Reconstruction with the latissimus dorsi flap after skin-sparing mastectomy.

The latissimus dorsi musculocutaneous island flap was once the standard for breast reconstruction. With the increased use of tissue expanders and the development of the transverse rectus abdominis musculocutaneous flap for autologous tissue breast reconstruction, use of the latissimus dorsi has decreased. To reassess the role of the latissimus dorsi musculocutaneous flap in breast reconstruction, a retrospective review was performed to evaluate women who had skin-sparing mastectomy followed by immediate reconstruction with a latissimus dorsi flap and permanent implants. The postoperative aesthetic results and donor site morbidity, including contour deformity and scarring, were examined. Satisfactory results were obtained in 17 of 18 patients. Complications were noted in 5 patients, and all were minor. Using the latissimus dorsi musculocutaneous flap and a permanent breast prosthesis for immediate reconstruction is successful because it provides sufficient muscular coverage of the implant. In addition, it provides a good aesthetic result using a single-stage procedure. Illustrative cases are presented.

Automation--down to the nuts and bolts.

Laboratories that once viewed automation as an expensive luxury are now looking to automation as a solution to increase sample throughput, to help ensure data integrity and to improve laboratory safety. The question is no longer, 'Should we automate?', but 'How should we approach automation?' A laboratory may choose from three approaches when deciding to automate: (1) contract with a third party vendor to produce a turnkey system, (2) develop and fabricate the system in-house or (3) some combination of approaches (1) and (2). The best approach for a given laboratory depends upon its available resources. The first lesson to be learned in automation is that no matter how straightforward an idea appears in the beginning, the solution will not be realized until many complex problems have been resolved. Issues dealing with sample vessel manipulation, liquid handling and system control must be addressed before a final design can be developed. This requires expertise in engineering, electronics, programming and chemistry. Therefore, the team concept of automation should be employed to help ensure success. This presentation discusses the advantages and disadvantages of the three approaches to automation. The development of an automated sample handling and control system for the STAR System focused microwave will be used to illustrate the complexities encountered in a seemingly simple project, and to highlight the importance of the team concept to automation no matter which approach is taken. The STAR System focused microwave from CEM Corporation is an open vessel digestion system with six microwave cells. This system is used to prepare samples for trace metal determination. The automated sample handling was developed around a XYZ motorized gantry system. Grippers were specially designed to perform several different functions and to provide feedback to the control software. Software was written in Visual Basic 5.0 to control the movement of the samples and the operation and monitoring of the STAR microwave. This software also provides a continuous update of the system's status to the computer screen. The system provides unattended preparation of up to 59 samples per run.

Management of wound and left ventricular assist device pocket infection.

Our patient developed a wound infection that involved an implanted left ventricular assist device. At surgery, the pump was washed with a detergent-containing bacteriocidal solution, then antibiotic-impregnated polymethylmethacrylate beads were placed around the pump. The wound was revised using rectus muscle to cover the pump. The incisions have healed and the patient is now at home. She is on no systemic antibiotics and has no evidence of infection 11 months postoperatively.

Nasal cartilage grafts: more than a decade of experience.

From 1985 to 1995, a total of 311 patients underwent nasoplasties. During this time period, the number of patients receiving grafts increased from 94 percent in 1985-1989 to 100 percent in 1993-1995. The donor grafts averaged 72 percent nasal cartilage, 10 percent conchal cartilage, 9 percent fascia, and 9 percent rib allograft. Graft recipient sites averaged 41 percent in the tip, 31 percent in the dorsum, 17 percent in the columella, and 3 percent in the region of the lower lateral cartilage; 8 percent were spreader grafts. During this time frame, tip grafting increased from 34 percent in 1985-1989 to 54 percent in 1993-1995. Reoperation for complications decreased from 17 percent in 1985-1989 to 2 percent in 1993-1995. During the time span examined, the use of rib allografts declined, the use of autologous cartilage increased, the use of onlay tip grafts increased, and the incidence of reoperations declined. Early in the series, 80 percent of the malplaced tips were shield type grafts. With the use of the onlay tip graft, the complication of a malpositioned tip has been substantially diminished. The increased use of crushed cartilage has resulted in improvement in results and patient satisfaction, as it serves to camouflage slight irregularities in the tip and dorsum of the nose.

Reconstruction of the abdomen and perineum in cancer surgery.

Trunk and perineal defects after tumor resection present a challenge to the reconstructive surgeon. When primary closure is not possible, the use of well-vascularized autogenous tissue is required to achieve adequate soft-tissue coverage. Pedicled muscle or myocutaneous flaps provide excellent sources of vascularized tissue for postradiation defects. When local tissues preclude the use of pedicled flaps, free-tissue transfers can be performed. A thorough understanding of radiation wounds and the reconstructive options is essential for treatment of these challenging defects.

Muscle flap coverage for the lower extremity.

The use of local transposition muscle flaps for coverage of the lower extremity has been overshadowed in recent years by the development of microsurgical techniques for tissue transfer. There are still definite indications for local muscle flaps in reconstruction of the lower extremity. An outline of criteria of selectivity as it applies to specific wounds and practical pitfalls of their use is presented.

Fasciocutaneous flaps in reconstruction of the lower extremity.

The fasciocutaneous flap, when correctly chosen, can supply an expedient solution for some of the challenging soft-tissue problems in the leg. The fasciocutaneous flap should be included in the list of reconstructive options for the lower extremity, particularly in the distal tibia. The improved knowledge of blood supply to the fasciocutaneous flaps allows the design of a safer, longer, more useful flap.

Salvage of prosthetic grafts and joints in the lower extremity.

Infection or exposure of prosthetic joints and vascular conduits continues to challenge the reconstructive surgeon. Techniques of regional muscle flaps, fasciocutaneous flaps, and free microvascular transfers have added much to the management of this problem, often converting a hopeless situation to a salvageable one. Close cooperation between the plastic, vascular, and orthopedic surgeons optimizes the chance for a satisfactory outcome.

Use of the omentum in chest-wall reconstruction.

Increased use of the omentum in chest-wall reconstruction has paralleled the refinement of anatomic knowledge and the development of safe mobilization techniques. Important anatomic points are the omental attachments to surrounding structures, the major blood supply from the left and right gastroepiploic vessels, and the collateral circulation via the gastroepiploic arch and Barkow's marginal artery. Mobilization of the omentum to the thorax involves division of its attachments to the transverse colon and separation from the greater curvature to fabricate a bipedicled flap. Most anterior chest wounds and virtually all mediastinal wounds can be covered with the omentum based on both sets of gastroepiploic vessels. The arc of transposition is increased when the omentum is based on a single pedicle, allowing coverage of virtually all chest-wall defects. The final method of increasing flap length involves division of the gastroepiploic arch and reliance on Barkow's marginal artery as collateral circulation to maintain flap viability. With regard to chest-wall reconstruction, we have included the omentum in the armamentarium of flaps used to cover mediastinal wounds. The omentum is our flap of choice for the reconstruction of most radiation injuries of the chest wall. The omentum may also be used to provide protection to visceral anastomoses, vascular conduits, and damaged structures in the chest, as well as to cover defects secondary to tumor excision or trauma. In brief, the omentum has proved to be a most dependable and versatile flap, particularly applicable to chest-wall reconstruction.