showed bulging immediately after the operation but decreased to normal contour by 4 weeks. FTSG is an option that can be safely used as a method of pedicle coverage during free flap reconstruction of digits.

Histological Study On Using Ileal Submucosa In Repairing Urinary Bladder Defect In Adult Albino Rat

Background Repairing urinary bladder (UB) defect by enterocystoplasty remains the gold standard surgical bladder reconstruction procedure to increase the capacity and compliance of dysfunctional bladders. However, many complications were recorded. Aim of the work This work aimed to compare the consequences of reconstruction of urinary bladder defect using untreated small intestinal submucosal (SIS) matrix versus seeded and unseeded decellularized SIS matrix. Material and Methods Fifty female albino rats were used in this study. The animals were divided into three groups: Group I (Control) included ten adult rats from which ileal tissue was obtained. Group II included ten adult rats in which their UB defect was repaired by untreated cellular SIS. Group III included twenty adult rats that were subdivided into two subgroups, 10 rats each; Subgroup IIIA where rats had their UB defect repaired by acellular SIS and subgroup IIIb where rats had their UB defect repaired by acellular SIS seeded with adipose mesenchymal stem cells (AMSCs).Ten young rats were used for preparation of AMSCs. Morphometric and statistical analysis were also performed. Results In rats where UB defect was repaired by untreated cellular SIS, the graft area showed loss of epithelial polarity, presence of intraepithelial cysts and occasional extension of urothelium to the outer surface forming fistula. There were areas of metaplasia with the appearance PAS positive cells. In the lamina propria, there was areas of lymphocytic infiltration together with significant increase in the collagen fiber deposition (p < 0.05). There was a significant decrease thickness of muscle layer as compared to control (p < 0.05). In rats where UB defect was repaired by acellular SIS, urothelium in the graft area showed occasional squamous metaplasia and often the urothelium extended to the deeper layers forming Brunn's nest. There was minimal muscle regeneration in the graft area. However, in rats where UB defect was repaired by acellular SIS seeded with AMSCs, the urothelium in the graft area was nearly similar to control group with uniform urothelium thickness, minimal collagen fibers deposition and thick muscle layer that showed no significant difference from the control (p > 0.05). Conclusion Acellular SIS seeded with AMSCs showed better results compared to non-seeded and cellular SIS in reconstructing urinary bladder defects.

Mechanical Tension-Stress in Alveolar Cleft Repaired With Autogenous Bone in Canine Models

Objective: Cleft lip and/or palate is a common birth defect worldwide, always accompanied by alveolar cleft. However, the success rate of secondary alveolar bone grafting is unsatisfactory. Rapid maxillary expansion (RME) often used after bone transplantation provides functional stimulation for bone graft area. This study aimed to investigate the effect of RME force on the bone graft area and midpalatal suture, and screen out the most suitable loaded force and loaded teeth, so as to provide a reference for clinical treatment. Methods: Fourteen 24-week-old male beagles were assigned randomly to 3 groups: blank control, autogenous, and autogenous with RME. Three-dimensional finite element analysis was conducted to evaluate the distribution and value of the stress in the model. The maxillae were collected and subjected to radiography and helical computed tomography to evaluate new bone formation in the graft area. Van Gieson’s Picrofuchsin staining was performed for histomorphological observation. Results: After 8 weeks of RME treatment, new bone formation of the dogs was markedly accelerated, and bone resorption was significantly reduced compared with the untreated dogs or those only treated with autogenous iliac bone. The treatment with RME evidently made the bone trabecula more abundant and the area of bone formation larger. Three-dimensional finite element analysis showed that the clinical effect can be achieved by using canine teeth as the loaded teeth and applying force of 10 MPa. Conclusion: Rapid maxillary expansion after bone grafting had a positive effect on osteogenesis in a canine model of alveolar cleft.

Is preoperative vestibular depth a factor affecting shrinkage of free gingival graft: A quasi-experimental study

Background The purpose of the present study was to evaluate the effect of preoperative vestibular depth (VD) on FGG dimensional shrinkage.Methods This study was performed on 20 patients with insufficient attached gingiva width (AGW). Under local anesthesia, a partial thickness bed with submarginal incision was created. An FGG was prepared from the palate and sutured to the prepared bed. Clinical parameters including VD, probing depth (PD), keratinized gingiva width (KGW), AGW, vertical graft dimension (VGD), horizontal graft dimension (HGD) and graft area (GA) were evaluated preoperatively and 1, 3, and 6 months postoperatively. Because the distribution of data was normal, t-test and repeat measurement test were performed to analyze the data.Results Six months after FGG surgery, AGW and KGW raised to 6.15±1.01 mm and 7.55±1.1 mm, which were statistically significant (P <0.001). The shrinkage rate of HGD, VGD, and GA were 13%, 34%, 42% respectively after 6 months. The VD was increased 2.05 mm compared to baseline which was statistically significant (P <0.01). 6 months after surgery, KGW and AGW were 6.95±0.89 mm and 5.62±0.88 mm in patients with baseline VD <9mm, and 8.57±0.53 mm and 7.07±0.34 mm in patients with baseline VD ≥9 mm respectively. The difference of postoperative KGW and AGW between these two groups (based on baseline VD) was statistically significant. (P <0.01, P =0.001 respectively). The decrease in KGW and AGW in patients with VD <9 mm was 1.62 and 1.45 mm respectively after 6 months and this decrease was greater than patients with VD ≥9 mm.Conclusions It was concluded that the shrinkage of FGG was significantly greater in patients with less preoperative VD 6 months after surgery.Trial registration: This study was retrospectively registered by Iranian Registry of Clinical Trials (IRCT) with the number: IRCT20101204005305N18. Registered 22 September 2019. https://irct.ir/trial/41736

Pitfall management of dermatofibrosarcoma protuberans on right leg

Dermatofibrosarcoma protuberans (DFSP) is a rare, locally invasive soft tissue sarcoma. The local recurrence rate is high, in some studies upwards of 60%, likely reflecting a failure to remove occult extensions of tumor. Surgical excision has been the treatment of choice for the resection of DFSP. Any pitfall on management therapy of DFSP not only increase the recurrence rate but also add new problems to patients with DFSP. 58-year-old male patient, came with a local recurrent of DFSP on his right leg. Then performed excision with margin one centimetre, and closing defect using pedicle sural flap, durante surgery turned pedicle on the flap is too short and because of poor soft tissue handling pedicle was injured. It consulted into the vascular division for evaluated and treatment pedicle. Postoperative evaluation, the flap experiences bluish due to vascularization compromised. It was decided to expose the flap and the defect was covered with skin graft. 2 months postoperative evaluation found local recurrent on skin graft area. Excision margins between 2 to 5 cm can reduce the recurrence rate. Proper planning in designing flaps to cover defects and the ability of good soft tissue handling is required to avoid new problems on management DFSP.

Influence of Cigarette Smoke Inhalation on an Autogenous Onlay Bone Graft Area in Rats with Estrogen Deficiency: A Histomorphometric and Immunohistochemistry Study

Purpose: The present study aimed to evaluate the influence of cigarette smoke inhalation on an autogenous onlay bone graft area, either covered with a collagen membrane or not, in healthy and estrogen-deficient rats through histomorphometry and immunohistochemistry. Materials and Methods: Sixty female rats (Wistar), weighing 250–300 g, were randomly divided and allocated into groups (either exposed to cigarette smoke inhalation or not, ovariectomized and SHAM). After 15 days, the test group underwent cigarette smoke inhalation. Sixty days after exposition, autogenous bone grafting was only performed on all right hemimandibles, and the left ones underwent autogenous onlay bone grafting with the collagen membrane (BioGide®). The graft was harvested from the parietal bone and attached to the animals’ jaws (right and left). They were euthanized at 21, 45, and 60 days after grafting. Histological measurements and immunohistochemical analyses were performed, and results were submitted to a statistical analysis. Results: The addition of a collagen membrane to the bone graft proved more efficient in preserving graft area if compared to the graft area without a collagen membrane and the one associated with cigarette smoke inhalation at 21 (p = 0.0381) and 60 days (p = 0.0192), respectively. Cigarette smoke inhalation combined with ovariectomy promoted a significant reduction of the autogenous graft area at 21 and 60 days. At 45 days, no statistically significant results were observed. In the immunohistochemical analysis, the ovariectomized and smoking subgroups, combined or not with collagen membrane, received moderate and intense immunolabeling at 21 days for Receptor Activator of Nuclear Factor Kappa-B Ligand (RANKL) (p = 0.0017 and p = 0.0381, respectively). For Osteoprotegerin (OPG), intense immunolabeling was observed in most subgroups under analysis at 60 days. Conclusion: Smoking inhalation promoted resorption on the autogenous onlay bone graft, mainly when associated with ovariectomy. Furthermore, when associated with the collagen membrane, a lower resorption rate was observed if compared to the absence of the membrane.

Lesion Size Does Not Predict Outcomes in Fresh Osteochondral Allograft Transplantation

Background: Cartilage repair algorithms use lesion size to choose surgical techniques when selecting a cartilage repair procedure. The association of fresh osteochondral allograft (OCA) size with graft survivorship and subjective patient outcomes is still unknown. Purpose: To determine if lesion size (absolute or relative) affects outcomes after OCA transplantation. Study Design: Cohort study; Level of evidence, 3. Methods: The study included 156 knees in 143 patients who underwent OCA transplantation from 1998 to 2014 for isolated femoral condyle lesions. The mean age was 29.6 ± 11.4 years, and 62.9% were male. The majority of patients (62.2%) presented for cartilage repair because of osteochondritis dissecans. The mean graft area, used as a surrogate for absolute size of the lesion, was 6.4 cm2 (range, 2.3-11.5 cm2). The relative size of the lesion was calculated as the tibial width ratio (TWR; ratio of graft area to tibial width) and affected femoral condyle ratio (AFCR; ratio of graft area to affected femoral condyle width) using preoperative radiographs. All patients had a minimum follow-up of 2 years. Further surgical procedures were documented, and graft failure was defined as revision OCA transplantation or conversion to arthroplasty. International Knee Documentation Committee (IKDC) pain, function, and total scores were obtained. Satisfaction with OCA transplantation was assessed. Results: The mean follow-up among patients with grafts remaining in situ was 6.0 years (range, 1.9-16.5 years). The OCA failure rate was 5.8%. Overall survivorship of the graft was 97.2% at 5 years and 93.5% at 10 years. No difference in postoperative outcomes between groups was found in absolute or relative size. Change in IKDC scores (from preoperative to latest follow-up) was greater for knees with large lesions compared to knees with small lesions, among all measurement methods. Overall satisfaction with the results of OCA transplantation was 89.8%. Conclusion: The size of the lesion, either absolute or relative, does not influence outcomes after OCA transplantation for isolated femoral condyle lesions of the knee.