Reconstructive Surgery Societys Congress

I. Head and Neck Surgery

II. Oncology Surgery
III. Plastic Reconstructive Surgery
IV. Chronic Wound Management

I. Head and Neck Surgery

1. Small volume tissue expansion of the face for reconstruction of congenital

and acquired head and neck defects
Alexander Margulis, Bruce S. Bauer, Michael Icekson, Tzur Tomer, Ravit Yanko-
Arzi, Andre Ofek, Keren Agam, Helen Kastiel-Green and Rami Neuman.

Distraction osteogenesis of the mid-facial skeleton: indications, techniques .2

.and complications
Alexander Margulis, Pravin K. Patel and Bruce S. Bauer

3. Our choices in calvarial reconstruction

Alexander Margulis and Pravin K. Patel

4. Distraction osteogenesis for closing calvarial defects - a sheep model

M. Icekson, A. Margulis, E. Rege, M. Harlev, S. Zamir, R. Neuman.

5. Severe Mangled Ear - Never Say Never

M .Icekson, Ioana .Nedelcu, R.. Yanko-Arzi, A.. Margulis, R. Newman.

6. Surgical treatment of severe dento-facial anomalies, between aesthetics

and functionality
Alexandru Bucur

7. Mandibular condyle prosthesis in the reconstruction of hemimandibular

deffects our experience
A. Bucur, O. Dinca, C. Totan

8. Our experience in the management of oral and maxillofacial carcinomas

O. Dinca, H. Ionescu, C. Totan, A. Bucur

9. Controvercies concerning SMAS in the surgical treatment of the parotid

pleomorphic adenoma
A. Bucur, O. Dinca, T. Ni , C. Totan
 10. Surgical reconstructive alternative after excision of eyelid basal cell
carcinomas
G.Noditi, Viorica Frantescu, M.Cojocaru, Ramona Butta, Neda Nicodemus,
T.Bratu

11. Forehead island flap in the reconstruction of total cheek defect case
presentation
I. Urda, A. Al Shaeir, C. Clepce, K. Bulbul, A. Elramlawy

12. Extended temporo-parietal flap for forehead, midface and nose reconstruction after
severe burn injury. Case report.
V. Stan, Ina Isac, N. Antohi, C. Stingu, Natalia Marcenco, Aliona Tofan.

13. Our experience in using regional flaps for post-excisional defects covering
in facial region
B. Andreescu, A. Rebosapca, D. Birzu, I. Marinescu

14. The use of silicone prothesis in Romberg disease. Case presentation

A. Reboapca, B. Andreescu, I. Marinescu, D. Barzu

15. An overview to congenital facial malformations

D. Enescu, S. Stoicescu, R Alexandru, I .Gutau, D. Ionita, G.Constantinescu

16. New technique for upper lid paralysis reanimation

G. Noditi1, M. Cojocaru, T. Bratu , Viorica Frantescu, L. Galosi, Sandra Dan

1. Small volume tissue expansion of the face for reconstruction of congenital

and acquired head and neck defects
Alexander Margulis 1, Bruce S. Bauer 2, Michael Icekson1, Tzur Tomer1, Ravit
Yanko-Arzi1, Andre Ofek1, Keren Agam1, Helen Kastiel-Green1 and Rami Neuman1.
1
Department of Plastic Surgery, Hadassah Medical Center of Hebrew
University, Jerusalem, Israel.
2
Division of Plastic Surgery, Children's Memorial Medical Center of
Northwestern University, Chicago, Il.

The authors present their experience with the use of small volume tissue
expanders inserted into the face and the upper neck for reconstruction of a variety of
congenital and acquired deformities. The indications for tissue expansion were
intermediate and large congenital pigmented nevi (72%), scar contractures (11%) and a
remainder for a variety of deformities. Surgical strategies are reviewed to determine the
location in the face where the tissue expansion was performed, the number of
procedures required to accomplish the reconstructive goal and the design of the
expanded flap that was used to reconstruct the involved area.
Specific points that are discussed include contour deformities (such as webbing
or dog ears), anatomic distortions (such as distortion of the eyebrow or the distance
from the brow to hairline) following reconstruction, final positions of the scars in
relation to anatomic landmarks, borders of aesthetic units and relaxed skin tension lines.
The technique and the modifications in the design of expanded flaps are
discussed in a series of representative cases. They emphasize the ability of expanded
transposition flaps of the face to dissipate tension, to improve contour and the position
of scars and to lower the risk of scar contracture.

Distraction osteogenesis of the mid-facial skeleton: indications, techniques .2

.and complications
1 2
Alexander Margulis , Pravin K. Patel and Bruce S. Bauer
1
Department of Plastic Surgery, Hadassah Medical Center of Hebrew
University, Jerusalem, Israel
2
Division of Plastic Surgery, Children's Memorial Medical Center of
Northwestern University, Chicago, Il.

First developed for orthopedic surgery, distraction osteogenesis has gained

increasing role in the treatment of deficient craniofacial skeleton. This technique is less
invasive and time intensive and has a significantly decreased morbidity rate compared
with traditional methods of craniofacial reconstruction. The main advantage of
distraction is the ability to generate new bone in patients with craniofacial skeletal
deficiency, rather than having to replace the missing parts with bone grafts harvested
from other anatomic areas. Over the years, there has been an evolution in design from
uniplanar to multiplanar devices, and from external to internal devices.
The purpose of this article is to report our clinical experience with distraction
osteogenesis in a consecutive series of mid-facial skeletal reconstruction in pediatric
patients. 12 patients with various mid-facial skeletal deformities were treated over a 3
years period (1999-2002) with this technique. The indications for distraction were mid-
facial hypoplasia secondary to cleft lip and palate and idiopathic dentofacial skeletal
deformities, and combined mid-facial and forehead retrusion in patients with Aperts,
Crouzons and Pfieffers syndromes. Lefort-I segment distraction was performed for
patients with deficient Maxillae and Class III malocclusion. Lefort-III segment
distraction was indicated in patients with more extensive hypoplasia of the mid- facial
skeleton, extending to the cheekbones, inferior orbital rim and the nasal bridge.
Monoblock segment distraction was performed in patients presenting with combined
deficiency of the mid- face and the upper orbital rim and the forehead. This group of
patients presented with significant exorbitism, and usually carried an identifiable
craniofacial syndrome.
The authors describe in details the surgical strategies and the techniques for
midfacial reconstruction with distraction osteogenesis and discuss the difficulties and
the complications with this technique. A short videotape of Monoblock segment
distraction is included in the presentation.
 3. Our choices in calvarial reconstruction
Alexander Margulis 1 and Pravin K. Patel2
1
Department of Plastic Surgery, Hadassah Medical Center of Hebrew University,
Jerusalem, Israel
2
Division of Plastic Surgery, Children's Memorial Medical Center of
Northwestern University, Chicago, Il.

This presentation is a comprehensive review of the arsenal to reconstruct complex

skeletal defects in the head and neck. Indications, techniques and complications of
autologous reconstructions are discussed and reviewed. The rapidly growing arsenal of
commercial materials is summarized. Structural and mechanical properties of these
materials are discussed using the finite element model. Patients are presented to make a
case for the selected type of reconstruction performed, and the pros and cons are
discussed.

4. Distraction osteogenesis for closing calvarial defects - a sheep model

M. Icekson, A. Margulis, E. Rege, M. Harlev, S. Zamir, R. Neuman.
Department of Plastic and Reconstructive Surgery, Hadassah medical center

Popularized by Gavril Ilizarov in the 1960s, monofocal distraction osteogenesis

has become a well-established method of endogenous bone engineering. This
revolutionary surgical technique has significantly augmented the available reconstructive
orthopedic and craniomaxillofacial procedures. Bifocal distraction has been applied
successfully to reconstruct complex mandibular and long bone defects. Because traumatic
or post surgical calvarial defects do not spontaneously heal in humans older than 18 to 24
months of age, we hypothesized that bifocal distraction osteogenesis could be applied to
the skull to close critical size calvarial defects.

A sheep model was developed to investigate this hypothesis. In four young

sheep, bilateral parietal bone windows were created and adjacent osteotomies
performed. On the experiment side a distractor was placed and the other side was
left open as a control. After a latency period the distractor was closed at a rate of
1mm per day. At the termination of closure and consolidation period, a CT scan was
performed and the animals sacrificed. Gross examination and histological
.examination were done

In the first case, both sides, the treated and the control, were closed. In the
next two cases the treated side was closed perfectly and on the control side the
calvarial bone window was open with no bone formation. In the 4 th case there was a
.technical failure as the distractor broke at the beginning of distraction

We concluded that the sheep model could serve successfully in investigating

calvarial defects. In the first case the sheep was too young resembling a young
 infant that has spontaneous defect closure. Further cases have to be done before
proceeding to humans. Distraction osteogenesis has a promising future in treating
.this difficult and challenging problem

5. Severe Mangled Ear - Never Say Never

M .Icekson, Ioana .Nedelcu, R.. Yanko-Arzi, A.. Margulis, R. Newman.
Department of Plastic and Reconstructive Surgery, Hand and Burn units,
Hadassah University Hospital, Jerusalem, Israel.
Herein, we present two cases of severely mangled auricle that were reconstructed
in the acute phase upon arrival to the hospital.
Case 1
The first patient presented with a near total amputation of the auricle that hinged
from a small ear lobe pedicle. The axial blood supply was severed and the blood supply
was random. The auricle was carefully repaired using anatomic guidelines and
meticulous technique. Complete survival of the avulsed flaps and an excellent aesthetic
outcome were achieved.
Case 2
The second patient presented is a special unit officer who suffered a gunshot
wound to the auricle. The bullet comminuted the ear severely passing through the
temporal muscle and fascia lacerating the superficial temporal artery breaking the
temporal bone and causing a small epidural heamatoma. The lost tissue was reconstructed
upon arrival using every vital piece of tissue left, including puzzle work with the
cartilages and creating a new shorter helical rim. In eight months of follow up the
aesthetic and functional outcome is good.
Discussion
The common practice for auricular reconstruction include reimplantation with
microvascular repair in cases of amputation and meticulous repair when the blood supply
is preserved by a large skin pedicle.(or Banking in the retroauricular skin area of the
cartilage) In this presentation we demonstrate that in acute trauma of the auricle more
surgical options exist for the reconstructive surgeons, in particular not saying never but
reconstruct immediately using every vital tissue left.

6. Surgical treatment of severe dento-facial anomalies, between aesthetics

and functionality
Alexandru Bucur
Head of Oral Maxillo-Facial Surgery Clinic
UMPh Carol Davila Bucharest

The dento-facial anomalies have a significant incidence in the general population,

of approximately 0.5%. The most severe form is the class III bimaxillary anomaly
(mandibular prognatism associated with maxillary retrognatism), creating difficulties in
the management for obtaining a functional dental occlusion that leads to an improvement
of the facial esthetics. There is a standardized management protocol: presurgical
orthodontic treatment, to decompensate the anomaly, followed by a well planned
surgery and a postoperative orthodontic treatment. The error factors in different treatment
steps and the factors of failure and relapse are analyzed.

7. Mandibular condyle prosthesis in the reconstruction of hemimandibular

deffects our experience
A. Bucur, O. Dinca, C. Totan
Oral Maxillo-Facial Surgery Clinic
UMPh Carol Davila Bucharest

There are many techniques described for reconstruction of the mandibular

condyle, for defects after mandibular hemiresection with de-articulation. One of the most
modern and methods is the inferior artroplasty with Stryker titan mandibular condyle,
attached to a fibular free graft. This type of intervention was performed for the first time
in Eastern Europe in the Department of Oral and Maxillofacial Surgery in Bucharest. We
present our experience on four cases, since may 2005. The use of this type of
reconstruction, with good results, allow a primary tumor removal with no compromise
and with respect to the quality of life.

8. Our experience in the management of oral and maxillofacial carcinomas

O. Dinca, H. Ionescu, C. Totan, A. Bucur
Oral Maxillo-Facial Surgery Clinic
UMPh Carol Davila Bucharest

The most frequent malignant tumors of the oral and maxillofacial territory are
squamous cell carcinomas, with a local infiltrating pattern and a high risk of cervical
metastases. Their complex treatment include a surgical step (primary tumor removal,
reconstruction of the defect, management of the lymphnodes) and adjunct radio-
chemotherapy. The reconstruction of the OMF defects is a challenge in assuring the
quality of postoperative life, because of the greater defects, highly specialised and
involved in facial esthetics and function. Considering the lymphophily of such tumors,
for N0 we recommend a prophylactic neck dissection, and for N+ a therapeutic neck
dissection, at 3-4 postoperative, or sometimes en bloc with the primary tumor.

9. Controvercies concerning SMAS in the surgical treatment of the parotid

pleomorphic adenoma
A. Bucur, O. Dinca, T. Ni , C. Totan
Oral Maxillo-Facial Surgery Clinic
UMPh Carol Davila Bucharest

Even though the management of the benign tumors of the parotid gland is well
defined, there are a few controvercies. The classical approach for total parotidectomy
sometimes leads to aesthetic deficits caused by the volumetric lack of tissue. The facelift
approach, with conservation of the superficial musculo-aponeurotic system (SMAS) has
better aesthetic results and limits the Frey syndrome, but also generates controvercies
about the radicality. The modifications of the surgical technique are presented and a
protocol is proposed for the conservation of the SMAS in total parotidectomy for
pleomorphic adenomas of the parotid gland.

10. Surgical reconstructive alternative after excision of eyelid basal cell

carcinomas
G.Noditi1, Viorica Frantescu2, M.Cojocaru1, Ramona Butta1, Neda Nicodemus1,
T.Bratu1 .
1
-Clinic of Plastic and Reconstructive Surgery - UMF Victor Babes Timisoara
2
-Clinic of Ophthalmology - UMF Victor Babes Timisoara

Reconstructive surgery for eyelid basal cell carcinomas (BCC) has normally three
main objectives: radical tumor excision, functionality and an aesthetic outcome.
Due to their local growth, the curative exeresis must be the preferred choice, but
an attempt to preserve the neighboring structures should be done for a further
reconstructive alternative.
In the last 5 years we have performed 53 reconstructive surgeries for patients with
different localizations of eyelid BCC. 23 patients have presented in our clinic with local
recurrences after surgery in other clinics. Usually local recurrences are more aggressive,
infiltrative and destructive that the primary tumor. Eyelid reconstructions can entail use
of complex methods. We have used different local cutaneos or fascio-cutaneos flaps with
random vascularization or with defined vascular axis. The morphological and functional
results of the reconstructive procedures were good. In 3 cases the enucleation was the
choice surgical method and the local reconstruction had a strictly morphological purpose.
It is advisable that the first surgical procedure for eyelid BCC to be radical, in respect
with the oncologic protocol and in order to avoid neoplastic recurrence. The local
reconstruction should offer not only a good aesthetic result, but also a good management
of the local tissues. This could be very important if another reconstructive method should
be used for a possible local recurrence.

11. Forehead island flap in the reconstruction of total cheek defect case
presentation
I. Urda, A. Al Shaeir, C. Clepce, K. Bulbul, A. Elramlawy
Plastic and Reconstructive Surgery Clinic
Clinical County Hospital Oradea

Aim: reconstruction of total cheek defect with forehead island flap.

Materials and methods: 83 years old patient with total defect of right cheek post excision
of a recurrent Basal Cells Carcinoma. Right forehead island flap was used to reconstruct
the cheek.
Results and conclusion: total reconstruction of cheek consists in restoration of
skin and mucosa. We have chosen this flap because the forehead region has almost the
same skin texture; this tip of flap is easy, simple, and quick. Further one single operating
time is needed (especially in old patients with anesthesia risk), and allow us to restore
both skin and mucosa
 12. Extended temporo-parietal flap for forehead, midface and nose reconstruction after
severe burn injury. Case report.
V. Stan, Ina Isac, N. Antohi, C. Stingu, Natalia Marcenco, Aliona Tofan.
University of Medicine and Pharmacy Carol Davila,
Clinical Hospital for Plastic Surgery and Burns, Bucharest, Romania

Deep facial burns with damage of the important structures is a challenging task for the plastic
surgeon to reconstruct, especially when there is a scarcity of local tissues to be used. Moreover, free
flaps are not indicated in all cases. We present a case in which we reconstructed the upper
(forehead), mid-face (upper and lower eye-lids) and the nose with a single extended superficial
temporal artery based scalp flap with exceptional survival and aesthetic postoperative appearance.
We present both the advantages and disadvantages of such a flap.

13. Our experience in using regional flaps for post-excisional defects covering
in facial region
B. Andreescu, A. Rebosapca, D. Birzu, I. Marinescu
Plastic and Reconstructive Surgery Department
Clinical Hospital Colentina

The great diversity of local flaps that can be made in facial region, allows us to
reconstruct small and medium tissular defects and conserve facial physiognomy, as well.
Thus, its adequate utilization becomes very useful especially in neoplazic tumoral
pathology, allowing safe-limited oncological resections, followed by appropriate
reconstruction.

14. The use of silicone prothesis in Romberg disease. Case presentation

A. Reboapca, B. Andreescu, I. Marinescu, D. Barzu
Plastic and Reconstructive Surgery Department
Clinical Hospital Colentina

We present the case of a female patient with atrophy of the hemi facial soft tissues
typical of Romberg disease. The volumetric reconstruction was made with custom-made
silicone implants. We present the strategy for approaching the case and the intermediate
steps which allowed us to avoid local complications encouraged by the regional sclerosis,
typical for the disease.

15. An overview to congenital facial malformations

D Enescu, S. Stoicescu, R Alexandru, I .Gutau, D. Ionita, G.Constantinescu
Plastic Surgery and Reconstructive Microsurgery Clinic
Clinical Emergency Hospital for Children Grigore Alexandrescu Bucharest
 The paper presents the most frequent congenital malformations of the face treated
by plastic surgery: clefts, external ear malformations, pigmented nevi, hemangiomas,
and the experience of the pediatric plastic surgery team from Bucharest, Grigore
Alexandrescu Hospital for Children.
Special focus is on cleft lip and palate, their multitude of anatomoclinical formes,
the specialists forming the team, the correct timing for primary and secondary
procedures, clasical techniques and new approaches.
Regarding ear malformations our unit has an important number of cases of
microitia treated with partial or total ear reconstruction.
Facial malformations need to be approached at specific ages, many times on
staged procedures, but the primary treatment need to be done before school age. Among
other children, those baring congenital malformations of the face should feel no
different.

16. New technique for upper lid paralysis reanimation

G. Noditi1, M. Cojocaru1,T. Bratu1 , Viorica Frantescu2 , L. Galosi 3, Sandra

Dan3
1
Clinic of Plastic Surgery, Reconstructive Microsurgery Timisoara
2
Clinic of Ophthalmology Timisoara
3
Phisical Terapist

Upper lid paralysis can occur after a traumatic episode or a surgical procedure
damaging oculomotorius nerve that is innervating the levator palpebrae superioris
muscle. The current techniques provide a relative opening of the upper lid being
necessary an extra extension of the head in order to obtain a good visual area. This could
be unpleasant for the patient. We have selected a 52 y old female patient with a 2 y upper
lid paralysis after a surgical procedure for a brain tumor. We have perform a new
technique by repositioning the orbicular muscle and the levator palpebrae superioris
muscle in such a way that the forces which are elevating the upper lid margin to act
uniformly, keeping its concave shape. An arcade line of repositioning the muscles to the
eyebrow levator muscle has realized the common place for acting the forces. We have
used 6/0 continuous nylon sutures for the muscles and interrupted subcutaneous sutures
for closing the wound. Steristrip has been used for skin closure. Immediate post operator
results were the almost symmetrical opening of the injured eyelid without other extra
movements as well as its closing without any other supplementary effort. Aesthetic result
was well appreciated by the patient and the surgeon. Further ophthalmologic
rehabilitation methods are necessary for facilitating improvement of the upper lid
function.
II. Oncology Surgery

1. Large and giant congenital pigmented nevi of the upper extremity: An

algorithm to surgical management.
Alexander Margulis and Bruce S. Bauer

2. Surgical approach to large congenital nevi of the eyelids and the

periorbital region
Alexander Margulis and Bruce S. Bauer

3. Soft-tissue Tumors: Diagnostic Accuracy of MR Imaging

N. Bolog, Angelica Mangrau, S.A. Popescu, D. Totir, Sanda Achim, I. Lascar

4. Actual concepts in the diagnose and therapeutic treatment in malignant

melanoma
I. Lascar, S.A. Popescu, A. Cinca, Ruxandra Andrei, C. Mitache, Alina Alboiu,
Monica Taracila
5. The algorithm of management in the most frequent cutaneous carcinomas
Noela Elena Ionescu, Carmen Ciure, S. Marinescu, Carmen Giuglea, Ruxandra Mihai,
I.P. Florescu
6. Cutaneous reconstruction after excision of facial carcinoma by MOHS
surgery
Mihaela Leventer, Diana Plcintescu, D. Totir, Mihaela Cara, Sanda Achim
7. The salvage reconstructive procedures in oncologic surgery
Penelopia Marinescu, CristinaBejan, B. M. Marinescu, R. Ionescu
T. Horvat, I. Timaru, I. Campeanu, P. Bratila, V. Ibric-Cioranu, Diana Toma
8. Giant Thigh Tumors
H. Parvanescu, M. Pasalega, Maria Vrabete, Corina Nicolae, M. Ciurea,
Camelia Foarfa, C. Mesina
9. Gorlin Syndrome dermatological diagnose and surgical excision.
Ileana Boioangiu, Ioana Suru Dumitrascu, Luminita Banacu, Crenguta Jecan

1. Large and giant congenital pigmented nevi of the upper extremity: An

algorithm to surgical management.
Alexander Margulis 1 and Bruce S. Bauer 2
1
Department of Plastic Surgery, Hadassah Medical Center of Hebrew
University, Jerusalem, Israel
2
Division of Plastic Surgery, Children's Memorial Medical Center of
Northwestern University, Chicago, Il.

The timing and choice of treatment for congenital giant pigmented nevi
continues to evolve under the influence of changing opinions regarding the risk of
malignant degeneration and the impact of excision and reconstruction on the affected
child. Many studies exist to support a significant enough risk of malignancy to warrant
excision, yet other series and pigmented lesion clinics suggest that the risk of
malignancy does not warrant the potential scarring and deformity that has followed the
surgery necessary to remove these giant lesions. In order to satisfy both sides in this
controversy, we have been challenged to modify our surgical techniques in a manner
that will minimize the risk of malignant degeneration and at the same time provide
optimal functional and aesthetic outcomes for these complex reconstructions.
In this paper, we describe the evolution of our techniques for the excision and
reconstruction of large and giant congenital pigmented nevi of the upper extremity and
propose a surgical algorithm for their management. Our current approach is based on a
review of a large series of patients in whom different techniques were used to provide
the necessary tissue to reconstruct this challenging area.
30 consecutive patients with large and giant nevi of the upper extremity were
treated over a 23-year period (1979-2002). These patients represent a subset of 259
children (12%) with large or giant congenital pigmented nevi treated and followed in
this period of time.
In proximal upper extremity lesions, expanded transposition flaps from upper
back and shoulder have effectively eliminated contour defects or circumferential
constriction in the upper arm and axilla. An expanded free transverse rectus abdominis
musculocutaneous flap has offered a possible avenue for larger lesions (shoulder and
upper extremity to below elbow), and pedicle flaps from the flank (both expanded and
non-expanded) have offered ways of improving the long-term contour in the forearm.
Expanded and non-expanded full thickness skin grafts were chosen for reconstruction of
the hand and the fingers, respectively.
The authors describe in details the surgical strategies and the techniques for
reconstruction of each region of the upper extremity and then bring these ideas together
in an algorithm for assessment and treatment of these challenging lesions.

2. Surgical approach to large congenital nevi of the eyelids and the

periorbital region
Alexander Margulis 1 and Bruce S. Bauer 2
1
Department of Plastic Surgery, Hadassah Medical Center of Hebrew
University, Jerusalem, Israel
2
Division of Plastic Surgery, Children's Memorial Medical Center of
Northwestern University, Chicago, Il.

The timing and choice of treatment of large congenital pigmented nevi continues to
evolve under the influence of changing opinions regarding the risk of malignant
degeneration and the impact of excision and reconstruction on the affected child. Many
studies exist to support a notable enough risk of malignancy to warrant excision, yet
other series and pigmented lesion clinics suggest that the risk of malignancy does not
warrant the potential scarring and deformity that has followed the surgery necessary to
remove these giant lesions. To satisfy both sides in this controversy, we have been
challenged to modify our surgical techniques in a manner that minimizes the risk of
malignant degeneration and at the same time provides optimal functional and aesthetic
outcomes for these complex reconstructions. Large synchronous nevi of the eyelids are
a perfect example for accepting this challenge.
Herein, we describe the evolution of our techniques for the excision and reconstruction
of intermediate and large congenital pigmented nevi of the eyelids, and propose a
systematic surgical approach for their management. Patients with large nevi of the
eyelids were treated with either expanded or non-expanded full-thickness skin grafts as
the main modality of treatment. Nevi extensions to the forehead, temporal and the
adjacent cheek areas were reconstructed with expanded local flaps prior to the grafting
of the eyelids. The grafts were then staged after most of the forehead and the cheeks
have been reconstructed. In selected patients, the grafting of the eyelids was performed
simultaneously with reconstruction of the cheek and/or the forehead. It has only been
through our widening experience with these complex nevi that we have been able to
establish these practical guidelines.

3. Soft-tissue Tumors: Diagnostic Accuracy of MR Imaging

N. Bolog1, Angelica Mangrau1, S.A. Popescu2, D. Totir2, Sanda Achim3, I. Lascar2
1
Department of Magnetic Resonance Imaging, Emergency Hospital Bucharest,
Romania
2
Clinic of Plastic Surgery, Emergency Hospital Bucharest, Romania
3
Department of Pathology, Emergency Hospital B+ucharest, Romania

PURPOSE:
To asses the accuracy of magnetic resonance imaging in soft-tissue tumors
characterization.
MATERIALS AND METHODS:
Between Feb 2002 and Mar 2006 74 patients, age range 1-91 (mean age 48)
underwent MR imaging for evaluation of soft-tissue tumors. The MR images have been
reviewed by two radiologists. Both observers were blinded to clinical data. The tumors
were first characterized as benign or malignant. Finally, both readers were asked to name
a specific diagnosis of the lesion based on the established criteria in the literature. The
results were compared with histological findings as standard of reference. ROC curves
and areas under the curves (Az) were performed.
RESULTS:
Forty-nine malignant tumors (25 sarcoma, 19 carcinoma, and 5 melanoma) and 25
benign tumors (9 tumors of nervous origin, 7 hemangiomas, 8 tumors of fibrous tissue,
and 1 synovioma) were evaluated. In terms of classification of detected lesions as benign
or malignant the area under the ROC curve (Az) was 0.87 (CI95%=0.77- 0.96). The
overall sensitivity and specificity of MR imaging in differentiation of benign from
malignant tumors was 73.5 % and 80%, respectively. In 36 % of cases a specific
diagnosis was possible based on MR examination.
CONCLUSION:
MR imaging is a valuable tool for assessment of soft-tissue tumors in clinical
practice.
 4. Actual concepts in the diagnose and therapeutic treatment in malignant
melanoma
I. Lascar, S.A. Popescu, A. Cinca, Ruxandra Andrei, C. Mitache, Alina Alboiu,
Monica Taracila
Plastic Surgery and Reconstructive Microsurgery Clinic
Clinical Emergency Hospital Bucharest, Romania

Malignant melanoma represents a surgery emergency due to its unfavorable

evolution. Therefore efforts should be made in the early diagnose as well as for a correct
and fast management of the disease. Collaboration between the dermatologist, the
imagistic department, laboratory findings, surgeon, histopathologist and oncologist is
paramount and can provide a long term surviving period in the early diagnosed cases.
This paper tries to discuss a protocol concerning all the therapeutic stages of this disease,
considering also the practical possibilities to deal with this problem locally and abroad.
The present statements in the treatment should not be regarded as controversial, but more
appropriate, as a stage in the management of a serious health problem.

5. The algorithm of management in the most frequent cutaneous carcinomas

Noela Elena Ionescu, Carmen Ciure, S. Marinescu, Carmen Giuglea, Ruxandra Mihai,
I.P. Florescu
Plastic Surgery Department
Clinical Emergency Hospital Bagdasar-Arseni

Skin malignancies represent a significant challenge to the health service due to the
high incidence. The paper emphasize our point of view in the most frequent skin tumors
management and is the result of combined experience between Plastic Surgeon,
Dermatologist and other important practitioners involved in sorting out the problem
(Oncologist, Radiotherapist, Psychiatrist etc). We discuss all the essential items involved
in the algorithm, the role of biopsy and how to chose the treatment. Finally, we analyze
the results and perspectives of treatment improvement.

6. Cutaneous reconstruction after excision of facial carcinoma by MOHS

surgery
Mihaela Leventer, Diana Plcintescu, D. Totir, Mihaela Cara, Sanda Achim
Dermastyle Clinic, Bucharest

Skin cancer is today the most frequent neoplasm in the world. With our love for
the sun, both melanoma and non melanoma skin cancer remain a risk. A successful
excision and a skillful reconstruction are important to the patient and challenging for the
surgeon.
MOHS is the acronym for microscopically oriented histologic surgery, a
technique pioneered by an American surgeon, Frederic Mohs. MOHS surgery is todays
gold standard treatment for cutaneous neoplasma: non-melanoma skin cancer, primary
basal cell and squamous cell cancer, melanoma, and numerous uncommon cutaneous
neoplasms.
The basic premise of MOHS is that malignancies grow in continuity. Through the
use of layered excisions to remove the cancer, the dermatologic surgeon can minimize the
waste of normal, non-cancerous tissue, can diagnose intraoperatively the tumor and its
extent up to the last malignant cell.
The relapse rate is less than 3%. The facial postoperative defect often demands
complex procedures, such as covering with various types of flaps.
We present some of our cases operated by this surgical procedure.

7. The salvage reconstructive procedures in oncologic surgery

Penelopia Marinescu, CristinaBejan, B. M. Marinescu, R. Ionescu
T. Horvat, I. Timaru, I. Campeanu, P. Bratila, V. Ibric-Cioranu, Diana Toma
Central Military Hospital - Bucharest

The large soft tissue defects resulting after radical exeresis set up a challenging
and a daring act for medical team. The paper is based on a patients selection ,assessed
with malignant tumors, in advanced stages of evolution, as volum, wideness and deep
invasion, who required radical excision and immediate reconstruction of local excisional
area.
The pacients also present a poor clinic-biological status, demonstrated by severe
anaemia, hypoproteinemia and cachexy. Major surgery,performed in complex team, have
had as location the facial massive, thoracic and abdominal wall. The immediate
reconstruction was done.
The surgical healing was obtained in the majority of cases,average healing period
was 10-30 days. The postoperative follow-up was possible within 6 month-2 years.

8. Giant Thigh Tumors

H. Parvanescu, M. Pasalega, Maria Vrabete, Corina Nicolae, M. Ciurea,
Camelia Foarfa, C. Mesina
Department of Plastic Surgery
Emergency Clinical Hospital Craiova, Romania

Background:
The purpose of this paper is to present 3 large tumors of the thigh and their
adequate therapeutic strategy.
Methods:
We studied 3 female patients aged between 53-61 years with thigh tumors of 3-7
kg in weight. One of the patients presented bilateral tumors. Both thigh ultrasound and X-
ray were required in order to set up the diagnosis. The routinely performed surgery has
been the tumoral excision. The histopathological exam revealed one hematic cyst, one
lipoma and one liposarcoma. The last patient underwent oncologic treatment.
Results:
The results were good and the esthetic appearance reasonable. No recurrences
were noted in the first or second year after surgery.
Conclusions:
The mentioned patients with huge tumors in the thigh demanded thorough
previous investigations so that an accurate diagnosis and surgical strategy to be
established. The excision of the tumor associated with oncologic treatment (1 case)
represented the regular therapy.

9. Gorlin Syndrome dermatological diagnose and surgical excision.

Ileana Boioangiu, Ioana Suru Dumitrascu, Luminita Banacu, Crenguta Jecan
Clinical Hospital for Plastic Surgery and Burns, Bucharest

Gorlin syndrome is an autosomal dominant cancer syndrome. Patients with this

rare syndrome often have anomalies of multiple organs, many of which are subtle. Study
of patients with Gorlin syndrome has yielded useful information about neural
development and carcinogenesis. Familiarity with Gorlin syndrome is important for
clinicians because of the propensity of these patients to develop multiple neoplasms,
including basal cell carcinomas and medulloblastoma, and because of the patients'
extreme sensitivity to ionizing radiation, including sunlight. The syndrome has also been
referred to as basal cell nevus syndrome. We present one clinical case, with physical
findings and surgical treatment.

III. Plastic Reconstructive Surgery

1. Posterior exanteration with immediate myocutaneous flaps

reconstruction -consecutive cases
M. Icekson, A. Pikarski, A. Margulis, T. Zur, E. Rosenshpier, R. Neuman.
2. Options in the soft tissue reconstruction after total pelvic exenteration
C. Stingu, G. Mitulescu, Cristina Huian, C. Ungureanu, G. Gluck, N. Antohi,
V.Stan, I. Popescu
3. Diagnose and treatment principles in necrotising fasceitis
I. Lascar, L. Cojocaru, S.A. Popescu, Ruxandra Andrei, S. Adetu, Khaled al
Fallah, Anca Breahna, Ioana Grintescu
4. The importance of fascia excision in extensive gangrene
I. Urda, A. Al Shaeir, C. Clepce,K. Bulbul, A. Elramlawy
 5. Knee and popliteal coverage by the lateral sural fasciocutaneous artery
island flap
C. Stingu, V.Stan, N. Antohi, Cristina Huian, D.Popescu, Natalia Marcenco, R.
Jecan

6. V-Y advanced tensor facia lata flap in coverage of the trochanteric region
C.Stingu, Cristina Huian, N.Antohi, V.Stan, A.Dragnea, Crenguta Jecan
7. The old tube flap. Beyond the limits
N. Antohi, V. Stan, C. Stingu

8. Ilizarov external fixator in plastic surgery

V. Stan, N. Antohi, S. Parasca, C. Stingu, I. Marinescu, N. Marcenco.

9. Limbs trauma with extensive tissue damages therapeutical attitude

Carmen Giuglea, Marinescu S., Ruxandra Mihai, Florescu IP

10. The reconstruction of the severely mutilated limb

I. Ghimis
11. Protocols in vascular lesions in children
S. Giuvelea, D. Enescu, S. Stoicescu, .I Nedelcu, R. Alexandru , I Gutau

1. Posterior exanteration with immediate myocutaneous flaps

reconstruction -consecutive cases
M. Icekson, A. Pikarski, A. Margulis, T. Zur, E. Rosenshpier, R. Neuman.
Department of Plastic and Reconstructive Surgery, Hadassah medical center
Department of General Surgery, Hadassah medical center

Hereby we present three consecutive cases of Gracilis myocutaneous flaps

reconstruction for Posterior exanteration (Vulvectomy, posterior vaginectomy,
uterectomy and abdominoperineal resection) performed by inter discipline
collaboration.
Case1
A 62-year with recurrent squamous cell carcinoma of the labia majora had had
primary and recurrent excision reconstructed with fascio cutaneous Singapure flap
and radiation therapy. After aggressive recurrence of the tumor Posterior exanteration
with immediate bilateral Gracilis myocutaneous flaps was performed. The Flaps fully
survived and a satisfactory vaginal pouch was created.
Case 2
A 56-year-old woman was diagnosed late with invading carcinoma of rectum.
The tumor invaded through the Recto vaginal pouch (Douglas pouch) to the Vagina.
After Adjuvant chemotherapy and radiation therapy, posterior exanteration was done
with immediate one-sided Gracilis flap reconstruction. The vagina was fully
reconstructed while the single flap serves as the posterior vaginal wall and perianal area
primary closed.
Case 3
 A 63-year-old woman with recurrent squamous cell carcinoma of the vagina
underwent primary excision and radiation therapy. The posterior and sidewalls of the
vagina, the rectum and anus, the perineal area and uterus were resected. Immediate
reconstruction with bilateral Gracilis myocutaneous flaps was performed. One of the
flaps suffered from partial necrosis that needed debridment and skin graft. Six months
post operation there is full recovery
Discussion
Posterior exanteration is a common surgical procedure for genital and perineal
tumors. Immediate reconstruction with myocutaneous flaps gives good results. The
reconstruction provides excellent wound closure with highly vascular tissue and in
some cases good functional outcome. Meticulous planning and execution are essential
for success.

2. Options in the soft tissue reconstruction after total pelvic exenteration

C.Stingu1, G.Mitulescu, Cristina Huian1, C.Ungureanu, G.Gluck, N. Antohi1,
1
V.Stan , I.Popescu
1
Clinical Emergency Hospital for Plastic, Reconstructive Surgery and Burns,
Bucharest
2
Department of General Surgery and Liver Transplantation, Clinical Institute
Fundeni, Bucharest
3
Department of Urologic Surgery and Kidney Transplantation, Clinical Institute
Fundeni, Bucharest

Described as the most aggressive and radical surgical option in the advanced
pelvic cancer, the total pelvic exenteration means the entire resection of all pelvic
structures including the urinary bladder, prostate, seminal glands, the inferior part of
ureteries, vagina, uterus and adnexae, rectum and anus associated with all adiacent
lymphatic tissue, with subsequent deffinitive colostomy and urinary diversions. In the
General Surgery and Liver Transplantation Clinic Fundeni, during 2000-2006, 61 total
pelvic exenterations were performed for local invasive pelvic cancer, with the initial
disease in the cervix 36, rectum 18, vagina and endometer 3. 49 females and 12
males, with ages between 29 and 78 years were operated. 29,5% of cancers were massive
initial invasion and 70,5% were recurrences of anterior operated pelvic cancer.
The remaining pelvic dead space and the absence of the perineal support
following TPE results in many postoperative complications (wound dehiscence, local
sepsis, bowel herniation).
In order to prevent complications and reduce mutilating consequences of the
exenterative procedure, surgical options are available for pelvico-perineal and vaginal
reconstruction.
The reconstructive procedures, single or associated, were performed in 36 of 61
patients. The methods of reconstruction are represented by:
- pelvic contention with non resorbable mesh in 8 patients
- omental flap for filling the pelvic defect in 17 patients
- muscular and musculocutaneous gracilis flap in 5 cases
- muscular and musculocutaneous rectus abdomins flap in 3 cases.
 - vaginal reconstruction in 3 cases

The gracilis and rectus flaps were associated for reconstruction of the pelvic floor
and perineal region in 4 patients. In 3 patients neovagina was constructed, using bilateral
musculocutaneous gracilis flaps in 2 and a vertical oriented musculocutaneous rectus
abdominis flap in one patient.
In 4 cases, due to lateral extension of the exenterative procedure, multi-flap
coverage was required. In 3 cases we experienced partial necrosis of the distal tip of the
musculocutaneous gracilis flaps. Defects were latter covered by inferior gluteal thigh
flaps.
The incidence of the complications mentioned above decreased dramatically after
reconstructive procedures.
Reconstruction after total pelvic exenteration provides stable coverage, rapid
recovery and improved quality of life.

3. Diagnose and treatment principles in necrotising fasceitis

I. Lascar, L. Cojocaru, S.A. Popescu, Ruxandra Andrei, S. Adetu, Khaled al
Fallah, Anca Breahna, Ioana Grintescu
Plastic Surgery and Reconstructive Microsurgery Clinic
Clinical Emergency Hospital Bucharest

Necrotising fasceitis represent a medical and surgical emergency and it is usually

accompanied by a high mortality level. There fore the accuracy and the fast diagnose
followed by a large surgical debridment, accompanied by an aggressive antibiotic
treatment and a good hemodynamic equilibration can make the difference between exitus
and survival. This papers tries to clarify the diagnose principles and especially the
differential diagnose and emphasize the importance of the undelyed large debridment.

4. The importance of fascia excision in extensive gangrene

I. Urda, A. Al Shaeir, C. Clepce,K. Bulbul, A. Elramlawy
Plastic and Reconstructive Surgery Clinic
Clinical County Hospital Oradea

Aim: quick and complete wounds healing in extensive gangrene patients.

Material and methods: patients with extensive gangrene who had a fascia excised
indifferent if it was affected or not, then soft tissues defect were restored with skin graft
which was utilized on a good vascularized muscular receptor site.
Result and conclusion: due to its poor vascularization, the fascia is not a very
good receptor site for skin graft. There for the fascia is always excised indifferent if it is
affected or not by the gangrene.

5. Knee and popliteal coverage by the lateral sural fasciocutaneous artery

island flap
 C.Stingu1, V.Stan1, N.Antohi1, Cristina Huian1, D.Popescu1, Natalia Marcenco1, R.
Jecan
1
Clinical Emergency Hospital for Plastic Reconstructive Surgery and Burns,
Bucharest
2
Plastic Surgery Clinic, Clinical Emergency University Hospital Bucharest

Knee joint and popliteal region coverage benefits from many reconstructive
methods. Among these, the lateral sural fasciocutaneous artery island flap issues as one of
the first options.
6 males, aged between 27 and 54 years-old, with 3 knee and 3 popliteal defects
following trauma, tumour excision and burn sequellae were operated.
5 flaps healed uneventfully, 1 flap failed due to venous congestion. This defect
was covered in a second stage with a distally based vastus lateralis muscular flap.
Healed flaps provided stable and sensory coverage and early functional recovery
of the knee joint.
Anatomic bases of the flap and technical steps are mentioned. The advantages and
disadvantages in using this flap are outlined. The flap is compared with other
reconstructive options used for coverage of this area.
The flap is reliable, easy to raise, sensate and provides good coverage and early
functional rehabilitation of the knee and popliteal regions.

6. V-Y advanced tensor facia lata flap in coverage of the trochanteric region
C.Stingu1, Cristina Huian1, N.Antohi1, V.Stan1, A.Dragnea, Crenguta Jecan1
1
Clinical Emergency Hospital for Plastic Reconstructive Surgery and Burns,
Bucharest
2
Department of General Surgery, Clinical Institute Fundeni, Bucharest

The defects in the trochanteric region are mostly resulting from pressure sores.
The golden standard in coverage of this region is represented by musculocutaneous flaps
raised from the thigh (tensor fascia lata, vastus lateralis, rectus femoris). A technical
modification in raising the tensor lata musculocutaneous flap is the V-Y advancement
with placing the proximal musculocutaneous part of the flap on the defect.
3 patients were operated by this method, 2 with pressure sore on the trochanteric
region and 1 with a gigantic reccurent squamos carcinoma. All flaps survived entirely
providing stable coverage. No pressure sore reccurence occurred.
The technique of V-Y advancement of the tensor lata fascia flap seems to be the
first option in the coverage of the trochanteric region as it precludes any dog ear
formation due to rotation of the flap and places on the defect the bulky muscular portion
which provides a better wound closure.

7. The old tube flap. Beyond the limits

N. Antohi, V. Stan, C. Stingu
University of Medicine and Pharmacy Carol Davila,
Hospital for Plastic Surgery and Burns, Bucharest, Romania
 TheOld tubed flap... Its almost 90 years since its first application concomitantly in the
same 1917 year by four surgeons - Filatov in Russia, Gillies in the U.K. and Aymard and Ganzer in
Germany.
With this paper we want to demonstrate that associating of the tube flap with the free tissue
transfer it is possible to cover extremely extensive defects in the different areas of the human body.
We report three cases of using such a combination.
From December 2002 to August 2006 we used the technique of combining free flaps with
tube flaps. The defects were localized on the upper extremity, lower extremity and scalp respectively.
In one case the soft tissue defect resulted from a traumatic injury and in the other two cases tissue
loss was caused by severe burn and electrical injuries.
There were two types of defects to
reconstruct: - Type I A round defect. This was a nearly total defect of the scalp including
occipital, parietal and both temporal areas.
- Type II Two longitudinal defects, one on the lower extremity and one
on the upper extremity. For the reconstruction of the type I defect the combined radial forearm free
flap and two oblique abdominal tubed flaps and the intermediary flap between them was used. For
the reconstruction of the type II defects we used the combined latissimus dorsi free flap associated
with tubed flaps.
One combined flap was successfully transferred. In another two cases partial necrosis of the
tubed part of the combined flap occurred.
In conclusion,
This proposed method of flap prelamination requires careful planning and staged
reconstruction, which involves5-7 operative procedures. Despite this time-consuming process, this
custom prelamination of a combined free and a tube flap provides an unlimited variety of
applications, especially in the coverage of extensive soft tissue defects.

8. Ilizarov external fixator in plastic surgery

V. Stan, N. Antohi, S. Parasca, C. Stingu, I. Marinescu, N. Marcenco.
University of Medicine and Pharmacy Carol Davila,
Hospital for Plastic Surgery and Burns, Bucharest, Romania

The well known Ilizarov external fixator is widely accepted in orthopedic surgery. Stable
fixation of the bone fragments, absence of foreign material in fracture site, easy and rapid recovery
and mobilization, distraction osteogenesis are incontestable advantages of this old but still actual
method developed by Russian orthopedic surgeon Ilizarov.
But, not only orthopedic surgery can benefit from this unique method. Its utility in plastic
surgery is indubitable highly useful. In this paper authors present their experience and new ideas
using Ilizarov external fixator in different areas and for different purposes in plastic surgery.

9. Limbs trauma with extensive tissue damages therapeutical attitude

Carmen Giuglea, Marinescu S., Ruxandra Mihai, Florescu IP
Plastic Surgery Department
Clinical Emergency Hospital Bagdasar-Arseni
 Crush trauma of the limbs with extensive distruction, sometimes circumferential
and associating muscle trauma, contusion or crushing of the vessels and nerves and
frequently fractures, are all of them surgical emergencies. Skin avulsion with vascular
impairement (on veins and arteries) lead to cianosis and necrosis. So its useful the
maneuver of precocious skin excision and defatted in Krasavitov manner with its
repositioning on debrided receptive area after 24-48h. Keeping in consideration the
accuracy and the right timing of selected treatment, one should obtain favorable local and
general patients evolution.

10. The reconstruction of the severely mutilated limb

I. Ghimis
County Hospital Bacau

The act of prehension assume some reflex circuits and voluntary movements;
thats why the impulse from the sensitive and muscular receptors are very important in
the feed-back of catch and release.
The wounds cover with smooth and sensitive skin is essential.
The presentation emphasis this aspect and the one of a proper surgical strategy
established in a specific case, passing through the classical procedures to the free tissue
transfers

11. Protocols in vascular lesions in children

S. Giuvelea, D. Enescu, S. Stoicescu, .I Nedelcu, R. Alexandru , I Gutau
Plastic Surgery and Reconstructive Microsurgery Clinic
Clinical Emergency Hospital for Children Grigore Alexandrescu Bucharest

The paper briefly presents information about vascular lesions.

General aspects regarding their incidence, pathology, etiology, distribution are
mentioned.
The positive diagnosis is obtained collecting data from history, clinical examination,
imagistic techniques such as ultrasonography and MRI, the latter being the most efficient
method of diagnosis..
Therapeutic approach can be conservative or surgical.
Conservative treatment relies on corticosteroids administration, laser therapy and
pressure therapy.
The surgical treatment implies excision followed by closing the created defect
through direct suture, local or neighboring flaps, or if there is a large defect, using the
tissue expander introduced prior to the excision.

IV. Chronic Wound Management

 1. Treatment of Pressure sores
Johannes C. Bruck,

2. Chronic wound management

I.Lascar, Rodica Crutescu , Anca Breahna, S.A. Popescu, D.Zamfirescu, Dana
Vasilescu, Ioana Dragoicea, D. Ionescu, Angelica Banu, Maja Corbolokovic, A. Frunza

3. Modern dressings in chronic wounds treatment- advantages and

disadvantages
I .Lascr, Rodica Crutescu, Dana Vasilescu, Anca Breahna, D. Ionescu, Ioana
Dragoicea, Angelica Banu, A. Frunza, Maja Corbolokovic,

4. Chronic wound debridement

I .Lascar, Rodica Crutescu, Dana Vasilescu, Anca Breahna, D. Ionescu, Ioana
Dragoicea, Angelica Banu, A. Frunza, Maja Corbolokovic

5. Leg ulcers treatment by tangential excision and skin grafting (Schmeller

method)
A. Botan

6. The biological basis of passive debridement

A. Botan,

7. Old and new in dermatological debridement - chronic cutaneous

ulceration
Mihaela Leventer, Diana Placintescu, T. Patrascu

1. Treatment of Pressure sores

Johannes C. Bruck,
Berlin

The general strategy of treating pressure sores is to find means to reliably close
an infected wound, which should be able to sustain pressure and sheer forces post-
operatively and be resistant to recurrence. This should be accomplished in a period of
hospital admission as short as possible, demanding little or no expensive additional
equipment.

Debridement of the wound and closing of the defect in one procedure is the
contemporary plastic-surgical golden standard in the treatment of pressure sores
although this request finds itself in contradiction to surgical standards forbidding
primary closure of an infected wound.

Today the surgical procedures for closing pressure sores have to be stable
enough to save the patient the prone position to reduce pressure on fresh flaps because
the prone position causes enormous respiratory and psychological stress on old and/or
paraplegic patients.

A conservative treatment of stage 3 pressure sores can be achieved in selected

cases but will result in a epithelialised scar with undesirable mechanical properties.
The same accounts for the use of vacuum assisted wound debridement which due to its
high cost has a limited acceptance by hospital administrators and is only justified
.during the short period prior to surgical treatment

As a general guideline the following criteria could be used to help making a

decision for a surgical treatment:

general prognosis quo ad vitam

Cachexia
Malignancies
Disorientation
Inability for mobilisation
Missing cooperation
Cardiac decompensation
Malignant diabetes mellitus

Methicillin resistant staph. aureus as a wound colonisation today requests

isolation of a patient and hospital admission is usually connected with a complicated
logistic regiment which up to day is not compensated for by health insurance
programs.

Surgical therapy:

The surgical therapy of pressure sores should be achieved with a single

procedure consisting of total debridement of necrotic tissue and selection of the
appropriate myocutaneous flap for coverage. I.v. antibiotics should be administered
according to the preoperative antibiogram from the wound at the beginning of the
surgery and continued for 3 weeks postop.

Surgical procedures:
80% of all pressure sores occur in the pelvic region over the prominences of Os
sacrum, Trochanter major and Ischial bone.18% occur on the ankles and the heel and
the rest over the spine, iliac crest and rarely on the occiput.

The sacral pressure sore:

The most appropriate flap to cover sacral pressure sores is the myocuteaneous
gluteus maximus flap. This is pedicled preferably on the superior gluteal artery and
vein. In paraplegic patients also the inferior gluteal pedicle can be used. Generally a
unilateral flap will suffice up to a diameter of the pressure sore of 11 cm. This has the
advantage that the scar is mainly lateral of the median line which presents the major
line of pressure along the spine. Even in bigger defects where bilateral flaps have to be
used, it is most advantageous to use two flaps of different size and arc of rotation to
place the vertical scar outside the median line.

Recurrence rate with this flap which covers 80% of all pressure sores in the
elderly patients are around 5% as a single stage procedure. It does have the advantage
of allowing further advancement in case of a recurrence.

Trochanteric pressure sore:

Flap selection for this pressure sore focuses on the tensor fascia lata flap (TFL)
which has a wide arc of rotation and a negligible donor defect in the elderly, which
usually can be closed primarily.

Ischial pressure sore:

While flap selection on the other areas is standardized options for closing ischial
pressure sores have a wider variety due to the relatively high recurrence rate in this
area. The majority of ischial pressure sores develope in paraplegic patients which
generally have a low compliance and ignore limitations for mobilisation and regular
decompression of the buttocks. 25% recurrence rate is assesed throughout the
literature as compared to 5% in sacral pressure sores.

Options for closing the defect after thorough debridement are:

myocutaneous hamstring flap based on the m. biceps femoris
myocutaneous m. vastus lateralis rotation flap
myocutaneous m. glutaeus maximus rotation flap
myocutaneous m.grazilis flap

Selection of the flap will depend on the individual situation of the patient and
personal experience of the surgeon. It is again paramount to properly deride the ischial
bone to promote fusion of the muscle tissue with the spongiosa of the bone.

As a salvage procedure and if no other means for covering this pressure sore
amputation of the extremity and utilization of the soft tissues of the upper thigh may
be considered for covering recurrent ulcerations.

Mobilisation and physical therapy:

As a consequence of our own study on the durability of myocutaneous flaps in

the post operative period we advice the following mobilisation program:

During the first 3 days postop. patients are repositioned in a 2 hour rhythm plus
allowing 30 minutes compression on the flap.

After the third post operative day the two hour rhythm is continued regardless of
the flap used to cover the defect.
 Ambulatory patients are mobilised out of the bed after the 5th post-operative day
except for sitting to avoid extra tear forces on the suture lines.

Mobilisation in the wheel chair starts two weeks post operatively but the
cushion is carefully selected. Air cushions are preferred to silicon gel cushions because
of better ventilation of the skin.

The complication rate of this mobilisation program compares favourably with

the complication rates in the literature.

2. Chronic wound management

I.Lascar, Rodica Crutescu , Anca Breahna, S.A. Popescu, D.Zamfirescu, Dana
Vasilescu, Ioana Dragoicea, D. Ionescu, Angelica Banu, Maja Corbolokovic, A. Frunza
Plastic Surgery and Reconstructive Microsurgery Clinic
Clinical Emergency Hospital Bucharest

We present here a case of a woman with Pyoderma Gangrenosum associated

with inflammatory bowel disease. Diagnosis is based on combination of clinical and
histologic features. A multidisciplinary approach is paramount for the effective
management of this condition, with close involvement of a wound care specialist and a
microbiologist.

Aim: The morbidity and mortality from chronic wounds of varying etiology
represent a significant health care problem. During one year(February 2004-february
2005) we examined the moist wound healing in 80 patients whose systemic disease
produced multiple local disturbances and impaired healing. Our goal was to evaluate the
benefit of using this large variety of modern wound dressings .
Methods: Between February 2004-february 2005 we examined 80 patients.
Approximately 75% were female and 25% were male. The average age was
64.This patients presented the following pathology:
1. Venous insufficiency-80%
2. Peripheral arterial disease-5%
3. Mixed : arteriovenous-10%
4. Other causes-10%
Neuropathy
Radionecrosis
Trauma
Infectious
Foot condition related
We used the following protocol: history, complete physical examination, general
biological profile, Doppler ultrasound, oscilometry, CT-scan.
Our indicators were:
1. necessary time to obtain granulation tissue
2. quality of the granulation tissue
3. number of dressings applied per week
4. total time necessary for complete wound closure
5. total time of hospitalization
6. recurrences of lesions in the same area
Results: 30 patients from the total of 80 needed surgical debridement. 50
patients needed mechanical and chemical debridement using topical
dressings( superabsorbant polyacrilate, silver-coated charcoal, calcium alginate, argentic
sulfadiazine).
Once the wound is clean of fibrotic an necrotic tissue we promote granulation
tissue formation using foam dressings, calcium alginates, polyurethane foam,
hyaluronic acid.
In 8 cases we obtained total spontaneous reepithelialization using collagen and
hyaluronic acid.70 cases were grafted and in 2 cases we used local flaps to cover the
wound.
The donor sites for skin grafts reepithelialization was promoted using tull in 65
cases and collagen in 15 cases.
Discussion: Appropriate selection and use of dressings that optimize the local
wound environment are part of the overall treatment plan of the patient with a chronic
wound. This permitted us to obtain complete wound closure in all cases studied, with
functional and aesthetically satisfactory scars, to manipulate less traumatic and less
frequently the wounds ,to shorten the time till grafting and the time of hospitalization
and to lower the costs of wound care.

3. Modern dressings in chronic wounds treatment- advantages and

disadvantages
I .Lascr, Rodica Crutescu, Dana Vasilescu, Anca Breahna, D. Ionescu, Ioana
Dragoicea, Angelica Banu, A. Frunza, Maja Corbolokovic,
Plastic Surgery and Reconstructive Microsurgery Clinic
Clinical Emergency Hospital Bucharest

The use of modern dressings in chronic wound treatment shortens the healing
time by accelerating the debridement, granulation and epithelium growth process.
The treatment is easy to apply, does not require hospitalization; the dressings are
changed every 3-4 days, according with wounds evolution and dressing type. This
allows home medical assistance and fewer care hours compared with classical
dressings witch are made in the hospital and need to change daily or twice a day.
The disadvantage of these dressings is the high price. The treatments costs on
the other hand are lowered compared with classical dressings by eliminating the need
of hospitalization and qualified staff.
These expenses can be cut by having a fraction paid by the patient, by the
medical insurance or even the producers.
All these conditions allow fewer expenses for the medical unit. Finally, these
patients can be managed by ambulatory units.
 4. Chronic wound debridement
I .Lascar, Rodica Crutescu, Dana Vasilescu, Anca Breahna, D. Ionescu, Ioana
Dragoicea, Angelica Banu, A. Frunza, Maja Corbolokovic
Plastic Surgery and Reconstructive Microsurgery Clinic
Clinical Emergency Hospital Bucharest

Wound healing is obtained using surgical, conservatory or mixed techniques.

The wound type decides the modality of treatment. These wounds can be acute or
chronic. The chronic ones may be associated or not with a poor general status.
The debridement represents a major stage in the healing process; it consists in
cleaning the wound of devitalized tissue. It can be followed afterwards by surgical or
conservatory procedures.
The debridement types are: mechanical, surgical or chemical using classic or
modern dressings. The use of modern dressings activates and accelerates local
fibrinolisis without removing healthy tissue, starting the granulation and epithelium
growth.
The modern dressings use organisms resources at maximum, shortening the
healing time. This is a major objective in chronic wound treatment.

5. Leg ulcers treatment by tangential excision and skin grafting (Schmeller

method)
A. Botan
Burn Centre & Plastic Surgery Department
Universiatry Emergency County Hospital of Targu Mures

Leg ulcers are over 50% of all chronic wounds operated in our department, and
for this reason,in the last 6-7 years, we have imagined a treatment protocol for large
lesions (over 8-10 cm diameter) especially. The most part of these ulcers are first cared
in the office for about 6-8 weeks, by polyurethane foam (Ligasano) dressings which
are changed at 3,5 either 7 days, depending on the exudate quantity of every wound
(the Ligasano foam is always combined with compression therapy by elastic
bandages). After the complete passive debridement by this method (which we called
synthetic maggot therapy), all patients with large ulcers are admitted for surgery in
the hospital. All wounds clean, granulate and have a small quantity of exudates;
besides this, the bacterial population decrease and change into a less aggressive one, as
well as the area of lipodermatosclerosis decrease in size and the wound edges soften.
Ligasano dressings are also used during the first 10-14 days in the hospital, before
surgery, afterthat the ulcers are debrided by tangential excision (Schmellers method);
the final result of this shaving is a supple, well bleeding, pre-fascial surface. The
hard, infiltrated edges of the ulcers are also excised, that is why the remaining wound
is always larger than the initial one. We could notice that in the rare cases when we
didnt use (for different reasons) the Ligasano foam dressing before surgery, we
couldnt obtain the same well vascularised wound bed and beside this, the area of
lipodermatosclerosis did not decrease in size and wound edges didnt soften. After this
tangential excision, the remaining bleeding surface was covered immediately by
meshed split skin grafts ( when brisk bleeding occurres, skin grafting can be delayed
for 24-48 hours); 10-14 days after full take of grafts, the Ligasano dressing and
compression therapy are resumed (but the dressings are now changed after 14-21
days). This treatment is maintained for another 3-4 months and is then replaced by
medical compressive stockings, antithrombotic creams and gels and oral Detralex.
Even though this good surgical management, we could notice a 30% rate of
recurrences in the next 2 years.

6. The biological basis of passive debridement

A. Botan,
Burn Centre & Plastic Surgery Department
Universiatry Emergency County Hospital of Targu Mures

According to DORLANDS ILLUSTRATED MEDICAL DICTIONARY 2003,

debridement means the removal of foreign material and devitalized or
contaminated tissue from or adjacent to a traumatic or infected lesion, until
surrounding healthy tissue is exposed.The same work classifies debridement into 4
categories: a) natural spontaneous debridement (also called physiological either
autolytic); b) passive debridement by different specialized dressings; c) enzymatic
debridement; d) surgical debridement. This topic analyses all 4 categories listed above
with all advantages and disadvantages of these methods, underling the passive
debridement and that by polyurethane foam dressing especially. The last 3 methods
already mentioned support and facilitate in fact the natural autolytic debridement
process, every one having particular indication and benfit which should be adapted to
each case. No one of these methods is never considered to be a panacea which
means that each one should be used when only the advantages are greater from a
distance then the disadvantages. Concerning the passive debridement by
polyurethane foam (Ligasano), this one has all the advantages of maggot therapy
with no one of its disadvantages, that is why we called this method synthetic maggot
therapy. In short, the amazing effects of Ligasano PUR foam are due to the special
structure and properties of this dressing which give particular qualities such as: a)
wound activation by mechanical stimulation (micromasage) of the lesion surface
and surrounding tissues improving the blood and nutrients supply of all area; b)
decrease of pressure on the wound surface which facilitates collagen deposition and
granulation; c) amazing suction power of exudates and debris , maintaining a
permanent wet wound environment which improves autolytic debridement; d)
improves the cost/efficiency ratio by avoiding expensive surgical techniques,
decreasing the in-patient period and the frequence of dressing change, and decreasing
the total treatment cost as well by improving the social and professional reconnection
of the most part of patients treated in this way. These are some advantages of
passive debridement, a complex treatment in which, according to the authors
experience, Ligasano PUR foam dressing has the most qualities.
 7. Old and new in dermatological debridement - chronic cutaneous
ulceration
Mihaela Leventer1, Diana Placintescu2, T. Patrascu3,
1
Clinical Hospital Colentina, Bucharest
2
Dermastyle Clinic, Bucharest
3
Cantacuzino Hospital, Bucharest

Debridement is defined as the removal of foreign material and devitalized or

contaminated tissue from / adjacent to a traumatized or infected lesion, until
surrounding (and underlying, in the case of a cutaneous ulcer) healthy tissue is exposed.
A variety of debridemet methods exist for the removal of necrotic material from
the surface of cutaneous ulcers.
A physician should adopt the preferred debridement method in accordance with
the type and appearance of the necrotic material. Healing of a cutaneous ulcer is a
dynamic process, subject to changes.
Will discuss different types of debridement procedures and the old / new
approach in this field:
Surgical debridement
Autolytic or chemical debridement
Hydrodebridement
Maggot therapy
Different types of dressings