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The authors present a case report of a patient with anophthalmia in whom retroauriculo-temporal flap (Washio flap) was used for reconstruction of eyelids. This flap, which is mostly used for reconstructions of nasal defects, was not used in this way according to available literature.

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OBJECTIVE: The oronasal cavity in humans develops during embryonic day 30-60. There are three critical periods when this process can be affected, resulting in a specific type of orofacial cleft: cleft lip (CL), cleft palate (CP), or most serious, total cleft lip+palate (CLP). We assessed whether gestational bleeding during early pregnancy might act to produce a non-specific worsening of embryo status resulting in extension of the basic cleft type (CL or CP) into more serious CLP. STUDY DESIGN: In a group of the child patients with orofacial clefts, the cleft spectrum was correlated with first trimester gestational bleeding reported by the mother. Data were also related to the gender of patients, hereditary factors and additional malformations. RESULTS: Among 2524 mothers who gave birth to babies with an orofacial cleft in the Czech Republic during 1983-2009, 253 (10.0%) had gestational bleeding. Among the children with an orofacial cleft, 497 (19.7%) had an orofacial cleft among relatives and 297 (11.8%) exhibited an additional congenital malformation. In comparison with mothers without bleeding, there was significant increase of children with CLP (p < 0.01) at the expense of children with CP, whose number significantly decreased (p < 0.01) in the bleeding mothers. In the group of children with clefts among relatives we did not find any significant change associated with bleeding. The maternal bleeding was more frequent in children with additional malformations, but this difference was not significant (p = 0.112). CONCLUSION: We hypothesize that size/extent and therefore seriousness of orofacial cleft might increase as a consequence of hypoxia resulting from gestational bleeding.

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BACKGROUND: The reconstruction of the nose is one of the most complicated aesthetic-reconstructive procedures. The difficulty of the procedure lies is in the necessity for reconstruction not only to capture the very complicated, various shapes of the nose but also to preserve the function of the nose: to allow the patient to breathe through the nose. MATERIALS AND METHODS: 12-year-old girl had loss injury of the part of left wing of the nostril. We used the compound nasolabial flap with a small excess to resolve the mucosal and skin defect. One year after the first operation relief of natural transition of the new wing of the nostril and cheek was created with small island flap. RESULTS AND CONCLUSIONS: The reconstruction of a wing of the nostril in multistage procedures with combined nasolabial flap and island flap allowed us to perform precise modelation of the nostril wing with the natural transition to the cheek. An island flap with its scars creates the required contour of a nostril wing and prevents the collapse and flattening of the nostril wing externally.

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The authors present an interesting case of a suckling baby treated for forearm tumour. All the preoperative examinations including the imaging methods are documented, as are the surgical procedures and the final results. The case report is interesting not only because such surgery is infrequent but also due to the unpredictable progress of the final diagnosis statement. Before surgery the tumour was diagnosed as an organising haematoma; based on clinical and radiological signs the diagnosis subsequently rose to rapidly growing haemangioma or vascular malformation causing arm paresis and vascular supply disorder. The diagnosis was changed to angiolipoma during surgery. The final histopathological statement was: infantile fibrosarcoma. Despite the virtue of imaging methods and meticulous clinical examination, the surgical and histopathological findings are not necessarily absolutely identical. Having presented this particular case the authors would like to share their experience.

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OBJECTIVE: The goal of this work is to compare therapeutic results of two groups of patients with an infected fracture or chronic osteomyelitis of the lower leg and ankle joint treated by the method of radical debridement followed by free flap transfer or muscle transposition. PATIENTS: In the period between 1 January 2002 and 30 September 2007 the authors used this method in the treatment of 52 patients (10 females and 42 males) with the average age of 44 years (ages ranged from 10 to 67). The observed group of patients was divided into retrospective and prospective subgroups. METHODS: The difference between the retrospective and prospective parts of the study was how radical the debridement and necrectomy of the soft tissues was. A comparison of therapeutic results in both subgroups was made by evaluation of the amounts of postoperative complications, number of follow-up surgeries and the actual weight-bearing ability of the treated extremity. RESULTS: The difference in the number of postsurgical complications (7 versus 2) was not significant (p=0.123), and neither was the difference in the number of follow-up surgeries (20 versus 17, p=0.706). The difference in the number of patients with fully weightbearing extremities (21 versus 22) was also not significant (p=0.670). CONCLUSION: The authors feel that analysis of complications showed somewhat better results in the prospective part of the study, despite the lack of statistical proof. Therefore the authors regard the method of extensive debridement with the following coverage of the soft tissue defect by muscle flap as suitable for the treatment of infected fractures in the area of the lower leg and ankle joint and the treatment of osteomyelitis of the tibia.

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BACKGROUND: Facelift is currently one of the most requested procedures among consumers of aesthetic plastic surgery. Like any operation, it is accompanied by a variety of potential complications, with postoperative bleeding probably the most frequent. Hematomas can cause hyperpigmentation,contour changes due to subcutaneous scarring, prolongation of healing, and necrosis of the skin flap. The most common treatment is manual expression of the blood coagula. Needle aspiration sometimes cannot be used because of the viscosity of the coagula. METHODS: Seven patients underwent a new method of hematoma removal from wounds. One to two sutures were removed above the hairline under local anesthesia and a short liposuction cannula, 2.5 mm in diameter and 10­15 cm in length with one or two openings, was used for coagulum suction. RESULTS: All treated patients had the hematoma suction procedure without complications and with satisfactory outcomes and no subsequent bleeding. CONCLUSION: Coagulum suction is a simple and fast method that can shorten the recovery following a facelift.This method cannot replace surgical revision in cases in which there is substantial and/or persistent bleeding.However, it can reduce hematomas that are large enough to delay healing and interfere with convalescence, yet too small to warrant surgical revision.

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The author presents experience with the treatment of chronic bronchopleural fistula in a patient who suffered a gunshot injury to his right chest. During the primary assessment the patient underwent resection of two lobes of the right lung, and the patient healed without complications. Four years later the patient presented with bronchopleural fistula with empyema. We had to proceed with right sided pneumonectomy and close up the fistula. The fistula recurred, and the patient underwent repeated operations by chest surgeons without success. Finally, the situation was solved by a contralateral latissimus dorsi muscle free flap. The free-flap was wrapped around the bronchial stump, and the muscle also filled the chest cavity. We discuss the post-surgical course and present the final result.

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Malignant vulvar tumors must be treated by radical removal of the tumor as well as a sufficient amount of surrounding healthy tissue. The resulting defects can be resolved by skin transplants, local transfers, skin flaps, muscle flaps or free tissue transfers. We describe the case history of a patient who underwent radical vulvectomy for a malignant tumor with immediate reconstruction by local flaps from the area of inner thighs and mons pubis. The advantages and disadvantages of this method are compared to other reconstructive surgery methods.

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Gradual particularization of medicine, as witnessed during the second half of the 20th century, resulted in a detailed development of individual subspecializations. Association of therapeutic options resulting from enormous development of these subspecialization brought a new dimension to the treatment of formerly unmanageable conditions. The closest cooperation between a plastic surgeon and a traumatologist is required in the management of patients with serious extremitiy injuries. The conditions include, in particular, amputations of extremities without skeletal and soft tissue devastation, where replantation may be considered, and extensive soft tissue and skeletal injuries, requiring replacement of the missing soft tissue cover following the treatment of the skeletal parts. A new aspect of the cooperation includes common care for infected long bone fractures and osteomyelitides, where primary and extensive skeletal and soft tissue debridement is followed by covering the defect with a muscular or a musculocutaneous flap, facilitating reperfusion and infection management.

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The authors present a case study of a patient with ischemic subtotal hand amputation in the palm. They describe an option to primarily reconstruct the arcus palmaris superficialis and common digital arteries by using a venous graft from the vena saphena magna with its several branches.

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PURPOSE OF THE STUDY: The aim of the study was to evaluate the results of treatment in patients with infected fractures or chronic osteomyelitis in the tibial and ankle regions by radical debridement of skeletal and soft tissues and coverage of the defect, using free flap transfer or muscle flap transposition. MATERIAL: Between January 1, 2002 and December 31, 2004, 26 patients were treated by this method; 13 had infected tibial or ankle fractures and 13 showed osteomyelitis of the tibia. All patients, in the case of failure, would have been indicated for below-knee amputation. The group comprised six women and 20 men at an average age of 46 years (range, 10 to 67 years). METHODS: In this retrospective study, the following data were recorded: type of injury (multiple trauma, combined trauma, single trauma), fracture type according to the AO classification, grade of injury in open fractures by the Gustillo and Anderson classification, number of previous operations in patients with infected fractures, microbiological findings in all patients before defect coverage with a flap, interval between the injury and flap coverage, number of post-operative complications, number of subsequent operations, period of relief for the treated limb, actual weight-bearing of the limb, patient's satisfaction with the therapy. RESULTS: Since one patient died of heart attack during follow-up, 25 patients (5 women and 20 men) were included in the final evaluation. The average follow-up was 27 months (range, 15 to 49 months). The healing of infection and union of bone were recorded in 21 patients (84 %). Healing with pseudoarthrosis development occurred in three patients (12 %). One patient (4 %) had to undergo leg amputation due to persistent secretion. The duration of treatment before coverage of the defect was on average 10 weeks (range, 4 weeks to 6 months) in the patients with infected fractures, and 9 years (range, 2 to 20 years) in the patients with osteomyelitis. Post-operative complications were recorded in seven patients (27 %). Impaired vascularization of the flap in the early post-operative period was found in two patients (8 %). In two patients (8 %) residual infected tissue under the flap resulted in purulent secretion. In three patients (12 %), at the time of evaluation, the lower extremity could not bear weight due to non-union of fractured bone. DISCUSSION: The use of free or transposition muscle is regarded as the optimal method for the treatment of extensive defects of soft tissues in limb traumatology. The advantages include: good quality coverage of the defect; ability of vascularized flap tissue to transport antibiotic to the defect area; long-term improved perfusion in the fracture region is important for fracture healing. CONCLUSIONS: The treatment of infected tibial and malleolar fractures by debridement and subsequent coverage of soft tissue defects, using muscle flap transfer, permits elimination of infection in most of the patients, but often requires subsequent surgery in order to provide biological stimulation for healing of defective fractures. Treatment of osteomyelitis of the tibia by this method is demanding, but has a good prospect of healing in a period shorter than is necessary for treatment without muscle flap transfer.

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The article summarizes the results of early primary lip repair in 44 newborns with cleft lip and palate. We present a study of the first 44 patients to undergo the surgery before the age of 1 week as performed by a surgeon who used a modified method according to Tennison with a nasal correction. Early lip surgeries started in 2005. Cleft patients are under the care of a multidisciplinary team. Preliminary results are very encouraging; we observed excellent esthetic results concerning lip scars and the appearance of the nose. We did not notice any impact on the maxillary development due to the short time interval. We consider early lip surgery with nasal correction the best method, and we would like to continue with it, monitoring its impact on the maxillary and nasal development.

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The arterial system of fingers is anatomically well described, and so, usually no difficulties arise during its preparation and the making of anastomoses in replantation surgery. Difficulties may occur, however, during manipulation in the dorsal vascular bed of fingers, known only as a random venous network. There are minimal references to its existence and the location of its valvular apparatus. Using a microscopic preparation, a contrast staining, and a histological assessment, topographic relations and the course of veins of the dorsal venous network, as well as the existence and location of their valvular apparatus, was investigated on 72 three-phalanx fingers. The specimens were either harvested from fresh cadavers or traumatically amputated. We found that veins of rather significant caliber predominantly run along the dorsal aspect of the finger on both the radial and ulnar sides above the proximal phalanx of three-phalanx fingers. Proximally, venous systems of respective neighboring fingers connect in the interdigital space. The valvular apparatus was found at all levels ranging from metacarpophalangeal joints to the distal phalanx. The valves were always located distally from the confluence of two veins. Aside from this confluence, the existence of valves was not observed. The exact description of architecture of this venous system, in practice, contributes to faster orientation, better preparation, and the creation of safer anastomoses of these structures, and thus, to an increased success of replantation.

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The authors describe modified thumb replantation technique. With this technique it is possible to avoid extensive mobilization of the digital arteries as well as incisions, particularly at the distal thumb phalanx, and therefore reduce further damage of the amputated part. Prior to the osteosynthesis a venous graft is harvested from the distal forearm or from the thenar area. Anastomosis between the venous graft and radial digital artery on the amputated part of the thumb is completed. Osteosynthesis of the bones with Kirchner wires follows. The venous graft is further anastomosed to the dorsal venous system of the stump. The arterial system is reconstructed with an anastomosis of the ulnar digital artery with a superficially positioned volar vein of the amputated part. The replantation technique described has proved effective in all cases when it was used.

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The authors present a case report of reconstruction after a degloving injury to hand by a combination of microsurgery and standard pedicle flaps. Degloving injury high on the hand was solved by free sensitive fasciocutaneous flap transfer from the radial forearm (Chinese flap), which covered the defect in the palm, while finger defects were covered by pedicle flaps from the abdomen. Dorsum of the hand was treated with a mesh skin graft. The authors also describe techniques of treatment and the relevant results prior to the time of microsurgery and compare them to the possibilities offered by microsurgery today, and they include comprehensive illustrations.

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Replantation surgery is a specialization in plastic surgery which, in comparison with other disciplines, has a relatively short history of only forty years. Replantation surgery developed due to experience with macrovascular anastomosis and to the evolution of the operative microscope, special micro-instruments and ultra delicate suturing material. Due to these advances, it is possible to implement anastomosis of blood vessels with a diameter smaller than 1-2 mm. Each of the three pillars of microvascular surgery has its own history. This work outlines their use and the contribution of each to the development of microsurgery. Finally, it compares the development of replantation surgery in the Czech Republic and worldwide within a specific time frame.

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