The fasciovascular flap: a new vehicle for islet transplantation.

In order to determine whether pancreatic islets could be neovascularized by a fasciovascular flap (FVP), islet transplant studies were conducted in Lewis rats. Islets from two donors were isolated by collagenase digestion and discontinuous gradient centrifugation on Ficoll. These islets were injected in syngeneic recipients either into random groin SC fat as a control, or into a flap composed of fascia and fat elevated from the groin based on the superficial inferior epigastric vessels. After two wk, islet viability was assessed by histological analysis. The degree of neovascularization of the islet tissue was evaluated with India ink injection through the vascular pedicle. Whereas control islets degenerated and did not show clear signs of neovascularization, FVP-islets showed rich neovascularization and viability as a large sheet of islet clusters. These results have demonstrated that the FVP-flap is a novel recipient site which can support a large quantity of islet tissue. This model constitutes a unique neo-endocrine pancreas flap, which can be subsequently transplanted at will to transfer the established neo-endocrine pancreas to a desired site using microvascular surgical technique.

Immediate reconstruction of full-thickness chest wall defects.

Twenty-one patients had full-thickness chest wall defects reconstructed at the New York University Medical Center in the last ten years. Marlex mesh provided chest wall stability in 5 patients. In 9 patients with radiation ulcers Marlex mesh was not required; a severe fibrotic reaction had obliterated the pleural space and prevented paradoxical motion. Partial sternal resections did not require Marlex stabilization, while a total sternectomy resulted in marked ventilatory insufficiency in a patient who would have benefited from the use of a stabilizing material. Random pattern flaps were used initially; more recently, axial pattern, myocutaneous, and myocutaneous free flaps were employed. Necrosis developed in 4 (36%) of the 11 patients with random pattern flaps, but was not seen with the newer flap techniques. Myocutaneous free flaps provided uncomplicated coverage of and stability to three large, potentially contaminated defects. It seems that with the currently available flap techniques and the methods of chest wall stabilization, immediate repair of all full-thickness chest wall defects is possible.

Surgical techniques in penile revascularization.

A review of the current status of penile artery revascularization and its methodology is presented. Microsurgical anastomosis of the inferior epigastric artery or central arteries produces good results in younger men. Older patients or those with diabetes, hypertension or who have had coronary bypass surgery do not appear to have good results.

Management of compartmental syndrome. Diagnostic and surgical considerations.

Compartmental syndrome is a condition in which swelling within a closed anatomic space increases the intracompartmental pressure to compromise the circulation and function of tissue within that space. Unless this condition is recognized early and treated by prompt surgical decompression, permanent neuromuscular deficits may result. In those instances in which early clinical evidence of this syndrome is difficult to assess, monitoring of intramuscular pressures may be valuable adjunct in the clinical evaluation of patients at risk for this syndrome. The association of compartmental syndrome with a wide variety of circumstances and the importance of an early diagnosis make it essential that all physicians be familiar with this condition. As physician awareness and recognition of this condition increase, the complications associated with it can be greatly reduced.

Clinical experience with a microvascular anastomotic device in head and neck reconstruction.

BACKGROUND: Despite numerous refinements in microsurgical technique and instrumentation, the microvascular anastomosis remains one of the most technically sensitive aspects of free-tissue transfer reconstructions. MATERIALS AND METHODS: Concurrent with the development of microsurgical techniques, various anastomotic coupling systems have been introduced in an effort to facilitate the performance and reliability of microvascular anastomoses. The microvascular anastomotic coupling device (MACD) studied here is a high-density, polyethylene ring-stainless steel pin system that has been found to be highly effective in laboratory animal studies. Despite its availability for human clinical use over the last 5 years, reported clinical series remain rare. Our clinical experience with this MACD in 29 head and neck free-tissue transfers is reported herein. RESULTS: Thirty-five of 37 (95%) attempted anastomoses were completed with 100% flap survival with a variety of donor flaps, recipient vessels, and clinical contexts. Two anastomoses were converted to conventional suture technique intraoperatively, and one late postoperative venous thrombosis occurred after fistulization and vessel exposure. CONCLUSIONS: We conclude that the MACD studied here is best suited for the end-to-end anastomosis of soft, pliable, minimally discrepant vessels. Previous radiation therapy does not appear to be a contraindication to its use. Interpositional vein grafts may also be well suited to anastomosis with the device. When carefully and selectively employed by experienced microvascular surgeons, this MACD can be a safe, fast, and reliable adjunct in head and neck free-tissue transfer reconstructions, greatly facilitating the efficiency and ease of application of these techniques.

Alginate microbead release assay of angiogenesis.

Recently, the acceleration (and retardation) of blood vessel growth has been an increasingly frequent subject of study. With its potential application to a wide range of clinical disease processes, investigation certainly remains essential and promising. While in vitro investigation is traditional, well-controlled, and objective, studying angiogenesis in vivo can be quite difficult for a number of reasons. One major reason is the inherent tissue differences associated with blood vessel growth. Because all tissues are different, certain tissues tend to be inherently more vascular than others. As such, the growth (and concentration) of blood vessels occurs at different rates and proportions depending on that specific tissue. In the past several years, most in vivo angiogenesis work has been performed in the sclera as it allows for relatively easy access and the possibility of repeated observation. The sites to which investigation of angiogenesis might be applied, however, are invariably quite different and therefore additional tissues such as solid organs, fascia, muscle, and skin need to be studied as well. How can this be performed?

Microsurgery--looking ahead.

The evolving areas of microsurgery pertinent to hand surgery are briefly described and outlined. The spectacular developments in the recent past are merely glimpses of what may yet be ahead for hand surgery. This is illustrated by a science fiction story of the management of an amputation injury in outer space in which many of the currently evolving technologies are employed.

Aesthetic reconstructions of the leg after trauma.

Lower extremity trauma often results in significant skin or contour deformities as a result of the tissues destroyed. Such deformities are poorly tolerated by most patients, especially younger women. To achieve a satisfactory aesthetic reconstruction, the surgeon must be familiar with the special anatomy of the lower extremity as well all the different reconstructive options at his or her disposal. Minor scars or contour deformities can be corrected by traditional methods of scar revision or serial excision. Tissue expanders or silicone implants have a somewhat limited role in the lower extremity as compared with elsewhere in the body. Most major defects require free flaps to replace the surface or contour. Because of the importance of aesthetic results in the legs, free flaps should be utilized more often during the original trauma surgery if their use is deemed necessary for aesthetic reasons (Case 6).

Bilateral free flap breast reconstruction.

Bilateral mastectomies are relatively frequent. Free flaps from the abdomen, buttock, and lateral thigh can be used for simultaneous or staged reconstructions. The more extensive surgery is well rewarded by the permanent and gratifying results achieved. For patients unsuitable for implants or who have had failed implant reconstructions, such autologous tissue reconstructions are important alternatives.

Superior gluteal free flap breast reconstruction.

The authors substantial experience with the superior gluteal free flap for breast reconstruction indicates that this is a more difficult but important free flap for breast reconstruction. Compared with the standard transverse rectus abdominis myocutaneous (TRAM) free flap, it is a much less forgiving operation with many specific technical details. With careful attention to details on flap design, recipient vessel selection anastomsis, and flap insetting, the success rate and morbidity of the gluteal flap operation are highly acceptable. For patients unsuitable for the TRAM flap for autologous tissue reconstruction, this is a very valuable alternative. It can achieve some spectacular results in breast reconstruction in terms of volume, replacement, and projection--even in very thin patients.

Microvascular free flap breast reconstruction.

As in other areas of reconstruction, microvascular free flaps have earned a definite role in certain breast reconstructions difficult to accomplish with conventional techniques. With improvements in techniques and survival rates, the advantages of such reconstructions have become increasingly more attractive to the patient and the surgeon.

The evolution of the surgical management of severe lower extremity trauma.

A hundred years ago, the question of whether to amputate a severely injured extremity could be answered rather easily and did not pose a serious dilemma. However, the increasing reconstructive capabilities have permitted the retreat to amputation to be made less frequently and occasionally create a dilemma concerning the best means of securing optimal function for the traumatized extremity. The surgeon must carefully balance the extent of trauma with the likelihood that his or her reconstructive efforts would surpass the functional results afforded by prompt amputation and prosthetic fitting. Although the mechanisms of limb destruction have changed in the past 2 centuries, the fundamental dilemma confronting the trauma surgeon has remained unchanged. In the words of Samuel D. Gross: "The cases which may reasonably require and those which may not require interference with the knife are not always so clearly and distinctly defined as not to give rise, in very many instances, to the most serious apprehension ... that, while the surgeon endeavors to avoid Scylla, he may not unwittingly run into Charybdis, mutilating a limb that might have been saved, and endangering life by the retention of one that should have been promptly amputated."

Lower extremity nerve injuries.

The surgical and anatomic features pertinent to lower extremity nerve injury are reviewed. The common problems associated with specific nerve lesions are discussed and reparative recommendations are offered. A more informed, aggressive approach to lower extremity nerve repair is suggested.

Reconstruction of foot injuries.

Foot injuries constitute a spectrum of problems that can be classified by severity. The development of successful techniques for the treatment of lower leg injuries has made the severity of a concomitant foot injury a key factor in determining the overall salvageability of the leg. A more complete classification of foot injuries is therefore needed and has been proposed. Preoperative assessment of foot injuries differs in the acute versus the delayed presentation. The acute case requires evaluation of wound conditions, exposed structures, and associated proximal injuries. The chronic injury requires gait analysis, study of weight-bearing patterns by Harris mat prints, skeletal evaluation, mapping of plantar sensation, and, in some cases, angiography. Thorough knowledge of foot anatomy is essential for developing a rational plan for treatment. The significance and course of the medial calcaneal nerve and the anatomy of the plantar nerves have not been fully appreciated in most reports on the treatment of foot injuries. The recognition of the proximal plantar subcutaneous plexus blood supply has modified the understanding of plantar flap design. It has simplified and improved the safety of dissection of sensate plantar flaps. A plethora of both local and distant flap options exist for the treatment of foot injuries. The foot is divided into four major areas based on different requirements for reconstruction and the types of flaps available. These areas are the proximal plantar area; the malleoli, Achilles tendon, and posterior (non-weight-bearing) heel area; the distal plantar area; and the dorsum. The options for coverage have been discussed in detail, and a summary of the reconstructive strategy by area has been presented in Table 3. Complex (type III) injuries are special injuries owing to their severity and multiple components. They require a careful initial evaluation for both feasibility and advisability of extremity salvage. Treatment of these injuries consists of bony stabilization and soft-tissue debridement followed by flap coverage.

Microvascular free flaps in breast reconstruction.

There is no longer any doubt that free flaps can achieve the best breast reconstruction. Proof is the rapidly increasing popularity of the method. Its many advantages, the indications for each flap, and the technical refinements are presented.

Principles of flap prefabrication.

Clinical flap prefabrication can be classified according to the basic technique of plastic surgery used for the prefabrication. There are currently three methods: (1) delay or expansion; (2) grafting; and (3) vascular induction by staged transfer. Illustrative cases are given to point out the advantages and indications for each method. A fourth, still experimental, method is based on cell biology advances that are looming on the horizon and may have revolutionary future clinical applications.

Vascularized calvarial flaps.

Vascularized calvarial transfers offer many advantages. In this article the anatomic (soft tissue, vascular, osseous) basis of flap design is summarized, and the technical details of two calvarial flaps, the temporoparietal and the frontoparietal, are presented.

Breast reconstruction by superior gluteal microvascular free flaps without silicone implants.

The author's experience with 10 gluteus maximus myodermal free flap breast reconstructions is reviewed against the current methods of reconstruction using silicone implants, latissimus dorsi flaps, regional skin flaps, and rectus abdominis myodermal flaps. The superior gluteal free flap can achieve a reliable, permanent, and aesthetic reconstruction of the breast without silicone implants. The softness, projection, natural appearance, and patient satisfaction are excellent compared with other methods. It is particularly useful in patients who object to the use of artificial implants, are not suitable for regional flaps, or have disappointing results from previous reconstructions. Technical modifications of the flap design and selection of the recipient vessels are important.

Wall Street's growing influence on plastic surgery.

The advent of managed care has unleashed market forces on the health care system. One result of these new pressures is a shift from nonprofit to Wall Street-based financing. This report quantifies these trends by comparing health organizations' financial structures in the 1980s and now. The reasons behind this shift and the function of the stock market are examined. A review of Wall Street's key financial measures confirms that health care has shifted to the stock market as its principal means of financing. The stock market works by assigning a current price to a company's stock based on estimates for future earnings. Thus, companies desire predictability in their costs, revenues, and profits. Plastic surgeons can master this system by meeting the challenges imposed by Wall Street financing. Important steps include continuously measuring costs and outcomes of procedures, demanding cost data from hospitals and payers, using these data to improve costs and outcomes, and taking advantage of the system's openness to innovation and easier access to capital. As they seek to protect their role as medical decision makers under the new free-market system, plastic surgeons can benefit from understanding the mechanisms of the stock market.

The financial environment of aesthetic surgery: results of a survey of plastic surgeons.

To gather information about aesthetic surgery's current practice structures, competitive environment, patient price sensitivity, and marketing and practice development requirements, a two-page survey was developed and mailed to all 1180 members of the American Society for Aesthetic Plastic Surgery. A total of 632 surveys were returned (response rate of 54.5 percent). Most aesthetic plastic surgeons said they were in solo practice (63.3 percent). More than two-thirds described the marketplace as "very competitive," with 59 percent reporting 25 or more surgeons offering aesthetic surgery in their area. They estimated their patients' average income at $62,800. Nearly all plastic surgeons labeled their patients as "moderately price sensitive" (62.3 percent) or "very price sensitive" (30.6 percent). Similarly, 23.2 percent estimated that they had lost 20 or more patients within the last year for reasons of price. Practice development and marketing efforts represented an average of 7.3 percent of plastic surgeons' working time. Parameters associated with a high percentage of time devoted to these activities were solo practice, percentage of revenue from aesthetic surgery greater than 50 percent, a practice environment designation of moderately or very competitive, and ten or more area surgeons offering aesthetic surgery (p < 0.05). High patient income led to only slight decreases in price sensitivity and did not significantly reduce the amount of time spent on marketing and practice development. Although the rest of the healthcare industry has undergone a period of consolidation, aesthetic surgeons have been able to resist these changes. The results of this survey suggest that the fragmented nature of the aesthetic surgery industry is associated with additional burdens on plastic surgeons. As the aesthetic surgery market becomes more competitive, plastic surgeons may benefit from consolidation to reduce costs and maximize efficiency.