The coverage of soft– tissue defects of the hand specially volar side needs special consideration. Although certain local flaps have been described and used for resurfacing the palm, Extensive injury requires distant or free flaps for coverage. abdominal pedicle flap has been traditionally used for extensive hand injuries, however there is no doubt that one of the ideal tissues for resurfacing the volar of hand is plantar tissue. We reconstructed the hand with a new procedure of combined medial plantar and medial pedis free flap, and compared it with 15 cases, whom their extensive palm injuries reconstructed with abdominal pedicle flap. The result was significantly better in respect to sensation, Texture of the Hand and patient satisfaction in compare of Abdominal flap.

Background: Upper tibia defects, type3b Gustilo, due to huge size and volume are very difficult to reconstruct, usually several operations are needed for bone and soft tissue defects and the definite one stage reconstruction is yet to be found.Objectives: In this article we reintroduce the rib- latissimus flap as an acceptable method to reconstruct tibia defects in selected cases.Materials and Methods: The latissimus muscle with one or two ribs revascualrized by reverse flow from perforators is harvested, the ribs are bisected after harvest yielding four to six struts of vascularized bone to fill the huge upper tibia defect. Internal fixation is very important and we favor LCP plates for long bone fixation and the rib struts are fixed in place by small titanium screws to maintain the “picket fence” design. The muscle is then wrapped around the ribs and the defect is completely reconstructed.Results: During the past 9 years we have used the rib-latissimus dorsi (RLD) muscle flap, without serratus muscle, in 7 patients with combined bone and soft tissue defects of the upper tibia. All the flaps healed without any major complications and only one stress fracture was seen and treated. The ribs healed and in a median of 14 months hypertrophied to the size of the upper tibia. Nonunion was not observed and patients with lower extremity defects were able to bear full weight within an average of seven months.Conclusions: The fractures of tibia type 3a and 3b Gustilo are devastating injuries requiring several operations. Several combinations of RLD-Serratus have already been reported but a rib-LD muscle with “picket fence” design has not been reported.The RLD transfer with two ribs divided into four struts for bone coverage and muscle to cover all the upper tibia soft tissue defect can be a useful tool in the armamentarium of the surgeon treating combined defects in a single stage.

Background: Vaginal aplasia is a rare congenital anomaly with different surgical techniques suggested for vaginal reconstruction. McIndoe vaginoplasty is an easy one of these surgical methods with a low morbidity rate, but its long-term results need to be further investigated. Therefore, the female genital anatomy and sexual function was examined after performing McIndoe vaginoplasty in patients with mullerian anomaly or androgen insensitivity syndrome. Materials and Methods: In this historical cohort study, the data of 25 patients undergoing McIndoe vaginoplasty with amniotic graft from 2006 to 2017 at four selected hospitals of Shiraz affiliated with Shiraz University of Medical Sciences in Iran were extracted from medical records. Then, the patients were called to refer for physical examination and fill the Female Sexual Function Index (FSFI) questionnaire. In addition, 31 women of the same age range and without a sexual problem, vaginal surgery, or delivery were selected as the control group. Finally, the results of vaginal measurements and FSFI scores of the two groups were compared together. Results: The average vaginal length of the case and control groups were 5. 60± 2. 38 and 8. 47± 1. 31 cm, respectively. Furthermore, the mean proximal vaginal diameter in case and control groups were measured 2. 94± 0. 92, and 4. 12± 0. 70 cm, respectively (P<0. 001). The mean FSFI score of the case group was 12. 81± 7. 87, and 24. 19± 2. 90 for the control group (P<0. 001). The vaginal indices and FSFI of the patients using mold routinely were still lower than the control group (P<0. 05) although theyhad a larger vagina (P<0. 001). Conclusion: Vaginal reconstruction using McIndoe vaginoplasty with amniotic graft failed to provide normal vagina function and anatomy for patients with congenital vaginal aplasia in long-term followup.

Introduction: Coverage of bone grafts is very important in reconstructive surgery. In edentulous alveolar ridges this coverage is particularly important for supporting dental prostheses. Here we present the case of a patient with a large deficient maxillary anterior region that was reconstructed with a bilateral palatal sub mucosal periosteal connective tissue flap: a soft tissue reserve for upper jaw reconstructive surgeries. The bilateral pediculated palatal periosteal connective tissue flap was used for coverage of a large bone graft in the anterior maxillary region.Conclusion: Palatal sub mucosa can be used as a soft tissue reserve in upper jaw reconstructions.

Background: Reconstruction of facial skin defects is challenging. Skin flaps and grafts are well-known techniques for reconstructing these defects. The outcomes of the surgeries can vary depending on the surgical procedures and the patient's characteristics. Objectives: This study aimed to compare the results of reconstructing facial skin defects using skin grafts and flaps in patients referred to Imam Reza Hospital, Birjand, Iran. Methods: This quasi-experimental study was performed on 100 patients with tumors and traumatic lesions in the facial area referred to the plastic surgery service of Imam Reza Hospital, Birjand, Iran. For comparison, the data of 50 patients with skin grafts and 50 patients with flaps who underwent facial skin defect repair surgery were collected. Patients' demographic characteristics were extracted from their hospital records. The final reconstruction results were evaluated based on the presence or absence of aesthetic or functional complications three months after surgery. Results: The mean ages of participants were 64. 6±, 14. 0 and 58. 3±, 19. 1 in the flap and graft groups, respectively. Women comprised 26 (52%) of the flap and 22 (44%) of the graft groups. The mean size of lesions in the graft group was 21. 3±, 17. 3 cm and 4. 7±, 3. 9 cm in the flap group (P=0. 001). The frequency of aesthetic and functional complications in the flap group was 13 (26%) and 9 (18%), and in the graft group was 24 (48%) and 15 (30%), respectively. The frequency of aesthetic complications in the flap group was significantly lower than that in the graft group (P=0. 023). There was no significant difference between the two groups in terms of the frequency of functional complications (P=0. 160). The frequency of disease recurrence was not significantly related to surgical technique (P=0. 749). Furthermore, the lesion location had a significant association with the surgical technique (P=0. 009),however, the number of surgeries had no significant association with the surgical technique (P=0. 389). Conclusion: In general, except for when there is an indication for using a method, the reconstruction of facial skin defects using a skin flap will have better results than a skin graft.

Burns account for a significant proportion of injuries, and of these the face, neck, and anterior torso are commonly affected. Burn scars remain a lasting reminder of the insult both for the patient and the outside world. There is little doubt that the change in appearance and the limitation imposed by a burn scar contribute to negative body image. Treatment of hypertrophic scars in the neck has been quite challenging if there is no intact tissue for local flaps. So application of full-thickness skin grafts could be of great value. We applied full-thickness grafts obtained from lower abdominal skin for treatment of severe neck contractures in four patients when other treatment modalities such as local flaps could not be used. Full-thickness skin graft of the neck is a safe and reliable treatment option with fairly good functional and aesthetic results. It has little donor site morbidity in spite of providing a large surface area of full-thickness skin.

Boari flap construction and ureteroneocystostomy is an appropriate technique for repairing the injuries in the distal ureter that result in shortening of the ureter. We report the use of laparoscopic distal ureterectomy consisting resection of the bladder cuff and Boari flap construction in a patient with low-grade transitional cell carcinoma of the distal ureter.

Background: Although bone grafts are commonly used in reconstructive surgeries, they are sensitive to local perfusion and are thus prone to severe resorption. Biphosphonates can inactivate osteoclasts and can be used to control the undesirable bone resorption.Objective: To assess the effect of administration of biphosphonates on bone resorption.Methods: 20 patients with bony defects who were candidates for free autogenous grafts were randomized into "pamidronate" and "control" groups. Bone segments were soaked in either pamidronate solution or normal saline and were inserted into the area of the surgery. Bone densities were measured post-surgery and in 6-month follow-up. Data were obtained via Digora software and analyzed.Results: The mean±SD bone density in pamidronate group changed from 93.4±14.6 to 93.6±17.5 (p<0.05), in the control group the density decreased from 89.7±13.2 to 78.9±11.4 (p<0.05). The mean difference of bone density in anterior areas of the jaws showed higher DXA in comparison to posterior regions (p=0.002).Conclusion: Locally administered pamidronate affects reduction in bone resorption.

Purpose: To present the results of a two-stage technique used for the treatment of proximal hypospadias with severe curvature.Materials and Methods: The medical records of children with proximal hypospadias and severe curvature were retrospectively analyzed. A 2-stage procedure was performed in 30 children. In the first stage, the release of chordee was performed, and a well-vascularized preputial island flap was created. The vascularized island flap was brought anteriorly and sutured over the ventral surface of the glans and degloved penile shaft. The second stage was performed 6-8 months later. A neourethra was reconstructed by the tubularization of the preputial-urethral plate utilizing the principles of Duplay technique. All surgical procedures were performed between 2005 and 2011.Results: The mean age of the patients was 4.4 years (1–17 years). The mean duration of urethral catheterization was 6 days after the first stage and 10 days following the second stage. The flaps were viable in all of the children. There was no residual chordee. Following the second stage (n=30), complications developed in 11 children (36%), namely, a fistula in 7, a pinpoint fistula in 3, and a diverticulum formation in 1. The cosmetic outcome was satisfactory. Uroflowmetry measurements were evaluated, and only one patient had a diverticulum formation at the late follow-up.Conclusion: Vascularized preputial island flap is an alternative to free grafts for the reconstruction of the urethra. The main advantage of this flap technique is the creation of a thick, healthy and well-vascularized urethral plate. The advantages of this technique include better aesthetic appearance, an acceptable complication rate, and a very low rate of diverticula formation.

Background: Skin flap procedures are employed in plastic surgery, but failure can lead to necrosis of the flap. Studies have used bone marrow mesenchymal stem cells (BM-MSCs) to improve flap viability. BM-MSCs and acellular amniotic membrane (AAM) have been introduced as alternatives. The objective of this study was to evaluate the effect of BM-MSCs and AAM on mast cells of random skin flaps (RSF) in rats. Methods: RSFs (80 × 30 mm) were created on 40 rats that were randomly assigned to one of four groups, including (I) AAM, (II) BM-MSCs, (III) BM-MSCs/AAM, and (IV) saline (control). Transplantation was carried out during the procedure (zero day). Flap necrosis was observed on day 7, and skin samples were collected from the transition line of the flap to evaluate the total number and types of mast cells. The development and the total number of mast cells were related to the development of capillaries. Results: The results of one-way ANOVA indicated that there was no statistically significant difference between the mean numbers of mast cell types for different study groups. However, the difference between the total number of mast cells in the study groups was statistically significant (p = 0. 001). Conclusion: The present study suggests that the use of AAM/BM-MSCs can improve the total number of mast cells and accelerate the growth of capillaries at the transient site in RSFs in rats.