Suprafascial pre-expansion of perforator flaps and the effect of pre-expansion on perforator artery diameter.

BACKGROUND: This study addresses the "pre-expanded perforator flap concept" by demonstrating a case series of relevant reconstructive procedures and evaluate the perforator vessel diameter changes that happen during the pre-expansion procedure. METHODS: Fourteen patients were treated with 15 flaps. One patient was treated with two pre-expanded internal mammary artery perforator flaps. In other cases, thoracodorsal, circumflex scapular, lumbar, intercostal, lateral circumflex femoral, and deep inferior epigastric artery perforator flaps were used. Technical details and rate of complications were noted. Evaluations of the flap pedicles were done both by hand held Doppler and by color Doppler ultrasound (CDU). RESULTS: Flaps successfully served to resurface and release thick and rigid broad scar tissues and contractures in 11 of relevant 12 patients (in one patient with 50% flap loss, adequate contracture release could only be obtained with addition of a secondary split thickness skin graft to the residual flap) and provided a good source of tissue for anterior neck reconstruction of one patient and penis reconstruction of another patient. In six patients, perforator artery diameters were measured by CDU both before and after the expansion process and a significant increase secondary to the pre-expansion procedure was detected (Pre-expansion mean: 0.48 ± 0.08 mm; post-expansion mean: 0.65 ± 0.10 mm; P < 0.05). Flaps as large as 30 × 20 cm were harvested. Totally three partial flap necroses were experienced in 15 flap procedures. CONCLUSIONS: Suprafascial pre-expansion of the perforator flaps seems to provide a solution to achieve broader and thinner perforator flaps with larger perforator arteries.

Major donor area complication after a mandibular reconstruction with an osseous fibular free flap: pseudo-compartment syndrome.

The popularity of the fibular free flap in mandibular reconstructions is persisting, and major donor area complications rarely occur after fibular free flap operations. Still, we have observed a pseudo-compartment syndrome in a 52-year-old patient on the 12th postoperative day after a mandibular reconstruction with a fibular free flap. When an obstruction in the deep venous system (deep vein thrombosis) was observed in the Doppler ultrasound-guided imaging, the patient has been taken to the operating room for an emergency surgery and the donor area has been completely reopened (in the manner of a fasciotomy). After this procedure, the circulation in the foot appeared to return to normal. The exposed muscles of the patient, who was started on a low-molecular-weight heparin treatment for the deep vein thrombosis, have been closed with skin grafts on the 10th day. No functional loss was observed during the 2-month follow-up period.

Tessier no. 3 incomplete cleft reconstruction with alar transposition and irregular z-plasty.

Facial clefts are extremely rare congenital deformities and there are only a few technique reports for surgical reconstruction of clefts in the literature. In this article, we report a Tessier no. 3 incomplete cleft reconstruction with alar transposition and irregular Z-plasty in a 2-year old female patient.

Improving bony stability in maxillofacial surgery: use of osteogenetic materials in patients with profound (> or =5mm) maxillary advancement, a clinical study.

PURPOSE: LeFort I osteotomy is a part of the standard surgical regimen in the treatment of patients with Class III dentofacial deformity. Inadequate osteosynthesis between the segments is a problem in patients with profound (> or =5mm) maxillary advancement. In this study an ideal ossification is aimed for by applying a combination of osteoinductive and osteoconductive materials. PATIENTS AND METHODS: Ten patients with Class III deformity were included in this study. At least 5mm of advancement was performed on each patient, while mean maxillary advancement was 5.7 mm. Human demineralised bone matrix (DBM, 1 cc) and 20 mg bovine bone collagen-protein extracts (Colloss) were applied in between the segments following rigid fixation. Recurrence rates were calculated via cephalometric analyses. Multislice tomography images were collected after the 3 and 12 months in an effort to document ectopic or abnormal bone growth patterns, if any present. Four patients underwent a second operation for plate removal 12 months postoperatively. Bone biopsies were collected from the anterior maxillary wall. RESULTS: The cephalometric analyses performed after 3 and 12 months were identical to the analyses calculated 1 week postoperatively for each patient, ruling out recurrences. No abnormal or ectopic bone growth was observed. Peroperative examination of four patients revealed a complete or near to complete osteosynthesis line at the anterior maxillary wall. The microscopic examinations of the bony samples retrieved from these borders revealed abundant osteoblasts, osteocytes, osteoclasts and a bony regeneration mimicking intramembranous ossification with its trabecular organisation. CONCLUSIONS: It is possible to achieve an acceptable line of osteosynthesis in cases in need of profound maxillary advancement by applying DBM and Colloss inbetween the bony segments.

Comparison of different methods of circumferential tracheal reconstruction: an experimental study.

OBJECTIVES: This study was designed to compare different prefabrication models for circumferential tracheal reconstruction. MATERIALS AND METHODS: Thirty adult female New Zealand rabbits were divided into six groups for circumferential tracheal reconstruction with a different tissue combination. Prefabrication of neotrachea was performed without anastomosis. Lateral thoracic fascia or pectoralis major muscle were used for vascular supply. Polypropylene mesh, polytetrafluoroethylene (Gore-Tex), or cartilage rings were used for skeletal framework. Hairless epithelial skin graft was used for inner lining. The groups were compared in terms of viability of hairless epithelial graft, longitudinal flexibility, rigidity, flap wall thickness, internal diameter, and flap viability. RESULTS: Epithelial skin graft was almost totally viable (95%-99%) in the polypropylene mesh groups. Gore-Tex groups exhibited almost total necrosis (74%-71%). Longitudinal flexibility and rigidity were similar to the native trachea in Gore-Tex and polypropylene mesh groups. Neotrachea prefabricated with cartilage grafts showed more than normal longitudinal flexibility and collapsed easily. CONCLUSION: The prefabricated model with the use of polypropylene mesh for skeletal framework and lateral thoracic fascia for vascular supply seems to be the best alternative in the reconstruction of circumferential tracheal defects.

Circumferential trachea reconstruction with a prefabricated axial bio-synthetic flap: experimental study.

OBJECTIVE: The ideal method, in reconstruction of circumferential tracheal defects more than 50% of the total tracheal length, is still a question. Current methods lack either in epithelial lining or in skeletal framework. In this study, we designed an axial biosynthetic prefabricated flap to reconstruct the circumferential tracheal defects in rabbits. METHODS: Ten rabbits are used. The inner mucosal lining is substituted by hairless epithelium obtained from proximal ear. The tracheal cartilage is substituted by polypropylene mesh and the tracheal adventitia is substituted by lateral thoracic fascia as a vascular supply. The study is designed in three stages. Stage 1: Hairless epithelial graft is obtained by secondary healing of a full thickness skin defect in ear. Stage 2: Epithelial graft, polypropylene mesh and lateral thoracic fascia are tubed around a silicone catheter. This structure is dissected through its pedicle (lateral thoracic vessels and fascia) to the axilla and mobilized. The prefabricated neotrachea is carried on its pedicle to the cervical area through a subcutaneous tunnel formed superficial to the sternum and left there for 2 weeks. Stage 3: The silicone catheter is taken out and prefabricated neotrachea is adapted to the defect formed in native trachea and anastomized. Later the animals are evaluated for 4 weeks. The patency of the lumen, the viability of the epithelial graft and fascia, airtightness of the anastomoses and other features of the reconstruction are evaluated by radiological, macroscopical and histological examinations. RESULTS: Survival at 4 weeks was 70%. All of the prefabricated neotracheas and epithelial grafts were viable. The rigidities, longitudinal elasticities, diameters and wall thickness were similar to native tracheas. Occlusion of lumen is encountered only in one animal. There was no hair growth from the epithelial lining. CONCLUSION: The study defines a new method of circular tracheal reconstruction with successful substitution of inner lining, skeletal framework and vascular supply.

Congenital mesenchymal chondrosarcoma of the orbit: case report and review of the literature.

PURPOSE: To report the first case of congenital extraskeletal mesenchymal chondrosarcoma arising in the orbit. DESIGN: Interventional case report and review of the literature. METHODS: Ophthalmologic examination and computed tomography scan of the orbit were performed. Histologic and histochemical examination and immunohistochemistry of the biopsy specimen were evaluated. MAIN OUTCOME MEASURES: Ocular and systemic disease control. RESULTS: A 5-month-old girl was seen with a papillomatous lesion in the right lower tarsal conjunctiva present from birth. Histologic examination demonstrated an admixture of undifferentiated mesenchymal cells and islands of mature hyaline cartilage, and immunohistochemistry studies revealing positivity for vimentin and S-100 were consistent with the diagnosis of mesenchymal chondrosarcoma. The patient was treated with combined chemotherapy (ifosfamide, epirubicin, and cisplatin), radiotherapy, and surgery (exenteration). She is alive with no evidence of disease after 4 years of follow-up. Facial asymmetry and dental malformations have developed as late effects. Further reconstructive surgery is planned for the malformations. CONCLUSIONS: Extraskeletal mesenchymal chondrosarcoma in the orbit is extremely rare. This study reports the first case of congenital extraskeletal mesenchymal chondrosarcoma arising in the orbit (also the youngest patient) both in skeletal and extraskeletal sites. Multimodality treatment (surgery, chemotherapy, and radiotherapy) may lead to long-term survival.

The use of the ipsilateral versus contralateral pedicle and vertical versus horizontal flap inset models in TRAM flap breast reconstruction: the aesthetic outcome.

The use of an ipsilateral or a contralateral rectus abdominis muscle as a pedicle and comparison of their advantages and disadvantages in TRAM flap breast reconstruction have been reported in the literature. In our clinical experience with 22 pedicled TRAM flap breast reconstructions, the use of either an ipsilateral or contralateral pedicle was found to be equivocal regarding the flap viability and the aesthetic outcome. Thus, it seems better to decide their use according to the needs of an individual patient. In our series, the contralateral pedicled TRAM flap with a vertical flap inset was preferred in patients with a small opposite breast or in patients with infraclavicular tissue losses (four patients). The ipsilateral pedicled TRAM flap reconstruction with a horizontal flap inset was preferred in patients with a full and attractive opposite breast, unless they received adjuvant radiotherapy (six patients). In patients who received adjuvant radiotherapy the contralateral pedicle was used regardless of the inset model preferred (10 patients). Bilateral TRAM flap breast reconstruction was applied in one of our cases, which is not included in the three categories above mentioned. The aesthetic outcome was determined by analyzing a patient satisfaction questionnaire. Overall satisfaction was achieved in 17 patients. Four patients were dissatisfied. We think that choosing the correct flap inset model is one of the most important factors in achieving a satisfactory aesthetic outcome. Choosing the correct pedicle regarding the type of the flap inset model is equally important to facilitate technical ease during flap transposition and to improve flap survival.