Rectovaginal Fistula Repair with a Vascularized Gracilis Muscle Interposition Flap

The surgical management of rectovaginal fistulas remains difficult, as they tend to be recurrent and vary widely in location and complexity. We present a case of a 63-year-old woman with a low-lying rectovaginal fistula who initially underwent chemoradiation and a Low Anterior Resection for a low-lying rectal cancer. Her course was uneventful until two years post-operatively, at which time her anastomotic staple line became stenotic with associated bleeding. This was initially addressed by Gastroenterology who executed a dilation and achieved hemostasis with Argon Plasma Coagulation. This remedied the stenosis, however, it was complicated by the formation of a rectovaginal fistula. Due to the low-lying location and its presence in an irradiated field, a transvaginal approach with an interposed gracilis flap was elected for repair.

Immediate post natal myelomeningocele defect closure using rhomboid fasciocutaneous flaps

Myelomeningocele is the most common form of neural tube defect, developing after the 4th week of gestation. Although diagnosed prenatally, many patients did not have a chance to be treated before birth. The best approach in these situation is to perform surgical treatment at time zero. A multidisciplinary team must be prepared to perform dural repair and soft tissue coverage. This video illustrates our approach for soft tissue reconstruction using rhomboid fasciocutaneous flaps with maximal preservation of perforator vessels.

Contributors
Dov Charles Goldenberg, MD Phd, Division of Plastic Surgery, Hospital das Clinicas, University of Sao Paulo Medical School
Vania Kharmandayan, MD, Division of Plastic Surgery, Hospital das Clinicas, University of Sao Paulo Medical School
Tatiana Moura, MD, MSc, Division of Plastic Surgery, Hospital das Clinicas, University of Sao Paulo Medical School

Surgical Treatment of Nasal Tip Hemangioma Using Open Rhinoplasty Approach

Hemangiomas are the most common benign tumors of the infancy and its location on the nasal tip poses particularly as a challenge. A recent study published by out group defined an algorithm for surgical approach to hemangiomas.
Nasal tip hemangiomas carry a high risk for growth related deformities and is a usual indication for surgery.
The best approach must warrant a result at least similar or even better to spontaneous involution.
In this video we present a case where an open rhinoplasty approach was designed to remove the tumor, reposition the anatomic structures and reduce visible scars.
Contributors
Dov Charles Goldenberg, MD Phd, Division of Plastic Surgery, Hospital das Clinicas, University of Sao Paulo Medical School
Vania Kharmandayan, MD, Division of Plastic Surgery, Hospital das Clinicas, University of Sao Paulo Medical School

Resection and modified purse-string closure of frontal hemangioma

Infantile hemangiomas occurring in the face may represent a real problem to a child. Clinical significance is ultimately determined by the degree of tissue deformation. Large dimensions; specific locations; and the presence of complications such as ulceration, bleeding, or infection indicate active treatment to minimize morbidity. The combination of clinical features and response to pharmacologic treatment are the main standpoints indicating surgery during the active phases of infantile hemangiomas.
The concept of minimal possible scar is relevant, and the use of purse-string sutures, initially proposed by Mulliken et al., promotes a real reduction in the final scar dimensions. In this video surgical resection of a frontal hemangioma illustrates a modified purse string suture, to reduce the dimensions of a linear scar.
Contributors
Dov Charles Goldenberg, MD Phd, Division of Plastic Surgery, Hospital das Clinicas, University of Sao Paulo Medical School
Vania Kharmandayan, MD, Division of Plastic Surgery, Hospital das Clinicas, University of Sao Paulo Medical School

Split Thickness Skin Graft

Skin grafting involves closure of an open wound using skin from another location which is transferred without its own vascular blood supply, relying on the vascular supply of the wound bed for survival. Skin grafts can be split thickness grafts that may involve meshing the donor skin in order to cover a proportionally larger area than the donor skin may have allowed. Besides the ability to cover a large area, a split thickness skin graft (STSG) allows for egress of fluids thereby maximizing close contact between the wound and the graft, which is necessary for vascularization and survival of the graft. A STSG can be taken at a variety of thicknesses but at any level taken, part of the donor dermis is left intact. Other options for skin grafts include full thickness grafts and biomedical grafts such as Integra. Full thickness skin grafts (FTSG) take the dermis as well as epidermis, usually covering smaller areas. FTSG has reduced contracture and often a better color match compared to STSG, but can have reduced survival due to increased thickness of tissue. The decision of the type of graft used in the procedure is made in accordance with the needs of the recipient site, the likelihood of graft take, and the availability of donor skin.

The patient may either go home after the procedure with small areas of skin grafting with instructions for immobilization and elevation of the grafted area. The patient may be admitted depending on the patient’s general health status and the wound. Shear forces are avoided to the grafted area, and the donor site dressings may require prn changes due to fluid leakage until the skin epithelium regenerates from residual dermal structures.

In the case presented in this video, a 12 year old girl was victim to a degloving injury of the left dorsal foot secondary to a motor vehicle accident. A STSG was determined appropriate for wound coverage as her wound bed had granulated in very well, covering all critical structures and providing a healthy bed for graft take.

Linda Murphy MA
Roop Gill, MD

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