ObjectiveFor skin defects caused by full-thickness burns, trauma, or tumor tissue excision, skin grafting is one of the most convenient and useful treatment methods. In this situation, graft fixation is important in skin grafting. This study was performed to compare the effectiveness of skin graft fixation between high-concentration fibrin sealant and sutures. There have been numerous studies using fibrin sealant for graft fixation, but they utilized slow-clotting fibrin sealant containing less than 10 IU/mL thrombin.MethodTwenty-five patients underwent split-thickness skin grafting using fast-clotting fibrin sealant containing 400 IU/mL thrombin, while 30 patients underwent grafting using sutures. Rates of hematoma/seroma formation, graft dislocation, graft necrosis, and graft take were investigated postoperatively. The graft surface area was calculated using Image J software (National Institutes of Health, Bethesda, MD, USA).ResultAfter 5 days, rates of hematoma/seroma formation and graft dislocation were 7.84 and 1.29% in group I, and 9.55 and 1.45% in group II, respectively. After 30 days, rates of graft necrosis and graft take were 1.86 and 98.14% in group I, and 4.65 and 95.35% in group II. Undiluted fibrin sealant showed significantly superior results for all rates (p < 0.05) except graft dislocation.ConclusionWhen high-concentration fast-clotting fibrin sealant was applied to skin grafts without dilution, no difficulty was experienced during surgery. Sealant showed superior results compared with sutures and had an excellent graft take rate.Level of evidenceII.
In spite of thorough presurgical planning, emergency situations requiring longer pedicle length may arise during anterolateral thigh (ALT) free flap surgeries. While performing vessel graft for pedicle lengthening, discrepancy may occur because of a certain genetic predisposition or vascular variation at the anastomosis site of the graft vessel and the flap pedicle. A 76-year-old male patient with neurofibromatosis type I had a 15 x 10 cm defect, which was caused by radical excision of a malignant peripheral nerve sheath tumor on his back. A 15 x 10 cm sized free ALT flap was obtained. The distance between the recipient vessels and the defect area was 20 cm. The diameters of vessels in the harvested flap were as follows: proximal end of the descending branch of the lateral circumflex femoral artery (LCFA)-artery/vein: 3.0/2.5 mm, distal end of the descending branch of the LCFA-artery/vein: 1.0/1.0 mm, and perforator in the ALT flap-artery/vein: 0.8/1.0 mm. The conventional method requires transfer of the distal portion of the LCFA (below the bifurcation) which mandates us to perform anastomoses with a vessel diameter discrepancy of 2 mm. As an alternative, a bifurcating perforator-including flap was transposed to the most distal part of the descending branch of the LCFA. An ALT flap with a pedicle having a total length of 20 cm was constructed. The flap survived without any complications. This technique may provide an option for resolving size discrepancy between the graft vessel and the ALT pedicle.
Various skin tumours such as squamous cell carcinoma and extramammary Paget's disease can occur in the vulval area, and reconstruction of the vulval area can be a very challenging task. A retrospective analysis of vulvar reconstruction using the new method 'internal pudendal perforator artery-based gull wing flap' was performed from April 2012 to December 2013. A perforator vessel from the internal pudendal artery was detected with a portable Doppler and marked, and this was the pivot point around which the flap was rotated. The flap was rotated by more than 150°-180° internally, and the labium and the external wall of the vagina were reconstructed with sufficient volume. Anatomical and aesthetic reconstruction of the labium and the vagina was performed without serious complications. Functional and aesthetic vulvar reconstruction can be achieved by using a flap that provides sufficient volume of the labium. Our new technique, the 'internal pudendal perforator artery-based gull wing flap', is good and it can be used to reconstruct a functional and aesthetically acceptable vulvovagina for large defect wound after tumour excision.
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