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Skin and soft tissue defect of the ankle usually mandates flap reconstruction; however, bulky flap and difficulty ambulance have been the major disadvantages after flap reconstruction of this area. We used the concept of full-thickness skin graft as a 1-stage method of secondary debulking procedure to achieve both aesthetic and functional results. METHODS Since January of 2004 to June of 2016, 22 one-stage secondary debulking procedures were performed on 22 patients who had received reconstruction with flaps for ankle defects. Nineteen cases were free myocutaneous flaps, 2 cases were free fasciocutaneous flaps, and 1 case was a distally based sural artery flap. In the operative technique, the full-thickness skin was harvested from the flap and regrafted on the defatted fascia with tie-over dressing. The functional and cosmetic outcomes as well as complications were reviewed. RESULTS The overall mean follow-up time was 12 months. After the debulking procedure, all of the grafted skins took well. The patients were able to wear their own shoes without difficulty and regained ease of ambulation. The reconstructed area was found to decrease to an average of 28.92% as compared with predebulking area. The reconstructed ankles achieve good symmetry with regard to the contralateral side (P < 0.05). All of the patients were satisfied with the results of the reconstructed ankles. CONCLUSIONS The 1-stage secondary debulking procedure is a safe and reproducible technique that achieves good functional and aesthetic outcomes after flap reconstruction of the ankle.

Summary Background Modern microsurgical reconstruction aims to achieve functional and satisfactory esthetic outcome and the primary thinning procedure results in one-stage reconstruction. However, current techniques are lacking of preoperative knowledge of the peripheral perforator in the adipose layer. We hypothesized that combination of the knowledge of microvasculature and visualization of such small vessels in the adipose layer by Color Doppler ultrasonography (CDU) will make the dissection of these vessels with simultaneous flap thinning of the perforator branch flap technique feasible and provide consistent results in variety of flaps. Methods Retrospective chart review of consecutive cases in which perforator branch flap technique was used from 2011 to 2019 was conducted. Entire course of the branch of the perforator in the adipose layer were traced up to the dermis by CDU, and marked on the skin surface. Based on CDU finding, perforator branches were dissected in the adipose layer simultaneously with the primary thinning of the skin flap. Results Thirty perforator branch flaps in 28 cases were elevated. The courses of the perforator branches detected by CDU were accurately corresponded to the surgical findings in all cases. There was no total flap loss in any of the cases and partial necrosis in one case. In five flaps a secondary debulking procedure was needed. Conclusions Combination of the knowledge of microvascularature with CDU guidance has made the perforator branch technique possible and allowed to safely transfer the skin flap from various body areas to the defect, thereby, achieving ”like with like” reconstruction in one-stage.

Summary Aim The aim of this study is to evaluate the use of one-stage debulking procedure to separate the fingers after flap reconstruction for degloving injury of the hand. Patients and methods From January 2009 to June 2014, 15 patients with degloving injuries of the hand were treated at the Kaohsiung Chang Gung Memorial Hospital. Among the 15 patients, 11 sustained degloving injury of the fingers; free flap reconstruction was performed in three patients, and a pedicle flap was used in eight. Four patients sustained complete degloving injuries of the hand; reconstruction was performed with an anterolateral thigh pocketing procedure. One-stage debulking procedure was performed for debulking of the flap and interdigitation from the flap envelope. Results After the 12-month follow-up and rehabilitation, the fingers could move independently and perform in opposition with the thumb. Protective sensation was also regained. The patients with degloving injury of the fingers could return to daily activity and work after 1-year follow-up, while those with complete degloving injury of the hand could return to daily activities and work after 18-month follow-up. Conclusion The use of ALT pocketing procedure is simple for salvage of complete degloving injury of the hand. One-stage debulking procedure provides thin and durable skin coverage for hand after reconstruction. The fingers can also be separated from the envelope of a bulky flap for independent movement to fulfill functional and aesthetic requirements.

Objective In this report, we present our experience on the use of bilateral lateral hallux osteo-onychocutaneous free flaps for reconstruction of distal finger and the aesthetic and functional results of this technique in a series of cases. Patients and methods From February 2005 to May 2015, 7 patients underwent finger reconstruction distal to the distal interphalangeal joint using the bilateral lateral hallux osteo-onychocutaneous free flaps. The mean age was 29.3 years (range, 24-33 years). The lateral hallux osteo-onychocutaneous flaps were harvested from bilateral donor sites. The size of each flap was designed based on the size of half distal finger defect. The lateral hallux osteo-onychocutaneous free flaps from both donor sites were combined to reconstruct the distal finger. More than 50% of hallux nail was preserved in each of donor sites, which was covered with a local flap. Results All flaps used for reconstruction survived without complications after surgery. The average length of follow-up was 93.4 months (range, 16-163 months). All reconstructed distal fingers showed good aesthetic appearance, except one that underwent a secondary debulking procedure. The average total active motion of the finger was 215.7 degrees (range, 200-230 degrees). Neither pain nor numbness sensation in the reconstructed fingers was complained by the patients. The donor site morbidity was minimal. All patients had pain-free and good function outcome in both feet. Conclusions The use of the bilateral lateral hallux osteo-onychocutaneous free flaps may provide an option for distal finger reconstruction with satisfactory function and anesthetic outcomes with minimal hallux donor site morbidity.

Intrascar excision with debulking procedure is a good choice for scar revision in unique 3-dimensional facial aesthetic units, especially in the auricular area. It can remove or reduce scars in a shorter course without distortion of the surrounding anatomic structures and visible operative scars. This retrospective study was done to present intrascar excision procedures in persistent auricular hypertrophic scars or keloids.Between 1997 and 2010, 18 ears in 13 patient cases with persistent hypertrophic scars and/or keloids in their external ear due to burns or trauma were collected for evaluation. There were 10 males and 3 females. The age distributions ranged from 5 to 49 years with an average of 20.1 years. All received intrascar excision with debulking procedure for their ear deformity. One case combined with YV-plasty procedure to obtain better aesthetic result. The follow-up period ranged from 0.3 to 14 years with an average of 3.6 years.There was no recurrence in a series of average 3.6 years follow-up. Of the 13 patients, 11 (84.6%) objectively presented good and satisfactory surgical outcomes and the other 2 patients were acceptable.The intrascar excision in auricular persistent scars or keloids has the following advantages: it (1) achieves primary closure, (2) does not distort the anatomic landmarks, (3) does not sacrifice the important structures, (4) has a debulking effect, (5) can be done anytime, even if scars are not mature, (6) has good cosmetic results, (7) may combine with Z- or VY-plasty for functional improvement, and (8) has minimal complications.

BACKGROUND A bulky flap on the hand can hamper its range of motion and result to unacceptable cosmoses and poor functions. Conventional debulking procedures cannot provide a one-stage adequate debulking of the hand after free-flap reconstruction. METHODS From January 2004 to December 2005, 12 debulking procedures were performed on 12 hands of 12 patients who had received reconstruction with free anterolateral thigh fasciocutaneous flaps for skin defect of the hands. The epidermis and most of the dermis were harvested from the flap, regrafted on the defatted wound and fixed with tie-over dressing for 7 days. The two-point discrimination and hair growth were assessed after 6 months during follow-up of each case. RESULTS The mean follow-up time was 6 months. The areas of flap size ranged from 5 x 3 cm to 15 x 5 cm. All the grafted skin took well except in 2 cases, which had small areas of superficial skin loss. The mean time frame of debulking procedure after primary reconstruction was 2.6 +/- 1.4 months (range, 0.6-5 months). The average thickness of removed fat was 8.3 +/- 2.6 mm (n = 12). The two-point discrimination test result of injured hands before and after debulking procedures were unmeasured and 13.1 +/- 1.4 mm (n = 12), respectively. The hair growth in the debulked areas was less than the original donor sites. The difference in hair growth of flaps before and after debulking procedures was statistically significant (p < 0.005). CONCLUSION This method can provide strict thin skin coverage for the hand after free flap reconstruction to achieve good functional and esthetic requirements.

Introduction The tripaddle posterior interosseous artery (PIA) flap can be used for multifinger defect resurfacing, but interpatient variations in perforator distribution remain an ongoing challenge when using this approach. This study aims to evaluate the efficacy of 3 different tripaddle PIA perforator flap designs according to the PIA perforator distribution for the repair of 3-finger defects. Methods In accordance with the size of the 3-finger defects and the position of the perforators, a tripaddle flap was designed on the multiple perforators of the descending branch of the PIA in the distal two thirds of the forearm. Patients received 1 of 3 distinct tripaddle PIA perforator flap designs based on perforator distributions of the PIA. Results Three cases of 3-finger defects were repaired with type A trefoil-shaped tripaddle flaps, whereas 4 cases were repaired with type B modified trefoil-shaped tripaddle flaps, and the other 3 cases were repaired with type C chain-shaped tripaddle flaps. All flaps survived except 2 paddles with tip necrosis. After 9.1 months of mean follow-up, 9 of the 10 cases demonstrated satisfactory cosmetic appearance, whereas the last case required a debulking procedure in the second stage. Conclusions The free tripaddle PIA perforator flap is an effective option for repairing 3-finger skin defects. Various flap designs based on the PIA perforator distribution allow for more individualized treatment approaches.

Background Bulky appearance is one of the major patient complaints after lower leg reconstruction with free flap transfer. This unsatisfactory outcome results from protuberance of the reconstructed section and an unequal limb diameter when compared with the normal side. Serial debulking procedures, such as staged excision, can result in some improvement, but these methods are time consuming and do not provide a one-stage procedure for flap thinning, especially for the pretibial area, ankle, and foot. The authors used a full-thickness skin graft as a one-stage debulking procedure to achieve good aesthetic and functional results. Methods From January of 2002 to June of 2004, 24 secondary debulking procedures were performed on 24 patients who had undergone reconstruction with free anterolateral thigh flaps. There were 12 perforator flaps and 12 myocutaneous flaps. Six flaps were on the pretibial area, eight were on the ankle, and 10 were on the foot. The full-thickness skin was taken away from the flap and regrafted onto the defatted wound. Results All of the skin grafts took well, except in three cases where there was superficial necrosis on the ankle. The circumference of the reconstructed limbs decreased to an average of 3.6 +/- 0.7 cm (mean +/- SD, n = 24), with no difference as compared with the normal side. Conclusions This method can provide a one-stage debulking procedure for the pretibial area, ankle, and foot after free flap reconstruction, and achieves good aesthetic and functional outcomes.

Primary malignant melanoma arising inform the ovary is rare, with only 30 cases described in the literature to date. The case reported here occurred in a 19-year-old woman and was rapidly progressive, resulting in death only 37 days following initial presentation. Management of this case is discussed in the context of the other reported cases. Surgery, ranging from an ovarian cystectomy to a radical debulking procedure, has been the main treatment with adjuvant chemotherapy utilized in only 4 of the previous cases. Key problems in management relate to the ability to make the diagnosis at the time of surgery and the overall poor response rates of melanoma to adjuvant chemotherapy.

Objectives Epithelial ovarian cancer (EOC) is an aggressive disease in which first line therapy consists of a surgical staging/debulking procedure and platinum based chemotherapy. There is significant interest in clinically applicable, easy to use prognostic tools to estimate risk of recurrence and overall survival. In this study we used a large prospectively collected cohort of women with EOC to validate currently published models and assess prognostic variables. Methods Women with invasive ovarian, peritoneal, or fallopian tube cancer diagnosed between 2000-2011 and prospectively enrolled into the Mayo Clinic Ovarian Cancer registry were identified. Demographics and known prognostic markers as well as epidemiologic exposure variables were abstracted from the medical record and collected via questionnaire. Six previously published models of overall and recurrence-free survival were assessed for external validity. In addition, predictors of outcome were assessed in our dataset. Results Previously published models validated with a range of c-statistics (0.587-0.827), though application of models containing variables not part of routine practice were somewhat limited by missing data; utilization of all applicable models and comparison of results is suggested. Examination of prognostic variables identified only the presence of ascites and ASA score to be independent predictors of prognosis in our dataset, albeit with marginal gain in prognostic information, after accounting for stage and debulking. Conclusions Existing prognostic models for newly diagnosed EOC showed acceptable calibration in our cohort for clinical application. However, modeling of prospective variables in our dataset reiterates that stage and debulking remain the most important predictors of prognosis in this setting.

A short columella can result in significant cosmetic and functional deformities. Various techniques such as local flap transfer and composite grafts have been reported for columellar lengthening, but the overall results remain unsatisfactory. Transferring a local flap cannot provide new tissue for the columella, which limits its application. Composite grafting can provide new tissue volume, and the composite tissue from the preauricular region has an excellent color and texture match. However, the lack of a stable blood supply for the composite graft restricts its clinical application due to problems such as viability, dimensions, and atrophy. To overcome these limitations, the authors harvested a vascularized preauricular flap for columella lengthening. Based on the superficial temporal vessels, the vascularized preauricular flap was harvested as a free flap and transferred to the columella region. The recipient vessels were angular vessels or facial vessels, and microsurgical anastomosis was performed between recipient vessels and the pedicle. The lateral femoral circumflex vessels were used as vascular grafts when the pedicle was not long enough. Eight patients who had short columellas were reconstructed with vascularized preauricular flaps. Six flaps were harvested in a reverse fashion, and the remaining two flaps were harvested in an anterograde direction. All the flaps survived well and showed a good color and texture match without hypertrophic scars. An average of 13.3 mm improvement in length was obtained for the eight patients. Two patients underwent a secondary debulking procedure to thin the flap. The free vascularized preauricular flap procedure is a reliable method for columellar lengthening and has wide clinical application. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

WOS: 000289788800001, PubMed ID: 21328193, Reconstruction of foot soft tissue is challenging particularly in the presence of a large defect involving both dorsal and plantar surfaces. In large defects, use of a latissimus dorsi muscle (LDM) flap is the preferred coverage method, yet LDM flaps are bulky. Despite undergoing multiple debulking procedures, patients whose feet are repaired with LDM flaps must wear oversized custom-made shoes. We developed an approach to allow patients to wear regular shoes. In six patients, we used a debulking procedure that was based on tangential trimming of the flap to the level of thickness required for normal foot contour. All patients underwent debulking 3 months after initial LDM flap coverage. The mean duration of follow-up care was 21 months (range, 8 to 32 months). All flaps survived a secondary debulking procedure. One patient developed an ulcer at the weight-bearing area of a sole. All six patients were able to wear regular shoes without difficulty.

Summary Upper-eyelid trichiasis often occurs with a single puffy eyelid or shallow eyelid crease in young Asian patients. This study presents a novel modified trichiasis correction method to simultaneously treat trichiasis and create a natural eyelid crease. It combines the modified small-incision debulking procedure and the orbicularis–levator fixation technique. The eyelash lift angle (LA), body curl angle (BCA) and end curl angle (ECA) were quantitatively analysed. A total of 90 patients (152 trichiasis eyelids) were followed up for approximately 22 months. The LA changed from 24.32° ± 9.21°–54.12° ± 10.32° in the nasal section of the eyelid (section 1), from 21.03° ± 11.34°–52.03° ± 10.56° in the middle section of the eyelid (section 2) and from 23.31° ± 8.12°–63.15° ± 8.43° in the temporal section of the eyelid (section 3). All patients were satisfied with the eyelid-fold appearance. In conclusion, for young Asian patients with upper-eyelid trichiasis, the small-incision orbicularis-levator fixation technique is able to acquire a stable up-curved position of the eyelashes and satisfactory aesthetic results.

Despite recent advances in free tissue transfer, management of a large upper tibial wound extending to the knee can be challenging for reconstructive surgeons. In this report, we present two cases where a free latissimus dorsi flap was used for successful soft-tissue coverage of the wound for limb salvage with optimal reconstructive outcomes. Our unique recipient vessel selection allows more effective free-tissue transfer without using a vein graft. Our preferred flap inset technique with multiple interrupted horizontal mattress sutures over a closed suction drain leads to an improvement of the initial contour of soft-tissue coverage that may contribute to the final optimized outcome in the lower-extremity reconstruction with or without a further debulking procedure.

Although denervated muscle and myocutaneous free flaps atrophy over a period of time, when used for surface coverage they may remain bulky, resulting in a less than optimal aesthetic result. With the availability of a number of donor sites, soft tissue defects can often be reconstructed with like tissue in a single stage. Even though the goal of all plastic surgeons is to achieve a good cosmetic result, special circumstances might dictate that need take precedence over form. We have had six cases where a bulky muscle was used to achieve well vascularised coverage. After wound closure had been successfully accomplished, a secondary debulking procedure was performed safely for a final acceptable aesthetic result.

Summary Second operations were performed as part of planned management in 53 patients 5–7 months after starting apparently successful chemotherapy. The survival of these patients is compared with 56 other patients who did not have a second laparotomy but appeared t o be responding to chemotherapy equally well. Survival advantage was seen for those who had a partial remission followed by a further debulking procedure later. However, those patients who have a clinical complete remission do not seem to benefit from a second surgical intervention.

The CO2 laser is being used in several otolaryngology departments around the world. Clinical experience has shown that it is a unique surgical tool in the management of benign and in some malignant lesions of the larynx. Until now, little has been written about its indications in patients with carcinomas of the larynx. The purpose of this paper is to present our experience with 58 patients with various premalignant and malignant lesions of the larynx in which the CO2 laser was employed as a curative or palliative debulking procedure.

From the end of 1979 to September, 1985, radical pelvic lymphadenectomy was performed at the Graz Clinic in 123 cases of Stages IA to IV ovarian cancer following maximum debulking procedure. In 97 patients lymphadenectomy was done primarily. In 26 it was performed during a follow-up operation to chemotherapy. The frequency of pelvic node involvement was 61.8% in the total material and 78.0% in 82 cases of Stage III disease only; 75.0% positive nodes were found in Stage III after chemotherapy. Aortic nodes were positive in 41.4%, but only when pelvic nodes were also positive. The 5-year actuarial survival rate for Stage III disease was 53.0% after pelvic lymphadenectomy compared with 13.0% without. In cases with negative nodes the survival rate was 74.7%; with positive nodes the survival rate was 45.9%.