Management of Extensive or Infected Soft Tissue Defects in Upper Limb by Means of Pediculated Omental Flaps
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The basis for the treatment of deep tissue defects, particularly those that are infected, is coverage of the exposed anatomical structures with well vascularized tissues. To this end various kinds of vascularized-pedicled and free flaps are utilized. Post-trauma, soft tissue defects in the region of the upper extremity often involve areas of tissue poorly perfused, affected by necrosis and bacterial colonization. The size of the defect with accompanying intense purulence limits the application of local reconstruction and fasciocutaneal and muscle flaps. The greater omentum is one of the most promising and universal flaps on account of it's bactericidal and angiogenetic properties. The first report regarding a successful application of omentum in plastic surgery dates from 1965 year.The aim of the study was to present treatment results of extensive as well as infected tissue defects of upper limb with the application of pedicled omental flaps in material from Sub-Department of Limb Replantation in Trzebnica.Material and methods. Between 2005-2009 in the St. Hedwig's Hospital 35 patients (30 M, 5 F) avg age 38.3 (range 10-73) were treated using omentum flaps. The causes of defects were primarily crush injuries (13), burn wounds (2), secondary necrosis of replanted/revascularized limb tissues (14) including chronic bone infections, contaminated degloving injuries of upper limb (4). The area of tissue defect amounted to avg 84 cm2 (range 25-227 cm2)Most of this, 31/35 (89%) posed infected wounds (Staphylococcus aureus 11, Escherichia coli 12, Enterococcus faecalis 11, Staphylococcus coagulsonegative 10, Pseudomonas aeruginosa 5, Acinetobacter baumanii 6, Proteus mirabilis 6, Enterobacter cloacae 4). The procedure was based on covering of the defects with pedicled omental flap obtained during epigastric laparotomy, with split- thikness skin graft. After the procedure apart from the surgical prophylaxis general antiobtic therapy was not applied, nor locally. After 3-4 weeks the pedicle of flap was cuted and it's appearance was modeled as well as covered using skin graft.Results. Complete healing with good fuctional and cosmetic results was achieved in 32/35 cases, after transplantation of omentum in 52% of wounds a change in bacterial flora was observed to saprofitic and antibiotic-sensitive, and in 38% donor site was aseptic. Cultures were attained, in the remainder signs of infection receded despite the presence of pathological flora. In 2 cases complete or partial necrosis of flap was observed, in one the vital flap was removed due to amputation of limb (crush syndrome). Complication in the form of hernia were observed in 5/35 patients, however no complaints of abdominal pain or abscess of space drawing.Conclusions. Free and pedicled omental flaps appear to be the ideal solution in the treatment of tissue defects and bone infections chronically infected with antibiotic-resistant cultures. The omentum also is a appropriate material for covering of fresh defects with exposed ligaments, nerves and bones. The complications at the obtaining site in our material occured rarely when compared to the available published data. Currently it is possible also to harvest the omentum laparoscopically.
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