Background: Infection of the grafted site or insufficient wound bed preparation can lead to skin graft failure. Therefore, we performed the buried patch skin graft technique using a granulation flap under local anesthesia in severe local wound site infections or severe general conditions. This report aims to demonstrate the utility and indications of this technique. Methods: A small split-thickness patch of skin was grafted beneath the granulation flap in cases with persistent chronic wounds secondary to skin graft loss after conventional split-thickness skin grafting under general anesthesia. Multiple square granulation flaps were elevated at all corners at straight angles. The skin graft patch was placed beneath these flaps, which measured 1–4 cm2. Both corners of the distal end of the flap were secured using absorbable sutures. The topical ointment dressing was changed daily. Results: This technique was performed in 10 patients under local anesthesia at the bedside or outpatient room. Survival and vascularization of the grafted skin were confirmed in all cases. The granulation flaps gradually fell between postoperative days 3 and 7. All cases, excluding two fatal cases, achieved wound closure. Conclusions: Buried patch skin grafting under a granulation flap should be considered in cases with insufficient wound bed preparation or compromised general condition to reduce the risk of skin graft loss.
Pigmented basal cell carcinoma (BCC) is more common in Asians than in Caucasians. In Asian patients, the boundaries of BCC are clear due to the presence of pigmentation, and the recurrence rate after conventional wide resection is low. However, determining the appropriate surgical margins for non-pigmented BCC is difficult, even with dermoscopy. In addition, subclinical extension of BCC may complicate the case further and require several rounds of Mohs surgery. Here, we report a case of a 39-year-old female patient, who was diagnosed initially with Pigmented BCC typical for Asians7 and underwent a resection. However, an area of extensive non-pigmented subclinical extension was found later, which required four additional rounds of resection. During the initial dermoscopic examination and first surgical resection in this patient, arborizing blood vessels were found around the ulcers and pigmented sites; however, there were no indications of any other widespread non-pigmented lesions. The following characteristics have been reported previously for patients getting subclinical extension: 1) being an elderly male; 2) Fitzpatrick skin type I; and 3) a history of BCC. As our patient did not have any of these characteristics, this case was considered to be unusual. After four rounds of excision, we could completely remove widespread non-pigmented lesions.
Breast reconstruction with a deep inferior epigastric artery perforator (DIEP) flap is now widely used. However, when the DIEP flap is not available, an alternative for patients who desire autologous breast reconstruction should be provided. This study aimed to introduce breast reconstruction with a lumbar artery perforator (LAP) flap for metachronous breast cancer that developed after contralateral breast reconstruction with a DIEP flap. A 45-year-old patient who developed metachronous breast cancer after contralateral breast reconstruction with a DIEP flap insisted on autologous breast reconstruction after metachronous breast cancer ablation. We chose the lumbar artery perforator (LAP) flap to ensure sufficient tissue volume and achieve a natural and symmetrical breast shape. Preoperative contrast-enhanced computed tomography indicated the presence of a large right fourth lumbar artery perforator. The LAP flap was harvested with a skin island size of 14×6 cm, including two perforators. The flap weight was 516 g, and the pedicle length was 2.5 cm. In addition, we used the left deep inferior epigastric artery, vein, and left superficial circumflex iliac vein (SCIV) for 6.0 cm as an interposition graft. The final length of the pedicle after DIEA and DIEV grafting was 8.5 cm. There were no postoperative complications. Six months postoperatively, the patient was satisfied with the shape and volume of the reconstructed breast and the donor site wound. A LAP flap may be an alternative option for patients who develop metachronous breast cancer after contralateral breast reconstruction with a DIEP flap.
In a 49-year-old man, a free flap was grafted to cover a tissue defect after surgery for frontal osteomyelitis. On the following day, due to venous thrombosis, the patient underwent removal of the venous thrombus and vascular re-anastomosis with a vein graft. A basic fibroblast growth factor-impregnated collagen-gelatin sponge (bFGF-CGS) was used to close the wound without compression of the vascular pedicles. Postoperatively, the free flap survived without recurrence of venous thrombosis, and the bFGF-CGS graft site was completely epithelialized without additional skin grafting. The grafted bFGF-CGS slowly released basic fibroblast growth factor, which in turn continuously promoted the proliferation of fibroblasts, angiogenesis, and epithelialization. Furthermore, bFGF-CGS is more durable because of its double-layered structure, and compression fixation is not required after grafting. The bFGF-CGS appears to be useful for the coverage of vascular anastomotic sites and vascular pedicles after free flap grafting, which requires strict management. Therefore, bFGF-CGS is an excellent material for regenerative medicine. We report its usefulness with regard to our first case, in which it was used to cover free flap vascular pedicles.
Calciphylaxis is a rare and life-threatening disorder characterized by painful skin ulceration. Intravenous sodium thiosulfate has proven effective for calciphylaxis treatment; however, its use is associated with risk of complications, potentially necessitating hospitalization. Herein, we describe the case of a patient with calciphylaxis who experienced recurrence approximately 5 months after healing with a combination therapy of intralesional/intravenous sodium thiosulfate. We successfully treated the recurrent ulcers in outpatient care with intralesional sodium thiosulfate, which reportedly has few side effects. Although intravenous sodium thiosulfate administration is the first-line treatment for calciphylaxis, intralesional administration seems to be a reasonable alternative for injectable small lesions, even in recurrent cases.
Wound contamination during open-heart surgery is the root of bacterial entry in the majority of cases of post-sternotomy mediastinitis (PSM). However, an alternative origin of infection, hematogenous metastasis from a remote body site, has been reported. We report a case of late-onset PSM with hematogenous metastasis of infection in a hemodialysis patient. A 75-year-old woman with hemodialysis was referred to our hospital with a complaint of high fever and chest swelling. She underwent aortic valve replacement via median sternotomy before 4 months. Emergent re-sternotomy revealed filled purulent discharge mediastinum despite complete sternal bony union. She also had left knee periprosthetic tissue and intrauterine device infections. Methicillin-resistant Staphylococcus aureus was detected in all three infected wounds and blood cultures. The mediastinal infection was well-controlled by negative pressure wound therapy with continuous irrigation; however, she died from multiple organ failure due to severe endocarditis infection. Patients on hemodialysis are prone to developing vascular access-associated bloodstream infections, including periprosthetic infections and infective endocarditis. The concordance of pathogens in the three distant wounds suggested that hematogenous metastasis of infection was the cause of late-onset PSM.