Thirteen patients have undergone reconstruction of large lumbosacral myelomeningoceles with bilateral paralumbar fasciocutaneous flaps. Fasciocutaneous flap closure is supported by a rich vascular network with three main dominant vascular territories. In the middle third of the flaps, a prominent transverse segmental vascular pattern originating from the muscular perforators and lateral cutaneous branches of the costal groove segment of the lower intercostal arteries was noted. The parascapular and scapular fascial branches of the circumflex scapular artery supplied the upper lateral portion of the flaps. Prominent lateral extensions of the superficial circumflex iliac arterial system formed the dominant fascial vasculature of the lower lateral flap, richly arborizing with the middle segmental intercostal extensions. All 13 patients tolerated the procedure without blood transfusion and without perioperative complications. Stable, durable cutaneous coverage was achieved in all patients. Two postmortem neonate humans with large lumbosacral myelomeningoceles were studied angiographically. Radiopaque silicone-rubber-lead-chrome matrix (Microfil) was infused under physiologic pressures in a 7-day neonate after successful defect closure with bilateral fasciocutaneous flaps. The flaps were reevaluated postmortem, and high-contrast, digitally enhanced computed radiographic imaging confirmed the rich vascular support of the bilateral fasciocutaneous flaps, identifying the dominant vascular pedicles. Rich vascularity was further documented by photographing the orange opaque Microfil cast vessels through the reelevated flaps. A second postmortem (stillborn) myelomeningocele specimen was studied with barium infusion with particular emphasis on the anomalous lumbar aorta. Angiographic studies provide a new understanding of the unique vascular anatomy of both the anomaly and the paralumbar fasciocutaneous flap.
A cutaneouš leiomyosarcoma arose in the upper lip skin of a 22-year-old patient. This unusual tumor was diagnosed clinically as a basal cell carcinoma although histological studies confirmed a leiomyosarcoma. The tumor was excised using Mohs technique and the wound reconstructed with a nasolabial flap and full-thickness skin graft. No recurrence or distant metastasis has appeared in a two-year follow-up.
The patient with a through-and-through defect of the nose suffers from a loss of skin, subcutaneous tissue, cartilage, and nasal lining. Repair of this defect is generally directed toward restoring the components of skin and lining [1–3]. The forehead flap is a useful substitute for nasal skin. A full-thickness skin graft may be used to substitute for absent nasal mucosa and serve as a lining for the forehead flap, covering its deep surface and retarding wound contracture. In the case presented, firm contact was maintained between the forehead flap and its full-thickness graft lining using a bolster dressing of simple design. We believe this dressing discourages seroma and hematoma formation while maintaining contact between the graft and the vascularized flap bed.
