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.

Brachioradialis musculocutaneous flap closure of the elbow utilizing a distal skin island: a case report.

A brachioradialis musculocutaneous flap with a distal skin island is described to close a chronic elbow wound. This newly described distal skin island directly over the brachioradialis tendon provides viable and durable coverage for the olecranon/posterior elbow region. The advantages and disadvantages of this treatment as compared with other historical reconstructive options for this region are analyzed. The patient has a stable healed wound at 2 years of follow-up.

Only a subset of trauma patients with depressed mitogen responses have true T cell dysfunctions.

Many studies have demonstrated depressed mitogenic responses in trauma/burn patients' peripheral blood mononuclear cells (PBMC). However, data attributing the relative contribution of secreted inhibitory factors versus a true T cell dysfunction to these depressed mitogenic responses have been conflicting. We have characterized the T cell dysfunctions in posttrauma mitogen depression by simultaneously assessing patient T cell proliferation in the phytohemagglutinin-stimulated PBMC and in the purified T cell population induced with anti-CD3 + anti-CD4. Patients' samples showed three distinct patterns or progressive phases of T cell responses: (i) normal or elevated T cell proliferation in both the whole PBMC and the isolated T cell population (phase I); (ii) depressed T cell proliferation in the PBMC but normal, or even elevated, proliferation in the isolated T cell population (phase II); and (iii) depressed T cell proliferation in both the PBMC and the isolated T cell population (phase III). Patients whose T cells exhibited only a phase I response experienced no major complications with a positive clinical outcome. Patients whose T cell alterations progressed to phase II experienced infectious episodes and some complications, but all had positive clinical outcomes. In contrast, patients whose T cells progressed to phase III dysfunction had severe clinical complications (multiple organ failure), with a negative clinical outcome (80% mortality). Patients whose T cells had a phase I or phase II response pattern had no true T cell dysfunctions in the absence of monocytes. However, patients whose T cells had a true T cell dysfunction (phase III) response pattern were at high risk for mortality. Thus, a true T cell dysfunction, though occurring in only a minority of trauma patients, is predictive of clinical outcome.

The microvenous valvular anatomy of the human dorsal thoracic fascia.

The use of free scapular fasciocutaneous flaps for reconstruction of recalcitrant grade 6 venous stasis ulcers has shown excellent early success rates. Venous refilling times measured postoperatively over the flaps by photoplethysmography have noted improvements to normal levels. Preliminary anatomic studies have demonstrated valves in the circumflex scapular veins of flaps used in reconstruction. The purpose of this study was to investigate and document the number, morphology, size, and location of valves in the human dorsal thoracic fascia. Ten scapular flaps were obtained from unembalmed cadavers and injected with methyl methacrylate. Each flap cast was divided into four parts: proximal, right and left, and distal, right and left. We reduced the size of specimens (the largest being 24 x 11 mm) and studied them in a scanning electron microscope. We identified all valves, estimated the diameter of the corresponding vein, calculated the depth of the valvular sinus, and related it to the corresponding venous size. Light microscopy and transmission electron microscopy were used as assisting tools applied to glutaraldehyde-fixed specimens. Analysis of injected specimens showed that valves were most abundant in veins with a luminal diameter of 30 to 120 microns (59.3 percent of 905 valves). The depth of valves became larger with increasing venous diameter. The sizes of valve sinuses were not different for individual valves. Except for veins larger than 1000 microns in diameter, there was no significant difference between the number of valves in different parts of an individual flap, nor were there significant differences between the valve numbers in different flaps. Most valves were bicuspid; only in the vein category of 30 to 120 microns were unicuspid valves encountered. Valves sometimes were located in series in a short segment of a vein; occasionally, they were found at the merging site of two veins. Transmission electron microscopy showed that valve leaflets had collagen fibers that ascended toward the tip of the leaflet and occasionally were accompanied by elastic fibers. Myofibroblasts were regularly present in the valve leaflets. These data show that fasciocutaneous flaps from the scapular region have numerous valves (90 valves on average in each flap) in the venous microcirculation. The microvenous valves in the dorsal thoracic fascia appear to be structurally similar to valves in larger veins. These valves may play a role in the improved hemodynamics and promising clinical outcome of patients with chronic venous insufficiency who have undergone free scapular flap reconstruction.

Latissimus dorsi free flap for sacral wound closure: the world's longest vein grafts for free tissue transfer.

In 1983, Salibian et al. reported the use of a two-stage latissimus dorsi free tissue transfer to cover a sacral radiation ulcer using 28-centimeter thoracodorsal interposition vein grafts. In 1985, Nahai and Hagerty reported a similar case in which the procedure was performed in one stage with 25-centimeter vein grafts. We present a case in which a large sacral osteoradionecrosis ulcer is closed using this one-stage technique with 46-centimeter vein grafts, the longest ever reported for free tissue transfer.

Elevated IL-8 production by trauma patients' monocytes is associated with elevated secretion of TNF alpha.

IL-8 is a recently described chemokine that increases polymorphonuclear neutrophil infiltration and has been implicated in inflammatory pathology. This study assesses monocyte (M phi) interleukin-8 (IL-8) levels in severe trauma patients (injury severity score > 16) who have elevated levels of M phi cell-associated tumor necrosis factor alpha (TNF alpha), a major marker for systemic inflammatory response syndrome after injury. We demonstrate elevated (p = .0007) levels of M phi IL-8 only in those trauma patients who also have increased (p = .0001) M phi-secreted TNF alpha whereas the patients having normal M phi-secreted TNF alpha levels have normal or even decreased M phi IL-8 production. There is no association between M phi IL-8 production and cell-associated TNF alpha levels. M phi induction by Fc gamma RI cross-linking, a common induction pathway in trauma patients' M phi that increases the production of both cell-associated and secreted TNF alpha, can also increase (p = .0022) M phi IL-8 levels. Therefore, post-trauma elevation of M phi IL-8 levels may be associated with increased secreted TNF alpha resulting from, at least in part, Fc gamma RI cross-linking stimulation in vivo.

First web space release with the dorsal hand rotation flap: closing the donor site.

Release of first web space contractures with the dorsal hand rotation flap depends on the mobilization of relatively large areas of skin. Fortunately, the dorsum of the hand has sufficient laxity to accommodate such substantial flaps. Closure of the resultant donor site may be challenging. Skin grafting over extensor paratenon requires prolonged immobilization and is often cosmetically unsatisfactory. The purpose of this report is to demonstrate various methods of closing these donor sites without skin grafting. We report a series of first web space contractures, all of which we released using the dorsal hand rotation flap. In closing the donor sites, we demonstrate the utility of advancing local tissues as well as bilobed rotational flaps. Our series shows that skin grafting is not necessary in the majority of patients. We expect that our results will encourage the use of the dorsal hand rotation flap because it yields both functionally and cosmetically acceptable results.

Abdominal surgery in patients with severe morbid obesity.

At the University of Massachusetts Medical Center, from 1984 to 1992, we performed laparotomy or panniculectomy on 42 individuals weighing from 290 to 600 pounds, each with a height-weight index of over 55. All patients weighted more than 220 percent of ideal body weight. Follow-up ranged 8 to 52 months. All patients underwent panniculectomy except one. Pannus resection was performed by means of a large transverse ellipse. A suprapubic wedge resection often was used to minimize the discrepancy between the lengths of the upper and lower transverse incisions. With severe discrepancy, lateral V-flaps also were utilized to minimize the lateral dog-ear. To facilitate preparation, pannus exsanguination, and surgical resection, 10 to 12 towel clips or 4 to 5 large K-wires or Steinmann pins were passed through the central pannus. These were then suspended by rope from the overhead lighting. A two-team approach appears to have distinct advantages, including minimized blood loss, operative time, pulmonary compromise, and hospital stay. The technical difficulties of manipulating a large pannus were simplified by pannus suspension. Early preoperative involvement of the entire operative team, particularly the plastic surgeon, the anesthesiologist, and the nursing staff, allows for proper evaluation of underlying medical problems and appropriately detailed anesthetic and surgical planning. Surgical management of the abdominal pannus in the morbidity obese patient in this series was performed with apparent clinical efficacy, reasonable safety, and long-term functional improvement.

Continued tumor necrosis factor receptor expression by trauma patients' monocytes (Mphi) despite TNF alpha secretion.

In investigating various mechanisms for continued elevated tumor necrosis factor alpha (TNF alpha) production in trauma patients' monocytes (Mphi), we examined TNF receptor (TNFR) levels on the patients' Mphi as a possible altered pathway leading to continued autocrine TNF alpha stimulation. Mphi TNFR synthesis and shedding are both increased as TNF alpha protein production increases. In fatal meningococcal infections, TNFR shedding fails to pace TNF alpha production. Here, isolated normal and trauma patients' Mphi (injury severity score greater than 30), were examined by flow cytometry using phycoerythrin-labeled TNF alpha to detect increased or decreased TNFR expression concomitant to Mphi production of secreted TNF alpha (as measured in the LM bioassay). Immunoaberrant patients (mitogen proliferation depressed) had reduction in detectable TNF alpha binding by their TNFR, while Mphi from immunocompetent (normal mitogen response) trauma patients' Mphi had a TNFR expression intensity comparable to normals' Mphi. Upon in vitro stimulation of TNF alpha (IFN gamma + muramyl dipeptide) normals' and immunocompetent patients' MO TNFR expression is decreased for the entire 18 h period during which secreted TNF alpha is produced, but immunoaberrant trauma patients' Mphi increased their TNFR expression, while concomitantly producing both secreted and cell-associated TNF alpha protein. Patients' Mphi with highly elevated TNF alpha levels are still expressing high levels of TNFR and capable of auto-stimulating TNF alpha production. This elevated TNFR expression could be due to reduced shedding, overproduction of TNFR, or both.

Free flap valvular transplantation for refractory venous ulceration.

PURPOSE: Nonoperative therapeutic approaches to chronic venous ulceration, although effective, often require prolonged dressing care and immobilization with leg elevation. Results of skin grafting, perforator ligation, and valve interpositions and reconstructions improve results of ulcer healing but have not uniformly prevented ulcer recurrence. Our hypothesis is that reconstruction of chronic venous ulcers by excision of the diseased tissue bed and replacement with a free flap containing multiple competent microvenous valves and a normal tissue microcirculation will result in long-term cure of these debilitated patients. METHODS: Six patients with chronic venous insufficiency and recurrent ulceration (class 3) underwent excision of ulcers and surrounding liposclerotic tissue beds and reconstruction with fasciocutaneous free flaps (two bilateral). Preoperative and postoperative photoplethysmography was used to assess venous refilling times. Duplex scanning was performed to assess deep venous reflux. RESULTS: There were no flap failures. Photoplethysmographic venous refilling times measured on flaps demonstrated significant immediate and long-term increases from preoperative values (all results +3 by Society of Vascular Surgery outcome grading). Long-term maintenance of tissue integrity is shown by absence of recurrent ulceration and no evidence of recurrent tissue lipodermatosclerosis in all flaps at follow-up (8 months to 7.5 years; mean 24 months). No recurrent lipodermatosclerosis was seen on flap biopsy at 2 and 7 years. Separate cadaveric injection studies, including scanning electron microscopy, revealed numerous microvenous valves directed toward the draining pedicle in the flaps used for reconstruction. CONCLUSIONS: This is the first comprehensive report providing combined laboratory and clinical evaluation, anatomic rationale, and long-term outcome of surgical rehabilitation of patients with chronic venous ulceration who have undergone microsurgical flap reconstruction.

Thumb replantation after cardiac transplantation.

Generally, severe medical illnesses, including chronic immunosuppression and heavy steroid use, have been deemed relative contraindications for replantation surgery. We report the successful replantation of an amputated thumb in a patient who had previously undergone heart transplantation and was on therapeutic immunosuppression. Despite extensive soft-tissue damage and joint involvement, thumb function and sensibility returned to acceptable levels. This case demonstrates that digital bony union, tendon repair healing, and nerve regeneration are not significantly altered by the standard immunosuppressive regimen following major organ transplant. The implications raised by this case for possible transplantation of allograft digits or limbs are discussed in detail.

Rectus abdominis flap closure of ischiosacral pressure sore.

An inferiorly based rectus abdominis musculocutaneous flap was used to close a large ischiosacral pressure sore refractory to the usual methods of closure in a paraplegic patient. The functions of the rectus abdominis muscle to initiate vertebral flexion from a supine position and aid in respiration, urination, defecation, and vomiting may play a proportionately greater role in the paraplegic patient. Although our patient did not experience any noticeable clinical deficits, this donor site is theoretically less functionally expendable in the paraplegic patient.

Microvascular thrombolysis to salvage a free flap using human recombinant tissue plasminogen activator.

Nonsurgical thrombolysis using tissue plasminogen activator (t-PA) in conjunction with intravenous heparin infusion was successfully used to salvage a free flap with acutely decreased arterial inflow thought to be due to anastomotic thrombosis. Intravenous infusion (12 mg/hr) of t-PA was stopped after 15 min of therapy when spontaneous bleeding was noted at the groin flap donor site. Concomitant treatment with intravenous heparin resulted in rapid improvement of flap perfusion and ultimately complete survival without surgical intervention. This report suggests that in selected cases, target-specific anticoagulant therapy may be beneficial in salvaging microvascular reconstructions complicated by thrombosis. Further experience is warranted to define more clearly the role, the risks, and the extended benefits of this new mode of nonsurgical therapy.

Growth of forelimb allografts in young rabbits immunosuppressed with cyclosporine.

Seventeen forelimbs were transplanted orthotopically from young Dutch rabbits to young New Zealand rabbits treated with cyclosporine. The transplanted limbs demonstrated significant bone growth. The growth in the transplanted limbs was about 75 to 80% of that observed in the unoperated limb. The long bones of the 3 longest surviving rabbits (133 days, 150 days, 150 days) studied radiographically demonstrated increases in length over their original lengths (humerus 22%, ulna 26%, and radius 31%). Hair and nail growth were noted at about day 10. Response to pain stimuli (withdrawal of forelimb) and functional use (ambulation with 50% weight bearing) was seen at two to three months. Permanent survival was not achieved because of a species-specific toxic wasting syndrome from cyclosporine.