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.

Disseminated Mycobacterium avium Complex Infection Causing Multiple Skull Defects in an Immunocompetent Patient: A Case Report

Mycobacterium avium complex (MAC) infection mainly causes pulmonary disease. However, in 20% to 30% of cases, it also induces various extrapulmonary diseases. Disseminated MAC infection occasionally occurs in immunocompromised patients but very rarely in immunocompetent patients. An 80-year-old immunocompetent woman presented with multiple chronic wounds on the scalp that had not improved despite prolonged treatment. A scalp abscess caused by disseminated MAC infection 4 years ago had gone through repeated cycles of improvement and aggravation despite continued use of anti-mycobacterial agents and active wound care. Enhanced brain computed tomography and magnetic resonance imaging revealed multiple skull defects and abscesses invading the dura mater. Under general anesthesia, the infected scalp skin and bone were sufficiently removed, and the bone and soft tissue defects were repaired with cranioplasty using a titanium mesh plate and local flap. As exemplified in this case, multiple chronic wounds unresponsive to treatment need to be screened for MAC infection. As chronic MAC infection in the scalp can cause skull destruction and brain infection, it needs to be treated aggressively at an early stage to prevent serious morbidity and mortality. Effective MAC infection management involves adequate medication, regular follow-up imaging, and active surgical procedure.

Reconstructive Outcomes of Extensive Soft-Tissue Defects after Palliative Mastectomy for Advanced Breast Cancer

Background: In advanced breast cancer, reconstruction can be performed depending on the patient’s situation, and can improve the subsequent treatment and quality of life. We examined the effect of reconstruction after palliative mastectomy on survival and quality of life.Methods: Between April 2010 and April 2021, 40 patients underwent reconstruction after palliative mastectomy for stage-IV breast cancer. To evaluate postoperative satisfaction, changes in the global health and quality-of-life scores after reconstruction were evaluated using questionnaires by the European Organisation for Research and Treatment of Cancer. The survival rate according to reconstructive surgery was estimated by the Kaplan-Meier survival analysis.Results: Reconstruction methods included free transverse rectus abdominis musculocutaneous (TRAM) flap (n=3), pedicled latissimus dorsi (LD) flap (n=3), pedicled TRAM flap (n=2), pedicled LD with pedicled vertical rectus abdominis musculocutaneous flap (n=1), tissue expander insertion (n=3), and split-thickness skin graft (n=28). There were no major complications or decreased life expectancy due to reconstruction. All patients healed well and started conventional chemoradiotherapy at 31.3 days postoperatively. The quality-of-life scores increased from 37 to 83 after reconstruction. There was no difference in the survival rates between those who underwent reconstruction with split-thickness skin graft and flap operation (P>0.05). The mean survival time postoperatively was 43.9 months.Conclusion: Compared to primary closure, reconstruction of extensive soft-tissue defects after palliative mastectomy did not affect life expectancy or delay postoperative chemoradiotherapy; it led to an improved quality of life. Therefore, the extensive defects expected after palliative mastectomy should not influence indications for reconstruction surgery.

Three-Dimensional Computed Tomography Follow-Up on Spontaneous Bone Healing after Excision of Periorbital Dermoid Cyst: A Case Report

Dermoid cysts are among the most common periorbital and orbital tumors presenting in childhood. Several studies have shown that dermoid cysts may deform adjacent bones; however, few studies have followed the course of bone regeneration after the excision of a cyst. We report a case of a 29-month-old female infant who presented with a palpable mass over her right lateral eyebrow. Ultrasonography findings suggested a dermoid cyst, and computed tomography revealed a 2.1-cm round bony defect in the right zygoma. After surgical excision of the dermoid cyst, we successfully applied fibrin sealant to eliminate the dead space. Pathological findings showed nodular lesions with flat cystic walls containing lamellated keratin and sebaceous glands, supporting the diagnosis of dermoid cyst. At 6 months postoperatively, a follow-up computed tomography scan confirmed complete recovery of the bone defect in the right zygoma.

Comparison of Satisfaction Levels between Conventional and Silicone-Adhesive Polyurethane Foam Materials in Patients with Skin Wounds

Background: Polyurethane (PU) foam dressing materials have been widely used in commercial wound dressing applications. However, the repeated application of adhesive tapes to keep the foam dressings in place can result in minor injuries to the peri-wound skin. Silicone-adhesive PU foam dressing materials have been developed to prevent such injuries. In this study, the satisfaction levels between conventional and silicone-adhesive PU foams were assessed through a survey of patients and physicians.Methods: A survey study of 140 patients with skin wounds was conducted in a single institution between July 2019 and May 2020. The patients were first treated with either conventional PU foam or silicone-adhesive PU foam, after which they were asked to record their levels of pain, adhesiveness, waterproofness, and satisfaction. At the next visit, dressings of the other material were applied to their wounds, and the same assessment process was repeated at the next dressing change.Results: The silicone-adhesive PU foam dressings demonstrably reduced the levels of dressing-related trauma and pain, compared to that of patients treated with conventional PU foam dressings. The silicone-adhesive PU foam dressings were also associated with substantially higher scores of satisfaction and waterproofness. In comparison, the mean adhesiveness score was superior in the group treated with conventional PU foam dressings, compared to that of the group treated with silicone-adhesive PU foam dressings.Conclusion: Silicone-adhesive PU foam contributed to minimizing pain during dressing change and increasing patient’s comfort. As a result, patients preferred dressing with silicone-adhesive PU foam over conventional PU foam.

Evaluating Effectiveness of Medical Grade Honey-Containing Alginate Dressing in Patients with Chronic Lower Extremity Wounds

Background: Chronic wounds of the lower extremities are challenging to treat. Recently, honey-based dressings have been shown beneficial effects in diabetic foot ulcers and venous ulcers. Here, we compared Medihoney alginate with a standard alginate dressing in lower extremity chronic wounds.Methods: We performed retrospective chart reviews of 37 patients between January 2019 and January 2021 with chronic lower extremity wounds who were treated with an Algisite M dressing (group A) or a Medihoney alginate dressing (group B). Microorganisms isolated from wound cultures, weekly decrease in wound area over 4 weeks, the number of patients who achieved complete wound closure, and the amount of time required for wound closure were compared between the two groups. Results: Sixteen patients were assigned to group A and 21 to group B. The isolated microorganisms were confirmed as methicillin-susceptible Staphylococcus aureus most commonly, followed by methicillin-resistant S. aureus. Wound area decreased from 12.71 to 2.34 cm² in group A and from 14.07 to 1.71 cm² in group B (P<0.05). Seven patients achieved complete wound closure in group A (43.75%) and 15 patients in group B (71.43%). Mean duration of wound closure was 36.31 days in group A and 34.62 days in group B.Conclusion: Considering the more rapid decrease in wound area in group B, application of a honey-containing alginate dressing to lower extremity chronic wounds, especially those infected with antibiotic-resistant bacteria, was proved to be a good treatment option.

Repair of Soft Tissue Defect with Intraoperative Tissue Expansion after Surgical Resection of Dermatofibrosarcoma Protuberans: A Case Report

While it is the most frequently observed subtype of all cutaneous soft tissue sarcomas, dermatofibrosarcoma protuberans is still uncommon, with a high local recurrence rate. Although surgical resection could be a simple curative procedure, surgeons can encounter difficulties when dissecting or closing the wound, depending on the location and the size of the tumor. We present a case report of direct repair of soft tissue defect with intraoperative tissue expansion after sarcoma resection. A 62-year-old male visited our clinic with an approximately 1.5×1.5 cm-sized mass on his lower leg. We excised the mass, which a pathologic study confirmed as dermatofibrosarcoma protuberans. The authors planned a wide excision of the lesion as soon as possible. The excised lesion was not large; however, the soft tissue defect could not be closed by direct approximation. We eventually closed the tumor resection wound using a Foley catheter as a tissue expander. The patient’s wound healed well, albeit leaving a minimal scar. This case suggests that a Foley catheter could be an effective and versatile tool that is readily available in any medical setting, including after a small tumor resection in outpatient surgery.

Negative-Pressure Wound Therapy in a Patient with Osteomyelitis Caused by Multidrug-Resistant Bacterial Infection: A Case Report

Uncontrolled infection, especially with multidrug-resistant bacteria, may significantly inhibit wound healing. Although negative-pressure wound therapy can help prevent infection, it is contraindicated in patients with untreated infections, including osteomyelitis. Here, we report successful wound healing by negative-pressure wound therapy in a patient with refractory osteomyelitis due to multiple multidrug-resistant bacterial infections. Soft tissue infection and osteomyelitis progressed deeply through subcutaneous tunneling; hence, bacteria were not excreted from the affected area. Negative-pressure wound therapy reduced the bacterial load and resolved the patient’s condition. Healing by secondary intention progressed with subsequent formation of granulation tissue. Despite recommendations against negative-pressure wound therapy in patients with osteomyelitis, this study highlights the application of the technique for infection control in patients with multidrug-resistant bacterial infections and osteomyelitis.

2-Octyl Cyanoacrylate Glue Application on Split-Thickness Skin Graft for Lower Extremity Reconstruction

A split-thickness skin graft (STSG) is a very effective method for reconstructing skin defects in the lower extremities; however, suturing all graft margins during surgery is time-consuming. As an alternative, 2-octyl cyanoacrylate glue attaches the epidermal layer of an STSG to normal skin and functions like a suture. In this study, we assessed 2-octyl cyanoacrylate glue as a time-saving step in STSG procedures. We reviewed the charts of 87 patients who underwent STSG between May 2018 and August 2020. For the 10 patients who consented to the STSG procedure with 2-octyl cyanoacrylate glue, we evaluated the treatment site for complications and engraftment every 2 days for 14 days. The STSGs were successfully engrafted in all cases. Seroma, hematoma, wound dehiscence, or infection were not documented. No additional revision surgery was required. The use of 2-octyl cyanoacrylate glue in STSG margin fixation was safe, effective, convenient, and time-saving. This study found 2-octyl cyanoacrylate glue a good option for lower extremity skin defect reconstruction.

Reconstruction of Lower Extremity Necrotizing Fasciitis with Tibialis Anterior Musculofascial Flap and Skin Graft: A Case Report

Necrotizing fasciitis of the lower extremities results in large tissue defects, and most cases require reconstruction using skin grafts or flaps. We describe a 61-year-old man who developed necrotizing fasciitis of the right lower leg and septic shock, following a traumatic injury to his leg. Wound culture yielded methicillin-resistant Staphylococcus aureus. Extensive debridement was performed four times along with the use of appropriate antibiotics. After 2 weeks, physical examination showed an open wound (approximately 30×20 cm in size) with partial tibial bone exposure. Subsequently, the patient underwent successful reconstruction using a tibialis anterior musculofascial flap and split-thickness skin grafting. The tibialis anterior muscle was bihalved and pivoted to cover the exposed bone surface. The patient was without pain and was able to successfully perform daily activities at the 15-month follow-up. This case report highlights the utility of a bihalved tibialis anterior musculofascial flap for lower extremity reconstruction, particularly in patients for whom free flap transfers are unviable.