Correspondence and communications
1319 ª 2015 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.bjps.2015.05.002
Figure 2 Schematic drawing illustrating the concept of “pedicle-in-a-trench” technique.
the wound has occurred via vacuum-assisted closure method.
Disclaimers and disclosure None.
Prior presentations None.
Funding None.
Conflicts of interest None declared.
Ethics This communication was published with the consent and permission of the patient involved.
Reference 1. DeFranzo AJ, Argenta LC, Marks MW, et al. The use of vacuumassisted closure therapy for the treatment of lower- extremity wounds with exposed bone. Plast Reconstr Surg 2001 Oct; 108(5):1184e91.
Hidehiko Yoshimatsu Takumi Yamamoto Taku Iwamoto Makiko Haragi Mitsunaga Narushima Takuya Iida Isao Koshima Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan E-mail address: [email protected]
Secondary total vagina reconstruction after total pelvic exenteration using the transverse musculocutaneous gracilis flap Dear Sir, We read with great interest the paper entitled “Reconstruction of the pelvic floor and the vagina after total pelvic exenteration using the transverse musculocutaneous gracilis flap” by Kaartinen IS et al., who reported their experience in immediate vagina reconstruction following total pelvic exenteration (TPE).1 We would like to share our experience with a case of a delayed vaginal reconstruction with the use of bilateral transverse upper gracilis musculocutaneous (TUG) flaps in a 29 year-old patient, who was referred to us 3 years following TPE. Given that the patient presented with good prognosis and had been disease-free for 3 years, and considering her desire for sexual life after having received sexual counseling from experts, the decision to proceed with the bilateral TUG procedure was made. The operative plan was similar to that described by the authors,1 but the delayed scenario exhibited the additional challenge of the creation of the vagina space that had been rendered more demanding due to scarring and radiotherapy. Moreover, the challenge of reconstruction of an adequately sized yet nonbulky vagina had to be met, thus to avoid jeopardizing the flap viability due to compression. The flap was designed similarly to the authors’ suggestion, with a horizontal skin paddle of 6 cm in vertical height and 20 cm in length,1 intending to result in functional vaginal circumference and length. The flap was raised as previously described2,3 and a 20 cm long gracilis muscle was included in both flaps. Nevertheless, targeting the aforementioned objectives, the surgical technique had to be modified. The muscles were not inserted behind the neovagina as Kaartinen IS et al.1 described, but after the division of their distal end (in order to ensure the adequate mobilization of the skin paddle) were left in their original position in the thigh (Figure 1). At the closure of the donor site the muscle’s distal end was loosely sutured to the adductor longus muscle. Introducing this modification the resulting neovagina was less bulky, thus facilitating the inset to the already narrow space. The muscles were spared as a lifeboat in case of wound breakdown, partial necrosis or fistula formation in the posterior wall, as reported by the authors.1 The wounds healed uneventfully resulting in a satisfactory neovagina (Figure 2). Magnetic resonance imaging at 2
1320
Correspondence and communications
References
Figure 1 Skin flaps raised and brought to the defect under the labia, whilst gracilis muscles were left in the thigh. The 2 flaps were sutured together to form the anterior and posterior wall of the neovagina.
years follow-up, demonstrated insignificant volume regression over time and the vaginal depth remained stable, without evidence of orifice constriction (Figure 2 insert). Interestingly, the patient reported entirely satisfactory sexual relations approximating pre-exenteration frequency, authorizing the effectiveness of the method in woman’s psychosocial well-being. The preservation of the medial cutaneous nerve of the thigh, branch of the obturator nerve that supplies the proximal median thigh skin, ensured the sensory rehabilitation of the neovagina. Given that both the anus and anal spinchter have been removed in the patient during the exenteration, with our modification of sparing the gracilis muscles there is a potential to perform neoanus dynamic anal myoplasty, in the future.4 In conclusion, the hereby-proposed modification of TUG flaps without gracilis muscle insertion in the neo-vagina, addresses effectively and prudently technical problems encountered in secondary post TPE vagina reconstruction, and safeguards the success of the method.
1. Kaartinen IS, Vuento MH, Hyo ¨ty MK, Kallio J, Kuokkanen HO. Reconstruction of the pelvic floor and the vagina after total pelvic exenteration using the transverse musculocutaneous gracilis flap. J Plast Reconstr Aesthet Surg 2015;68:93e7. 2. Whetzel TP, Lechtman AN. The gracilis myofasciocutaneous flap: vascular anatomy and clinical application. Plast Reconstr Surg 1997;99:1642e52 [discussion 1653e5]. 3. Wechselberger G, Schoeller T. The transverse myocutaneous gracilis free flap: a valuable tissue source in autologous breast reconstruction. Plast Reconstr Surg 2004;114:69e73. 4. Pirro N, Sielezneff I, Malouf A, Ouaı¨ssi M, Di Marino V, Sastre B. Anal sphincter reconstruction using a transposed gracilis muscle with a pudendal nerve anastomosis: a preliminary anatomic study. Dis Colon Rectum 2005;48:2085e9.
Andreas Gravvanis Despoina Kakagia Dimitrios Haidopoulos Dimosthenis Tsoutsos Department of Plastic Surgery e Microsurgery, General State Hospital of Athens “G. Gennimatas”, 154 Mesogion Avenue, 11527 Athens, Greece E-mail address: [email protected] ª 2015 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.bjps.2015.05.018
Keeping it simple: Improving dental outcomes with osseointegrated implants after “single barrel” free fibula reconstruction of the mandible Dear Sir
Figure 2 Two years postoperatively. The wounds healed uneventfully resulting in a satisfactory neovagina. MRI demonstrated insignificant volume regression over time, stable vaginal depth, without evidence of orifice constriction (insert).
After mandibular resection, precise restoration of form and function is critical to achieving satisfactory post-operative mastication, deglutition, and speech. The free fibula flap is the workhorse for mandible reconstruction, with aesthetics and dental rehabilitation being the primary goals of reconstruction. Early descriptions focused on aesthetic restoration, emphasizing alignment of the fibula with the inferior mandibular border to recreate the three-dimensional contour of the native mandible.1 In patients with dentition, osseointegrated implants are essential to the final reconstructive outcome. The recipient bone must have adequate height (>10 mm) and width (>6 mm) to accept osseointegrated implants, making the fibula excellent source of vascularized bone for prosthodontic reconstruction.2 A shortcoming of the fibula flap is its lack of vertical height compared to the native mandible body. Fixation of the fibula
1319 ª 2015 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.bjps.2015.05.002
Figure 2 Schematic drawing illustrating the concept of “pedicle-in-a-trench” technique.
the wound has occurred via vacuum-assisted closure method.
Disclaimers and disclosure None.
Prior presentations None.
Funding None.
Conflicts of interest None declared.
Ethics This communication was published with the consent and permission of the patient involved.
Reference 1. DeFranzo AJ, Argenta LC, Marks MW, et al. The use of vacuumassisted closure therapy for the treatment of lower- extremity wounds with exposed bone. Plast Reconstr Surg 2001 Oct; 108(5):1184e91.
Hidehiko Yoshimatsu Takumi Yamamoto Taku Iwamoto Makiko Haragi Mitsunaga Narushima Takuya Iida Isao Koshima Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan E-mail address: [email protected]
Secondary total vagina reconstruction after total pelvic exenteration using the transverse musculocutaneous gracilis flap Dear Sir, We read with great interest the paper entitled “Reconstruction of the pelvic floor and the vagina after total pelvic exenteration using the transverse musculocutaneous gracilis flap” by Kaartinen IS et al., who reported their experience in immediate vagina reconstruction following total pelvic exenteration (TPE).1 We would like to share our experience with a case of a delayed vaginal reconstruction with the use of bilateral transverse upper gracilis musculocutaneous (TUG) flaps in a 29 year-old patient, who was referred to us 3 years following TPE. Given that the patient presented with good prognosis and had been disease-free for 3 years, and considering her desire for sexual life after having received sexual counseling from experts, the decision to proceed with the bilateral TUG procedure was made. The operative plan was similar to that described by the authors,1 but the delayed scenario exhibited the additional challenge of the creation of the vagina space that had been rendered more demanding due to scarring and radiotherapy. Moreover, the challenge of reconstruction of an adequately sized yet nonbulky vagina had to be met, thus to avoid jeopardizing the flap viability due to compression. The flap was designed similarly to the authors’ suggestion, with a horizontal skin paddle of 6 cm in vertical height and 20 cm in length,1 intending to result in functional vaginal circumference and length. The flap was raised as previously described2,3 and a 20 cm long gracilis muscle was included in both flaps. Nevertheless, targeting the aforementioned objectives, the surgical technique had to be modified. The muscles were not inserted behind the neovagina as Kaartinen IS et al.1 described, but after the division of their distal end (in order to ensure the adequate mobilization of the skin paddle) were left in their original position in the thigh (Figure 1). At the closure of the donor site the muscle’s distal end was loosely sutured to the adductor longus muscle. Introducing this modification the resulting neovagina was less bulky, thus facilitating the inset to the already narrow space. The muscles were spared as a lifeboat in case of wound breakdown, partial necrosis or fistula formation in the posterior wall, as reported by the authors.1 The wounds healed uneventfully resulting in a satisfactory neovagina (Figure 2). Magnetic resonance imaging at 2
1320
Correspondence and communications
References
Figure 1 Skin flaps raised and brought to the defect under the labia, whilst gracilis muscles were left in the thigh. The 2 flaps were sutured together to form the anterior and posterior wall of the neovagina.
years follow-up, demonstrated insignificant volume regression over time and the vaginal depth remained stable, without evidence of orifice constriction (Figure 2 insert). Interestingly, the patient reported entirely satisfactory sexual relations approximating pre-exenteration frequency, authorizing the effectiveness of the method in woman’s psychosocial well-being. The preservation of the medial cutaneous nerve of the thigh, branch of the obturator nerve that supplies the proximal median thigh skin, ensured the sensory rehabilitation of the neovagina. Given that both the anus and anal spinchter have been removed in the patient during the exenteration, with our modification of sparing the gracilis muscles there is a potential to perform neoanus dynamic anal myoplasty, in the future.4 In conclusion, the hereby-proposed modification of TUG flaps without gracilis muscle insertion in the neo-vagina, addresses effectively and prudently technical problems encountered in secondary post TPE vagina reconstruction, and safeguards the success of the method.
1. Kaartinen IS, Vuento MH, Hyo ¨ty MK, Kallio J, Kuokkanen HO. Reconstruction of the pelvic floor and the vagina after total pelvic exenteration using the transverse musculocutaneous gracilis flap. J Plast Reconstr Aesthet Surg 2015;68:93e7. 2. Whetzel TP, Lechtman AN. The gracilis myofasciocutaneous flap: vascular anatomy and clinical application. Plast Reconstr Surg 1997;99:1642e52 [discussion 1653e5]. 3. Wechselberger G, Schoeller T. The transverse myocutaneous gracilis free flap: a valuable tissue source in autologous breast reconstruction. Plast Reconstr Surg 2004;114:69e73. 4. Pirro N, Sielezneff I, Malouf A, Ouaı¨ssi M, Di Marino V, Sastre B. Anal sphincter reconstruction using a transposed gracilis muscle with a pudendal nerve anastomosis: a preliminary anatomic study. Dis Colon Rectum 2005;48:2085e9.
Andreas Gravvanis Despoina Kakagia Dimitrios Haidopoulos Dimosthenis Tsoutsos Department of Plastic Surgery e Microsurgery, General State Hospital of Athens “G. Gennimatas”, 154 Mesogion Avenue, 11527 Athens, Greece E-mail address: [email protected] ª 2015 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.bjps.2015.05.018
Keeping it simple: Improving dental outcomes with osseointegrated implants after “single barrel” free fibula reconstruction of the mandible Dear Sir
Figure 2 Two years postoperatively. The wounds healed uneventfully resulting in a satisfactory neovagina. MRI demonstrated insignificant volume regression over time, stable vaginal depth, without evidence of orifice constriction (insert).
After mandibular resection, precise restoration of form and function is critical to achieving satisfactory post-operative mastication, deglutition, and speech. The free fibula flap is the workhorse for mandible reconstruction, with aesthetics and dental rehabilitation being the primary goals of reconstruction. Early descriptions focused on aesthetic restoration, emphasizing alignment of the fibula with the inferior mandibular border to recreate the three-dimensional contour of the native mandible.1 In patients with dentition, osseointegrated implants are essential to the final reconstructive outcome. The recipient bone must have adequate height (>10 mm) and width (>6 mm) to accept osseointegrated implants, making the fibula excellent source of vascularized bone for prosthodontic reconstruction.2 A shortcoming of the fibula flap is its lack of vertical height compared to the native mandible body. Fixation of the fibula
