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A 17-year-old girl presented with bilateral lower limb lymphedema since 3 years. Lymphedema in the right leg was Grade III, not pitting and not reducing in size after limb elevation. She hailed from a tribal community. Considering her young age, a single-stage operative procedure for her lymphedematous leg was followed, as she was not prepared for a multistaged operation. However, this operative procedure needed to be a combination of both, debulking and physiological procedures, so as to give her immediate limb girth reduction as well as reduction in recurrence, as seen with debulking procedures. We report a newer technique that could achieve both goals.

OBJECTIVE Free or local flaps that are used to reconstruct the lower limb often result in poor functional outcome because of bulkiness of the flap and scar contracture over ankle joint region. The aim of this study was to evaluate the functional results of ankle joint after 1-stage secondary debulking procedure for lower limb trauma. MATERIAL AND METHODS From January of 2002 to October of 2018, debulking procedures were performed for 66 patients after flap reconstructions of the lower limb. Thirty-eight patients (group 1) of foot injury without ankle joint involvement and 20 patients (group 2) with ankle joint involvement were included. Range of motion (ROM) of ankle joint before and after debulking procedure was measured after 6 months of follow-up. RESULTS After debulking procedure, all the patients were able to dress in their preinjury shoes without any difficulty and with ease of ambulation. For all patients, with or without ankle involvement, the postdebulking ROM versus predebulking ROM improved significantly (P < 0.01). The ROM improvements for patients with ankle involvement were significantly better then patients without ankle involvement (P = 0.032). CONCLUSIONS One-stage debulking procedure can provide long-term constant, reliable, thin skin coverage for the lower limb after flap reconstruction with improved ankle ROM. This allows better functional results, especially for lower limb trauma patients with initial ankle involvement.

Background One-stage reconstruction of complex soft tissue defects of the extremities is a challenging problem. Repair of complex soft tissue defects requires adequate skin tissues to cover the large surface wound and special tissues for obliterating the dead space. The chimeric flap is one of the most popular approaches for reconstruction of complex soft tissue defects. However, the problems of donor-site morbidity and inability to repair very large defects at one-stage remain. The purpose of this study was to present our clinical experience using sequential chimeric perforator flaps for reconstruction of complex extremity defects with primary closure of the donor site. Methods From August 2013 to March 2017, 12 patients with complex soft tissue defects underwent extremity reconstruction using sequential chimeric perforator flaps, which were composed of a chimeric anterolateral thigh perforator (ALTP) flap and an additional free perforator flap. The skin paddles were placed side-by-side to cover the large surface soft tissue defects, and the muscle component was used to obliterate the dead space. Of these patients, one was injured by a crushing accident, while the other 11 patients were injured in traffic accidents. Results The size of the skin paddles ranged from 26 cm × 8 cm-10 cm × 6 cm to 30 cm × 8.5 cm-29 cm × 9 cm. The muscle paddle size ranged from 2 cm × 3 cm × 4 cm to 22 cm × 4 cm × 2 cm. All-components of the sequential chimeric flaps survived in all-patients. Vascular compromise was observed in one case. One case suffered minor wound-edge necrosis and was treated conservatively. Primary closure of donor-site was successfully achieved in all-patients, and all-donor-site wounds healed uneventfully. The mean follow-up time was 15.25 months. Most of the cases showed a satisfactory contour, and only two patients presented with mildly bulky appearance that treated with a debulking procedure. Conclusions The sequential chimeric perforator flap is an alternative procedure for reconstruct complex soft tissue defects of the extremities. This approach allows for flexible design, a larger cutaneous area, and low donor site morbidity.

Background Over the past 2 decades, the surgical treatment of lymphedema has advanced considerably with lymphovenous bypass and vascularized lymph node transfer. Despite these advances, some patients can only be treated with a radical debulking procedure, commonly known as Charles procedure. However, the Charles procedure is not a commonly performed procedure and can have significant risks such as fluid shifts, blood loss and wound infections. In this article, we present our experience with Charles procedure and share pearls to perform this procedure expediently while avoiding potential pitfalls. Methods Patients with severe lymphedema who were treated by the senior author with Charles procedure were evaluated. The medical record was queried for their pertinent medical history, including cause of lymphedema, prior treatments for the condition, medical comorbidities and preoperative and postoperative course. The surgical technique and lessons learned from each case are described. Results Three patients were identified within the study period who underwent treatment with the Charles procedure. All patients had secondary lower extremity lymphedema. All patients had single-stage direct excision and skin grafting. One patient required postoperative ICU stay due to significant fluid shifts and blood loss, another suffered from a wound infection. All 3 patients ultimately recovered to exceed their preoperative activity levels with satisfactory outcomes. Conclusions The Charles procedure continues to have clinical utility in modern lymphedema treatment. Despite potential risks, it can be done successfully with proper planning and careful attention to technical details; it can be life changing for patients suffering from most extreme lymphedema.

Lymphoedema is a chronic condition that has significant functional and psychosocial morbidity. We report a case of severe lower limb lymphoedema successfully treated with a two-stage debulking procedure, highlighting the significant improvements in function and quality of life this operation can have with the appropriate multidisciplinary support.

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.

BACKGROUND: Management of neuroendocrine liver metastasis (NELM) in the setting of unresectable disease is poorly defined and the role of debulking remains controversial. The objective of the current study was to define outcomes following non-curative intent liver-directed therapy (debulking) among patients with NELM. METHODS: 612 patients were identified who underwent liver-directed therapy of NELM from a multi-institutional database. Outcomes were stratified according to curative (R0/R1) versus non-curative ≥ 80% debulking (R2). RESULTS: 179 (29.2%) patients had an R2/debulking procedure. Patients undergoing debulking more commonly had more aggressive high-grade tumors (R0/R1: 12.8% vs. R2: 35.0%; P < 0.001) or liver disease burden that was bilateral (R0/R1: 52.8% vs. R2: 75.6%; P < 0.001). After a median follow-up of 51 months, median (R0/R1: not reached vs. R2: 87 months; P < 0.001) and 5-year survival (R0/R1: 85.2% vs. R2: 60.7%; P < 0.001) was higher among patients who underwent an R0/R1 resection compared with patients who underwent a debulking operation. Among patients with ≥50% NELM liver involvement, median and 5-year survival following debulking was 55.4 months and 40.6%, respectively. CONCLUSION: Debulking operations for NELM provided reasonable long-term survival. Hepatic debulking for patients with NELM is a reasonable therapeutic option for patients with grossly unresectable disease that may provide a survival benefit. info:eu-repo/semantics/publishedVersion

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 Purpose We report the clinical outcome after coverage for soft-tissue defect on the medial foot and ankle with an adipofascial fold-down flap based on the posterior tibial artery perforator branch proximal to the defect. Materials Nine patients (five males and four females) with soft-tissue defects on the medial foot and ankle area underwent the procedure from March 2009 to May 2014. The average age of the patients was 54 years (range, 8–82). The pivot point of transposition of this flap is the posterior tibial artery perforator proximal to the defect. Therefore, the adiposal side of this flap was folded down to resurface the defect. The donor site was closed primarily with the preserved skin flap. The skin graft to the flap was delayed until the flap became mature. The difference between the circumferences of both ankles was measured. Results All flaps survived and adequate soft-tissue coverage was obtained for the medial foot and ankle after the skin graft. Wearing normal footwear was possible for all patients because of thin coverage of the flaps. No secondary debulking procedure was performed for the patients. The difference between the circumferences of both sides of the ankle was not significant. The skin necrosis of the donor site was also managed conservatively and healed well. Conclusion For the medial foot and ankle soft-tissue defect, the fold-down adipofascial flaps based on the posterior tibial artery perforator branch proximal to the defect could be a good option to cover it.

Free or local flaps that are used to reconstruct the foot are often associated with a multitude of problems, most with regard to poor aesthetic and functional outcomes. This is because of the bulkiness of the flap and its difference from the native glabrous skin of the weight-bearing region of the foot. Although these can be improved using various debulking procedures, the results are not satisfactory. From January of 2002 to July of 2014, one-stage debulking procedures were performed for 42 feet after flap reconstructions. Twelve patients (28.6 percent) had bulky flaps over the weight-bearing area of the foot compared with 30 (71.4 percent) on the non–weight-bearing area. The functional and cosmetic outcomes were reviewed after 12-month follow-up. The overall mean follow-up time was 20 months. All the grafted skin took well, except for partial superficial skin necrosis, which healed by secondary intention, and one skin loss that needed further skin grafting. The patients were able to dress in their preinjury shoes without any difficulty and with ease of ambulation because of improvement in skin stability. The skin sensation and texture of the reconstructed feet matched the normal sides well. No long-term ulceration was noted. All of the patients were satisfied with the results. A one-stage debulking procedure can provide long-term constant, reliable, thin skin coverage for the feet after free flap or local flap reconstruction. Therapeutic, IV.

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.

Within the last years, many new endovascular treatment modalities have been invented for treatment of peripheral arterial disease. To leave nothing behind and to keep options for future treatment are key issues of these new revascularization procedures. Drug coated balloon technology (DCB) is one key element in this strategy but there are still limitations for this revascularization technology. Especially calcium rich lesions and long lesions are still challenging in terms of treatment success and long-term patency. Treatment of both calcified and long lesions continues to be a clinical challenge for every interventionalists. Therefore, a treatment combination of debulking procedure using atherectomy plus antirestenotic therapy using DCB seems to be promising to treat complex lesions.

Lipomatosis of nerve (LN) is one part of the spectrum of adipose lesions of nerve. Nerve-territory overgrowth is present in approximately 62% of cases. Given the wide variability in published reports, there is substantial need to understand the results of surgical treatment and outcomes in this disorder.Raw data from the published systematic review of LN were used for this analysis. PubMed and Google Scholar databases were also screened for any additional papers. The cases were sorted into 2 groups: (1) definite LN cases and (2) probable LN cases (lacked definite proof of LN diagnosis). For statistical analysis, P-value0.05 was considered statistically significant.The total number of 486 definite and 160 probable LN cases (646 cases combined) was included for analysis. The most commonly performed procedure was nerve decompression in both definite (n = 104; 21.4%) and combined definite and probable LN groups (n = 107; 16.6%). Improvement of symptoms was most often reported after nerve decompression (n = 52). A soft-tissue debulking procedure had the highest association with improvement (odds ratio 144.6, 95% confidence interval: 13.8-1516.2, P0.001) in the definite LN group.Treatment options for LN ranges widely, although notable consistencies exist. The most conservative procedure involving nerve decompression was the most commonly performed procedure, with reported good outcomes. In contrast, worsening of symptoms was most commonly reported when nerve resection was performed. All treatment modalities were associated with improvement compared with no treatment. Diagnostic biopsy should be avoided.

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.

Die endovaskulare Behandlung zentralvenoser Stenosen bei Shuntpatienten ist durch eine hohe Restenoserate gekennzeichnet. Der Einsatz eines direktionalen Atherektomiesystems zeigte viel versprechende Ergebnisse, die retrospektiv hinsichtlich der primaren Offenheitsrate (definiert als keine oder 50% wurden behandelt. Die Ergebnisse wurden hinsichtlich der primaren Offenheitsrate und „Target Lesion Revascularisation Rate“ mit Publikationen hinsichtlich anderer interventioneller Verfahren verglichen. Der technische Erfolg – definiert als erfolgreiche Drahtpassage und Wiedereroffnung des Gefaslumens ohne Residualstenose – konnte bei allen Patienten ohne Komplikationen erreicht werden. Verletzungen der Vene oder Lungenembolien traten nicht auf. Die Shuntfunktion war postinterventionell in allen Fallen regelgerecht, die teils ausgepragten Armodeme waren innerhalb von 24 Stunden rucklaufig. In einem Nachbeobachtungszeitraum von 12–27 Monaten trat kein Reverschluss auf. Die primare Offenheitsrate der Ziellasion lag nach 12 und 24 Monaten bei 89% bzw. 79%, die TLR bei 11% bzw. 21%. Die direktionale Atherektomie im Sinne eines zentralvenosen Debulking mit Reduktion der neointimalen und fibrotischen Wandanteile erscheint nach den bisherigen Erfahrungen sicher und effektiv. Weitere Daten sollten in Form einer prospektiven kontrollierten Studie erhoben werden, um daruber hinaus eine begleitende Kosten-Nutzen-Analyse durchfuhren zu konnen. The endovascular treatment of central venous stenosis in patients with arteriovenous access for hemodialysis shows high re-stenosis rates. The use of directional arterectomy showed promising results which were retrospectively evaluated in terms of primary patency rate (defined as re-stenosis below 50%) and Target Lesion Revascularisation Rate (TLR). Results from 19 Patients treated for central venous stenosis with directional arterectomy were evaluated. All of them had hemodialysis access dysfunction or arm swelling and a minimum follow-up of 12 months. During follow-up a phlebography was performed when changes of flow patterns, recurrent swelling or access dysfunction, were detected. Target lesion re-stenosis > 50% was treated. The results were compared to published results from other studies. Technical success – defined as wire passage and recanalization without residual stenosis – was achieved in all patients without complications. Vein injuries or pulmonary embolizations were not observed. All patients showed regular access function. Arm edema disappeared within 24 hours. No re-occlusion occurred. Primary patency was 89% and 79% and TLR was 11% and 21%, after 12 and 24 months. Directional arterectomy as an endovenous debulking procedure in the central venous system seems to be safe and effective. Further data have to be collected in a prospective controlled study. A health economy study could be conducted parallel to evaluate the cost effectiveness.

Because of limited flap alternatives, soft tissue reconstruction over the knee is a challenging problem for reconstructive surgeons. When accompanied with surrounding tissue damage in major injuries, local flap alternatives are not available and reconstruction is more difficult. In this report, we present the first case in the literature of a patient who had reconstruction by the reverse fasciocutaneous anterolateral thigh (ALT) flap harvested from a deeply wounded and scarred area for soft tissue defect of knee region. It was shown that the ALT flap can be harvested from deeply wounded and scarred thigh and without any major complication and debulking procedure and that ideal cosmetic and functional results could be achieved.

We report a rare case of a 23-year-old male who presented with a four-week history of unilateral recurrent epistaxis and nasal obstruction. This was subsequently diagnosed as high-grade chondroblastic osteosarcoma of the maxillary antrum. Neo-adjuvant chemotherapy was commenced following a multidisciplinary team discussion. The disease progressed through first-line treatment. A radical surgical resection was not possible, and a palliative debulking procedure was performed. The literature comprehensively points towards an early surgical resection with suitable margins at the earliest possible stage. This case highlights that osteosarcoma of the maxilla can be challenging to diagnose and manage. Thus, a high index of suspicion and an early referral to a head and neck specialist is imperative to improve the long-term prognosis in such patients.

Lipoblastomatosis is a benign tumor of embryonic fat that is more common in male infants. It occurs more frequently in the soft tissues of the extremities. The diagnosis is made by biopsy, which shows globules of lipocytes and lipoblasts mixed with spindled and myxoid cells. MRI demonstrates fat infiltrating fascia and muscle. The infant described had clinical, histologic, and radiologic findings consistent with this diagnosis. Because of concern that total excision would compromise function, a debulking procedure is planned.

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 Large complex soft-tissue defects on the dorsum of the foot, with exposed tendons, joints, bones, nerves and vessels, have to be reconstructed by transplantation of free tissue grafts with good blood flow. PATIENTS AND METHODS Evaluation of 19 patients with an average age of 38 years who underwent closure of defects on the dorsum of the foot with free muscle flaps (with split-thickness skin grafts) in 14 cases and with free fasciocutaneous flaps in 5 is presented. In 10 patients a gracilis muscle flap was used, in 4 patients a latissimus dorsi flap, and in 2 patients a groin flap, while in 1 patient each an anterolateral thigh flap, an anteromedial thigh flap and a lateral arm flap was used. The aesthetic outcome was evaluated with reference to skin texture, pigmentation, thickness of the free flap and scar formation. The Stanmore system was used to determine the postoperative functional results. RESULTS On average, patients were followed up for 29 months. We had no flap loss. A flap debulking procedure was performed in 6 patients. Better aesthetic results were obtained with muscle flaps plus skin graft than with fasciocutaneous flaps. Functional results were excellent in 6 patients, good in 5 and poor in 8 patients. CONCLUSION Free muscle flaps with skin grafts, particularly the free gracilis muscle flap, are superior to fasciocutaneous flaps and perforating flaps in aesthetic outcome and donor site morbidity.

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.

Introduction While cytoreductive surgery and platinum-based chemotherapy remain mainstays of the primary treatment of epithelial ovarian cancer, 60% of patients will be diagnosed with a recurrence. Depite the large number of patients who experience recurrences, the econdary treatment of choice varies widely. Secondary cytoreductive surgery (SCR) in platinum-sensitive disase is a viable option for the treatment of recurrent epithelial ovarian ancer. The theory behind this technique stems from the same ratioale as that behind primary debulking procedures as developed by riffiths in 1975. It was hypothesized that by decreasing the tumor burden, the growth fractions of the tumor should increase. In doing this, tumor cells that are poorly perfused secondary to a large tumor size should be reduced. This leads to increased accessibility of the remaining tumor cells to chemotherapy delivered via the blood stream. Finally, by decreasing tumor burden, the chance that these ells would then undergo spontaneous mutation ending in drug-resisant strains should also decrease. This theory, along with the evidence that will be presented, justifies that a second debulking procedure, in the appropriate candidate, is an attractive option in the treatment of recurrent epithelial ovarian cancer in platinum-sensitive disease.

A 19-year-old male patient with type 1 von Willebrand's disease underwent two separate superficial inferior epigastric artery free flap tissue transfers and three revision procedures for reconstruction of a postextirpative mid-facial defect. Intravenous 1-desamino-8-D-arginine vasopressin (DDAVP) was administered as bleeding prophylaxis prior to incision for free tissue transfer. For each debulking procedure, DDAVP was administered by intranasal sprays in minutes prior to incision and redosed 12 and 24 hours postoperatively. There were no incidents of either thrombosis or bleeding. This outcome indicates that 0.3 μg/kg intravenous DDAVP may be effective as bleeding prophylaxis for patients with mild and quantitative defects in von Willebrand factor undergoing microvascular reconstruction. © 2011 Wiley-Liss, Inc. Microsurgery, 2011.

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.

We present a case of benign mature orbital teratoma in a neonatal boy that involved the chiasmal area and cavernous sinus and displaced the nasopharynx. Visual potential was deemed to be good. Because of the chiasmal involvement, complete surgical resection, which would have compromised his visual function, was considered inadvisable. A debulking procedure, mainly of the cystic parts of the tumor, was performed. The patient remains stable at 3 years of age, with no further growth of the tumor and good vision in the affected eye.

Data guiding the appropriate management of patients with hepatic metastases arising from NE primaries, including pancreatic NE tumors, are limited. Long-term survival seems to be enhanced in those patients undergoing resection when it is done with a curative intent and potentially when per-formed as a debulking procedure. Symptoms, includ-ing those arising from hormone production, and pain are effectively treated with locally aggressive treatments including resection, thermal ablation, and tumor embolization. Given the lack of effective chemotherapy, the limited duration of response with hormonal therapy, the often indolent oncologic nature of these diseases, and the increasingly safe profile of these local options, locally aggressive treat-ments remain an important component of care.

Summary: A 26-year-old woman sustained a traffic accident injury to her left medial malleolus. A soft-tissue defect 15 × 7 cm with exposure of bone was found and underwent free anterolateral thigh flap to cover it. On the second postoperative day, venous congestion occurred and re-exploration was performed. Re-anastomosis of the vein was done after the thrombectomy; unfortunately, the flap did not recover. We found there was a good granulation bed under the failing flap and thinned the failing flap and used it as a full-thickness skin graft. The graft survived completely; 9 months later, the graft site was softer and of good texture. The patient can wear the same size shoes without a debulking procedure. The free flap provided nutrients to the raw surface and nurtured a good granulation bed while it survived for 50 hours; as a result, it was used as “the nutrient flap.” Reuse of the failing free flap as “the nutrient flap” is useful as an alternative backup procedure.

Background While reconstruction of soft tissue defects is the common purpose, surgical reconstructions of upper extremities and lower extremities have different goals in terms of functional and aesthetic outcomes. The purpose of the current study was to compare and analyze differences between reconstructions of upper extremities and lower extremities using an anterolateral thigh (ALT) flap. Methods We analyzed 74 patients who underwent reconstructions of upper extremities and lower extremities using an ALT flap from October 2006 to August 2012 (upper extremities, 45 cases; lower extremities, 29 cases). The study focused on the statistical analysis of patient satisfaction according to the donor site of the ALT flap and the timing of a debulking procedure. Results On the choice of donor site, in the upper extremity reconstruction, flap elevation from the opposite side of the recipient limb was preferred (p = 0.019) because it causes less inconvenience while walking. In the lower extremity reconstruction, flap elevation from the same side of the recipient limb (p = 0.002) was preferred. The debulking procedure performed on the upper extremities at 4 weeks after reconstruction led to better functional results and enhanced patient satisfaction (p = 0.022). In the case of lower extremities, enhanced satisfaction was noted in patients who underwent the procedure at 6 months after reconstruction (p < 0.001). Conclusions Elevation of the flap in reconstruction reduced inconvenience when performed on the same side of the recipient limb for lower extremities and on the opposite side for upper extremities. In addition, debulking resulted in better satisfaction when performed 4 weeks postoperatively in the upper extremities and 6 months postoperatively in the lower extremities.

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 .

A 45-year-old black patient presented with right-heart failure. Echocardiography showed a large tumor mass in the right atrium and a debulking procedure was performed. Histological and immunohistochemical studies revealed a high grade angiosarcoma infiltrating the myocardium and extending to the pericardial surface. Metastatic work-up showed no evidence of dissemination. The patient made an uneventful postsurgical recovery and was treated with chemotherapy, consisting of epidoxorubicin and dacarbazin. Following chemotherapy, echocardiographic re-evaluation failed to show any residual tumor in the right atrium. At present, one year following diagnosis, the patient is alive with no evidence of disease. Therapeutic options of primary cardiac angiosarcoma are reviewed. © 1994 Wiley-Liss, Inc.

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.

Second-look surgery for recurrent colorectal carcinoma has been advocated for over four decades. Routine follow-up procedures gave way to clinically directed or carcinoembryonic (CEA)-directed procedures in the mid-1970's. In this paper, we review the results of second-look surgery for recurrent colorectal carcinoma and ask the question, "Is it worthwhile?" Excluding surgery for symptomatic patients, we conclude that second-look surgery should only be performed for recurrent colorectal carcinoma with the intent of rendering the patient disease-free. Without effective systemic therapy, "palliative" or "debulking" procedures probably do not increase survival. The most likely candidates for such a curative approach with second-look surgery are those with isolated liver, pulmonary, and, less frequently, regional recurrences.

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.

UNLABELLED A large, recent study has shown significantly improved survival in women with epithelial ovarian cancer treated with intraperitoneal chemotherapy. This review is intended for all clinicians caring for women with ovarian cancer, including family physicians, general gynecologists, and oncologists. The subset of patients most likely to derive a survival benefit from intraperitoneal chemotherapy should be distinguished. Because effective surgical debulking is critical to long-term survival for ovarian cancer, it is important that women known or suspected to have ovarian cancer should be referred to centers with the surgical expertise and resources necessary for aggressive tumor debulking and safe delivery of intraperitoneal chemotherapy. TARGET AUDIENCE Obstetricians & Gynecologists, Family Physicians. LEARNING OBJECTIVES After completion of this article, the reader should be able to state that there is a subset of women with widespread intraabdominal ovarian cancer who will have improved survival after a debulking procedure and intraperitoneal (IP) chemotherapy and explain that there needs to be the expertise and resources necessary to follow these patients.

Objectives: The goal of this study is to determine if the use of Cidofovir injected locally reduces the number of debulking procedures on pediatric patients with recurrente respiratory papillomatosis. Methods: We injected 37.5 mg of Cidofovir intralesionaly in each patient with a laryngeal gauze 27, each 3 weeks for a total of 5 times on each patients.In each patients Hematic count, Hepatic enzymes, and BUN in each patient was done 1 week after and 1 week before each injection. Results: We included 7 patients in a 18-month period, 6 of the 7 patients have not needed a debulking procedure in the last 10 months, the obstruction and voice improved, 1 of the patients needed 3 more injections, and has not needed another debulking procedure in the last 3 months; none of the patients had any laboratory alteration. Conclusion: Cidofovir is a drug effective in the treatment of recurrent respiratory papillomatosis, probably reducing the papilomatosis activity in the laringeal tissue.

We present a debulking procedure for the removal of a stage IVA thymoma in a patient with myasthenia gravis (MG). This included thymectomy to remove the primary thymoma, resection of an anterior paracardial mass, a posterior pleural mass, partial pleurectomy, resection of phrenic nerve and wedge excisions of the right upper, middle and lower lobes.

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.

We find that, when metastases are present, a nephrectomy for renal cell carcinoma is not justified in the vast majority of cases. The only noncontroversial indication is for palliative nephrectomy which is performed to relieve intractable symptoms in the properly chosen patient. However, it is unusual to see a patient with tumor-related symptoms that cannot be conservatively managed. A relative indication for nephrectomy is found in the patient with osseous metastases only, as some studies have demonstrated a prolongation of survival by adjunctive nephrectomy in this setting. Another relative indication is in the patient with limited metastases that are amenable to surgical or radiation ablation coupled with nephrectomy; patients in whom the metastasis appears years after the nephrectomy have the best chance for a successful outcome. When therapy that is effective against metastatic tumor is eventually found, adjunctive nephrectomy as a debulking procedure may become indicated; until then, surgery is not justified. On the basis of data presently available, adjunctive nephrectomy in the hope of inducing spontaneous regression of metastases is never indicated.

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 role of surgery for children with neuroblastoma was evaluated by using a recently proposed TNM staging system. One-hundred thirty patients were retrospectively assigned a TNM clinical stage (CS) preoperatively and a pathologic stage (PS) postoperatively. Patients with CS 4 were separated into CS 4A and CS 4B according to their age and pattern of metastases. Patient survival was analyzed according to CS, age, location of primary, and PS. Actuarial survival of patients was as follows: CS 1, 100%; CS 2, 82%; CS 3, 63%; CS 4A, 50%; and CS 4B, 5%. For all stages, patients younger than 1 year old survived longer than those older than 1 year (72% v 32%). Prognosis for CS 1 was the same regardless of age. For CS 2 and CS 3, patients younger than 1 year old lived longer. CS 4A had better survival than CS 4B. Survival by site was 100% for cervical, 62% for mediastinal, 45% for pelvic, and 36% for retroperitoneal primaries. The role of surgery was evaluated by analyzing survival according to the postoperative PS. PS 1-2-3 A were regarded as satisfactory resections since all macroscopic tumor was removed, PS 3B as a debulking procedure, and PS 3C as an unresectable lesion which was biopsied. Patients with nonmetastatic disease (CS 1–3) with PS 1 and PS 2 disease had a 100% survival rate; PS 3A, 93%; PS 3B, 58%; and PS 3C, 21%. This proves the value of total resection in nonmetastatic disease. The role of surgery could also be proven in metastatic disease. For CS 4A, the survival rate was 100% for PS 1-2-3 A, 50% for PS 3B, and 25% for PS 3C. For CS 4B, PS 1-2-3 A had 11% survivalr ate and PS 3B, 10%. No PS 3C patient survived. In this group, if metastatic disease is controlled prior to operation, total resection improves prognosis.

Although giant congenital melanocytic nevi (CMN) may undergo malignant transformation, their complete surgical removal is commonly difficult to achieve and may require sacrifice of normal skin. We treated a patient with CMN by a combination of full-thickness excision and primary closure of the central atypical portion and split-thickness excision of the remainder. Histometric analysis of the tissues obtained at surgery indicated that the split-thickness procedure removed approximately 70% of the cellular nevus content from that area. Total debulking by the combined procedure was calculated to be approximately 80%. If the risk of malignant degeneration is proportional to the number of melanocytes present, the debulking procedure described may provide a useful alternative for the management of some giant CMN. The cosmetic result is satisfactory and the significant lightening in color and removal of nodular irregularities may facilitrate prospective follow-up of the residual lesion.

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.

In Reply .—We certainly appreciate Dr Levitt's concern about the three patients we reported. These three patients, however, had stage IV (advanced metastatic) disease and they were thus appropriately treated with combination chemotherapy. Furthermore, all three patients achieved complete remission, which continued for greater than 30,19, and 16 months, respectively. This remission duration is greater than the median duration of survival for patients with advanced metastatic disease and is therefore remarkable in itself for three sequential patients. The more significant feature was that the combination chemotherapy shrank the primary masses, allowed for simple localized surgery to produce hygienic results, and perhaps more interestingly, this debulking procedure in two patients after they had achieved a stable partial response allowed the remaining measurable metastatic disease to respond even further and the patients achieved complete remission. It would be logical to hypothesize that a similar event may occur with micrometastases, and thus our

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%.