Managing the outer limits of reconstruction with microsurgical free tissue transfer.

Six patients had major deficits reconstructed with microsurgical free tissue transfer. In contrast to some opinions that free tissue transfer is a "method of last resort," these patients were selected for microsurgical reconstruction as a method of first choice due to the qualities desired in the reconstruction, the reliability of the technique, and the desire to minimize the functional or aesthetic deficit at the donor site. Microsurgical techniques allowed a reconstruction in these cases that would have been difficult or impossible by conventional techniques, while they markedly improved the quality and reliability of the reconstruction and decreased the donor morbidity. Microsurgical free tissue transfer has been reported to have a success rate of 94% in centers where a significant volume of surgery is done. We believe the continued refinement of microsurgical techniques and their increased application will improve the results of reconstruction in a large category of severe traumatic and cancer defects.

Mandibular reconstruction with microvascular bone transfer. Series of 10 patients.

Mandibular reconstruction with microvascular bone transfer was carried out in 10 patients, including 8 with far advanced intraoral carcinoma and 2 with posttraumatic facial and mandibular defects. Eight patients presented with compromised defects as a result of radiation injury, infection, and scarring. Nine patients experienced primary bony union with complete functional and esthetic reconstruction of the mandible, and two patients eventually received dentures. This technique has resulted in a more effective, more reliable, and earlier reconstruction compared with conventional methods.

Ischemia of the upper extremity due to noncardiac emboli.

Nine cases of microemboli of arterial origin to the upper extremity are reported. The source of emboli in five of these cases was in the subclavian artery compressed by osseous anomalies in the thoracic outlet. Three aneurysms, one in a subclavian vein graft and two traumatic false aneurysms in the hand, were also noted to be the sources of distal emboli. One unproved case of emboli from an atherosclerotic plaque of the subclavian artery is also reported. Chronicity of symptoms and delay in operation are often noted and lead to difficulties in surgical management. The compressing osseous structures causing the vascular lesion in the thoracic outlet syndrome must be resected, along with removal of the source of emboli. Cervicodorsal sympathectomy is often needed in cases of extensive thrombosis and/or long-standing ischemia. Embolectomy is usually a futile procedure when the main arterial trunk contains old, organized thrombus. Differential diagnostic problems between collagen vascular disease, vasculitis, vasospastic disease, and microembolic disease in cases of unilateral Raynaud's phenomenon are pointed out.

Reconstruction with free bowel autografts after pharyngoesophageal or laryngopharyngoesophageal resection.

Reliability has become a foremost requirement in pharyngoesophageal reconstruction because of the disastrous consequences after a failure. Our institution has achieved a 97 percent success rate using the free bowel autograft. We believe that this represents a significant accomplishment and designates the free bowel autograft as the reconstructive method of choice after pharyngoesophageal resection.

Microvascular free tissue transfer in head and neck and esophageal surgery.

Successful reconstruction for excisional defects of the head and neck and esophagus was accomplished in 93 percent of our patients using microvascular free tissue transfer. Complete failure occurred in 7 percent of the patients. Major defects after head and neck cancer surgery constituted the main indication for use of microvascular free tissue transfer for reconstruction. Ninety-four percent of the patients had undergone an extensive excisional procedure. A wide range of cutaneous, myocutaneous, and osteocutaneous free flaps, as well as free bowel autotransfers were used. Complete failure was three times higher in the previously irradiated patients (4 of 41 patients) compared with nonirradiated patients (1 of 34 patients). Morbidity and mortality rates were consistent with expected ranges in patients who were undergoing major head and neck resection. Donor site complications occurred in 23 percent. Thin flaps are favored for reconstruction of anterior defects in the oral cavity, whereas bulkier flaps are more suitable for deeper defects in the oropharynx and hypopharynx. The advantages are both aesthetic and functional. The free jejunal autograft is considered the reconstructive method of choice for defects produced by laryngopharyngoesophagectomy. Highly developed and sophisticated microsurgical skills continue to be the mainstay of success. The implication of free tissue transfer failure, especially for defects of the upper aerodigestive tract, are impressive in terms of morbidity, mortality, and cost. These considerations limit the application of this method of reconstruction to centers that have sophisticated and productive reconstructive surgeons with microsurgical skills.

Refinements in free flaps for head and neck reconstruction.

The decade of adolescence of microsurgical techniques of head and neck reconstruction has led to a further clarification of the indications and methods for microsurgical reconstruction of head and neck defects. A review of the defects and the variety of flaps available for reconstruction leads to an increased understanding of the advantages and disadvantages of these various methods. When assessing a defect in the head and neck for microsurgical reconstruction, the surgeon should consider the various advantages of the flap to be used and weigh them against the disadvantages. The specialty has long since passed the point when one or two donor flaps could be considered to answer all of the reconstructive questions. We must now thoughtfully consider all the available options before settling on a course of treatment.

Microsurgical adjuncts in salvage of the ischemic and diabetic lower extremity.

Revascularization of distal occlusive disease in the diabetic has been markedly enhanced by microsurgical techniques. Extremely small, heavily calcified vessels are able to be reliably reconstructed using microsurgical techniques and high magnification. Additionally, revascularization followed by microsurgical free tissue transfer has proven to be a valuable alternative to amputation in patients with major soft-tissue loss, or bony or tendon lesions requiring soft-tissue reconstruction. Although metabolic risks are potentially high, we have experienced a very low morbidity and mortality with a thorough medical work-up and follow-through in conjunction with these major procedures. It is our expectation that judicious application of microsurgical techniques in treatment of the ischemic diabetic lower extremity will continue to improve the chances for long-term bipedal ambulation in this patient population.

Microsurgical reattachment of totally amputated ears.

At a time when microsurgical reattachment of amputated limbs is commonplace, successful reattachment of total ear amputations is rare. Avulsed vessels, small diameters (0.3 to 0.7 mm), and technical difficulties provide primary obstacles. Three clinical cases of ear reattachments are presented which encompass the clinical spectrum of an uncomplicated success, a salvage of an impending failure, and a late failure due to venous thrombosis. In all cases there was difficulty with identification of vessels, with differentiation of arteries from veins, and in the performance of venous anastomoses. Vein grafts were necessary in two of the three patients. Anticoagulation was essential in alleviating venous thrombosis. Medicinal leeches (Hirudo medicinalis) were used to salvage one case with venous thrombosis. Despite the technical difficulties and long operative times, successful microvascular reattachment of an amputated ear is superior to any other means of reattachment or reconstruction.

Electromagnetic flowmetry--an experimental method for continuous blood flow measurement using a new island flap model.

We describe a reliable experimental method for direct, continuous measurement of the rate of blood flow in an island skin flap, using an electromagnetic flowmeter applied to the artery of the flap. The canine saphenous island flap model, developed as part of this study, is a large (11 x 14 cm) island flap, based solely on the saphenous artery (2 mm in diameter). We describe the anatomy of the flap and the method of raising it. Electromagnetic flowmetry is the only method of blood flow determination that provides immediate, continuous, and quantitative measurement of flow. We describe the principles and pitfalls of the electromagnetic flowmeter and the numerous rules of practice that must be observed to obtain consistent results. A validation study was carried out, in which we simultaneously measured arterial inflow with the flowmeter and venous outflow from the flap using direct collection. This study was based on the assumption that at any point in time the arterial and venous rate of flow were equal. We present the results of the study, which show an extremely close linear relationship between the measured and actual rates of flow. We intend to use this experimental method to study the factors that affect the rate of blood flow in free skin flap transfer.

Prefabricated jejunal free-tissue transfer for tracheal reconstruction: an experimental study.

Reconstruction of long-segment tracheal defects is a problem for the reconstructive surgeon. Difficulties arise with the use of prosthetic materials because of their propensity for infection and extrusion. Autologous tissue is limited by poor structural characteristics and technical complexity. We propose a simple composite bioprosthesis that, through a process of prefabrication and subsequent neovascularization, may provide a functional tracheal analogue superior to existing forms of reconstruction. Ten rats had composite flaps constructed by combining an isolated, perfused, mucosectomized segment with an outer covering of a ring-reinforced woven Dacron vascular graft. This unit remained in the intraabdominal milieu for 20 days and was then inspected for viability, incorporation of jejunum and graft, flexibility, and tolerance to negative pressure. Seven experimental animals survived the initial phase. The jejunal bioprostheses in all cases tolerated negative pressures to -200 mmHg, rotation of 180 degrees, and flexion to 90 degrees without collapse of the graft segments. Vascular casts and standard histologic examination showed neovascularization of the Dacron graft and dense fibrovascular ingrowth into the interstices of the graft. We conclude that prefabrication utilizing autologous and prosthetic components to create a single axial flap for transfer is a feasible solution to long-segment tracheal reconstruction. Neovascularization permeates the full thickness of the prosthetic component and is accompanied by dense fibrous ingrowth during the delay period. This neotracheal analogue also possesses structural characteristics similar to those of the native trachea and a durable submucosal layer that can support ingrowth of epithelium.

The osteocutaneous scapular flap for mandibular and maxillary reconstruction.

Microfil injections in 8 cadavers and clinical experience with 26 patients have demonstrated a reliable blood supply to the lateral border of the scapula based on branches of the circumflex scapular artery. This tissue has been used successfully for reconstruction of a variety of defects resulting from maxillectomy and mandibular defects from cancer and benign tumor excisions. Advantages of this tissue over previous reconstructive methods include the ability to design multiple cutaneous panels on a separate vascular pedicle from the bone flap allowing improvement in three-dimensional spatial relationships for complex mandibular and maxillary reconstructions. The lateral border of the scapula provides up to 14 cm of thick, straight corticocancellous bone that can be osteotomized where desired. The thin blade of the scapula provides optimum tissues for palate and orbital floor reconstruction. There have been no flap failures and minimal donor-site complications.

Effect of low dose aspirin on thrombus formation at arterial and venous microanastomoses and on the tissue microcirculation.

In free flap/replantation surgery, failure is usually associated with thrombotic occlusion of a microvascular anastomosis (risk zone I) or, on occasion, flow impairment in the microcirculation of the transferred or replanted tissue (risk zone II). The objective of this study is to describe the effect of low dose aspirin on blood flow at both risk zones in microvascular surgery. Risk zone I: In rat femoral arteries and veins, thrombus formation was measured at the anastomoses using transillumination and videomicroscopy. Forty male Wistar rats were assigned in equal numbers to four groups: either arterial or venous injury with either aspirin (5 mg/kg systemically) or saline treatment. We found that aspirin significantly reduces thrombus formation at the venous anastomosis (p = 0.001). Risk zone II: In the isolated rat cremaster muscle downstream from an arterial anastomosis, we measured capillary perfusion, arteriolar diameters, and the appearance of platelet emboli for 6 hours in the muscle microcirculation. Sixteen male Wistar rats in two equal groups received either aspirin (5 mg/kg systemically) or saline. We found that in aspirin-treated animals, capillary perfusion is significantly (p = 0.002) improved, whereas arteriolar diameters and emboli only slightly increased. In conclusion, low dose aspirin inhibits anastomotic venous thrombosis and improves microcirculatory perfusion in our rat model. These studies provide quantitative data confirming and clarifying the beneficial effects of low dose aspirin in microvascular surgery.

Microsurgical replantation of the lip: a multi-institutional experience.

Traumatic amputation of the lip is a rare yet devastating event affecting both form and function. Considering the available methods for reconstruction, replantation may offer a reasonable solution. We sought to characterize the variables associated with lip replantation and to assess the outcome in a retrospective review of 13 lip replantations performed in 12 institutions utilizing a form database and clinical and photographic analysis. Lip replantation was successful in all 13 patients; partial flap loss occurred in one patient owing to iatrogenic injury. Follow-up averaged 3.1 years. Average patient age at the time of injury was 21.1 years. There were six male and seven female patients. Injuries in two patients were the result of a human bite, the remaining injuries resulted from dog bites. One patient had significant associated injuries. Average length of hospital stay was 11.9 days. Ten patients suffered amputations of the upper lip, and three suffered amputations of the lower lip. Average defect size was 10.6 cm2. Operative time averaged 5.7 hours (range 2.5 to 12 hours). Warm ischemia time averaged 2.9 hours, and cold ischemia time averaged 2.7 hours. Donor and recipient veins were often scarce; all patients had at least one arterial anastomosis, whereas no vein was available in 7 of 13 patients; vein grafts were required in one patient. Leech therapy was employed in 11 of 13 patients. Anticoagulant therapy was administered in the majority of patients. Systemic heparin was utilized in 10 of 13 patients, low molecular weight dextran was used in 7 of 13 patients, and aspirin was given to 7 of 13 patients. One bleeding complication was incurred. An average of 6.2 units of packed red blood cells was administered to 12 of 13 patients (adjusted to 250 cc/unit). Antispasmodic therapy was employed in six of eight patients intraoperatively and in two of eight patients postoperatively. Intraoperative complications included difficulty identifying veins in 7 of 13 patients, arterial spasm in 1 of 13 patients, and vessel diameter < 0.5 mm in 4 patients. Postoperatively, one patient suffered vein thrombosis requiring anastomotic revision. Broad spectrum antibiotics were administered to all patients, and there were no infections. Nearly one-third (4 of 13) patients suffered prolonged edema lasting > 4 months. Color match of the replanted lip segment was rated excellent in all cases. Hypertrophic scarring occurred in 6 of 13 patients. A total of 12 revision procedures was performed in six patients. Interestingly, leech therapy resulted in permanent visible scarring as a result of the leech bite in 6 of 11 patients treated. Ten patients demonstrated active orbicularis muscle contraction in the replanted lip segment. Stomal continence was present in all lips. Sensibility return in the replanted lip segment was quite good with 12 of 13 patients demonstrating at least protective moving two-point sensibility (> or = 10 mm). Partial replant necrosis in one patient resulted in significant scar and contraction that compromised the aesthetic appearance. Overall, however, all patients were uniformly pleased with their final results. This clinical study is one of the largest of its kind on lip replantation. Although this represents a multi-institutional experience, the data are remarkably consistent. Re-establishment of venous outflow seems to be the most problematic technical challenge. By incorporating the adjuncts of anticoagulation, leech therapy, and antispasmodics, a successful outcome can be expected despite the paucity of vessels and small vessel size. The risks of blood transfusion, lengthy operative time, and hospital stay must be weighed against the functional benefits.

Glabrous skin grafts for plantar defects.

The principle of reconstructing like to like has been a long-standing and useful concept for plastic surgeons. One arena in which this concept has not been put to its full use is that of reconstructing soft tissue deficits of the sole of the foot. Most commonly, plantar defects that are to be skin grafted are reconstructed with split- or full-thickness, nonglabrous skin grafts. Nonglabrous skin grafts have significant disadvantages when used for reconstruction of plantar defects. These include painful hyperkeratotic build up at the periphery of the skin grafts, craters, contractures, and tight subgraft fibrosis. Glabrous skin grafting has been applied widely for coverage of smaller defects in the hand and has yielded superior results with improved function and sensation, more normalcy of appearance, and increase durability. The concept of reconstructing plantar defects by this method has probably been impeded by the vague and erroneous, but broadly held, belief that donor-site healing in the foot would be problematic, that is, significant potential for excessive scarring, pain, and functional deficit. The long-standing use of glabrous skin grafts for plantar defects in this unit, however, confirms the desirability, functional advantage, and minimal morbidity of this technique.

Risk assessment and management in hand and facial tissue transplantation.

PURPOSE: Since hand and facial tissue transplantation are new treatments, risk data must be derived from early reports of the few cases done to date combined with extrapolations from other procedures with similar risks. This manuscript summarizes data from both sources including eight separate studies that measure the real and perceived risks associated with hand and facial tissue transplantation. METHODS: Real Risks: Several large clinical studies describing risk data from kidney transplant recipients (10-years experience) and risk data from 49 human hand transplants in 33 recipients (>10 years experience) were reviewed. Perceived Risks: Over 500 subjects with different life experiences (facially disfigured, amputees, laryngectomees, kidney transplant recipients, transplant and reconstructive surgeons, and controls) were surveyed using a standardized and validated risk assessment instrument. RESULTS: Real Risks: Contrary to earlier estimates the risks of acute rejection are higher (80-85%) while the risks of chronic rejection (<5%) and other complications are lower than previously reported. Perceived Risks: Despite different life experiences, those questioned would accept similar amounts of risk to receive different types of transplant procedures (hand, foot, face, larynx, and kidney) but all would accept the most risk for a facial tissue transplant. Kidney transplant recipients, who live with the risks of immunosuppression, would accept the most risk while facially disfigured individuals and reconstructive surgeons, who have real-life experience with facial disfigurement, would accept the least. CONCLUSIONS: These studies contribute to the growing body of risk data necessary for moving hand and face transplantation into mainstream medicine.

Thin cutaneous flap for intra oral reconstruction: the dorsalis pedis free flap revisited.

The dorsalis pedis flap provides thin, hairless tissue for a variety of intra oral defects. Due to concerns for the donor site, reconstructive surgeons have largely overlooked this flap, despite its numerous desirable qualities. The paper focuses on the anatomy of the first dorsal metatarsal artery and techniques which insure the preservation of adequate flap vascularity. The prevention of donor site complications centers around meticulous attention to the placement of skin grafts, with a secure tie-over dressing and the use of a posterior splint. Patients are allowed to ambulate in the early postoperative period only when venous compression is provided with an ace bandage. Vigorous attention to detail on reconstructing the foot has minimized donor site complications. The dorsalis pedis flap continues to be an important method of reconstruction in our armamentarium of free tissue donor sites.

Oral commissure expansion prosthesis.

An expansion prosthesis to stretch commissures and fibrotic muscles is often essential for patients recovering from head and neck trauma or burns. The prosthesis is easily made in one appointment using Triad resin and a 7 mm expansion screw. Depending on the frequency of use, varying degrees of opening of the jaws can be obtained. The prosthesis is inexpensive to make and can easily be modified as needed. It is convenient for use because the patient controls the pressure that is applied by the prosthesis.

Angiography as an aid in extra-enteric gastrointestinal bleeding due to visceral artery aneurysm.

Three unusual patients with visceral artery aneurysms involving the hepatic artery, inferior pancreaticoduodenal artery, and a mesenteric branch artery are presented. Each of these lesions is unusual and all were diagnosed preoperatively. Surgical intervention was planned on the basis of angiography. In two patients with hypovolemia a simple diagnostic approach employing emergency selective angiography was formulated and successfully used.

The lateral upper arm flap: anatomy and clinical applications.

There is a highly dependable free flap donor site of moderate size on the posterolateral aspect of the distal upper arm. The area is supplied by the posterior radial collateral artery, a direct continuation of the profunda brachii. The flap area is supplied by a direct cutaneous nerve. It can be raised on its own, with underlying tendon, with bone, or with fascia only. This article describes our findings in 32 cadaver dissections and in 23 clinical cases.