Tongue reconstruction with a combined brachioradialis-radial forearm flap.

Total glossectomy adversely affects speech and swallowing, and subsequent reconstruction results in limited functional return. The radial forearm flap has been reliably used to resurface glossectomy defects, but has limited bulk with which to aid in palatoglossal contact for speech. The authors have modified the forearm flap by incorporating a segment of brachioradialis muscle, to increase bulk posteriorly and to aid in speech. Sufficient muscle perforators arise from the proximal brachial artery and enter the brachioradialis to permit transfer of the muscle with the fasciocutaneous forearm flap as a single free-flap unit. The muscle is folded onto itself and enclosed within the forearm flap skin to create a neotongue. Coaptation of the antebrachial cutaneous nerves can provide a senate flap. Successful transfer of the combined brachioradialis/forearm flap in a patient who had undergone total glossectomy resulted in a neotongue good shape. Speech was rated good by a speech pathologist, and palatoglossal contact was observed on cineoradiograph. No functional loss at the donor site occurred. Inclusion of the brachioradialis muscle with the radial forearm flap as a combined unit results in a neotongue with good form and increased bulk posteriorly at the base, compared to a standard fasciocutaneous flap alone. This is a useful variation of the forearm flap. Sensory return is possible if the medial and/or lateral antebrachial cutaneous nerves of the flap are coapted to the lingual nerve.

A comparison of pedicled and free TRAM flaps for breast reconstruction in a single institution.

Several reports concluded that free tissue transfer of the transverse rectus abdominis muscle (TRAM) flap for breast reconstruction is superior to pedicled transfer of the flap. In an effort to compare the various parameters of both techniques, the authors took advantage of a unique experience at one hospital where one surgeon (D.L.L.) used only the pedicled method and the other (N.J.Y.) used only free tissue transfer. Additionally, the authors compared the findings of the study with the experiences of other surgeons by surveying active members of the American Association of Plastic Surgeons. The records of 119 patients who underwent TRAM flap reconstruction between January of 1988 and July of 1997 were reviewed. Of these, 33 patients received free TRAM flaps, and 86 received pedicled TRAM flaps. To provide an adequate number of patients for statistical analysis, only those with unilateral, single-muscle reconstructions were considered (immediate or delayed). This provided 61 patients in the pedicled flap group and 26 in the free tissue group. Parameters examined included length of operation and of hospitalization, amount of pain medication used, amount of blood lost and received, and complications. A small subset of the patients had hospital records available to compare hospital charges; the comparison of 17 pedicled and 12 free TRAM flaps showed a mean difference of $15,637 (p < 0.001) in favor of the pedicled flap. On the basis of the findings from this study, it seems that the pedicled TRAM flap has significant economic and clinical advantages over the free TRAM flap. There is less need for blood, a shorter operating time and hospital stay, and a need for less pain medication. However, both methods of transfer have indications and contraindications in certain clinical settings. It will always remain the responsibility of the surgeon to evaluate all issues and select a method that is economically responsible and within the abilities of the surgeon, while producing a satisfactory outcome that best serves the patient. The information provided in this report should aid in accomplishing this goal.

The innervated gracilis musculocutaneous flap for total tongue reconstruction.

A functional neotongue following total glossectomy requires both soft-tissue bulk and reconstruction of muscle function. We used innervated transverse gracilis musculocutaneous flaps to reconstruct total glossectomy defects in eight patients. The obturator nerve to the gracilis muscle was approximated to the hypoglossal nerve to reinnervate the gracilis muscle by using microsurgical technique. The cutaneous paddle of the gracilis flap easily supplies sufficient bulk to replace the total glossectomy defect. Follow-up of patients ranged from 3 to 47 months. All patients were able to resume oral feeding. Electromyographic studies performed on one patient showed reinnervation of the flap with active elevation of the posterior pharynx. Ultimately, seven patients died because of recurrence of their disease. The innervated gracilis musculocutaneous flap may benefit patients who have a total glossectomy by allowing them to achieve a more functional recovery.

Sequential transfer of free flap to two defects.

This case report describes the use of a single lateral arm flap sequentially transferred to two defects in a bilateral hand injury. We believe this is a novel approach in reconstructing defects in bilateral hands when a staged reconstruction is planned.

Analysis of the distribution of cutaneous perforators in cutaneous flaps.

An anatomic and statistical analysis was performed on the distribution of cutaneous perforators that perfuse the scapular, radial forearm, and lateral arm cutaneous flaps. Perforators were categorized as direct, terminal, and intransitive, depending upon perforator origin and termination site relative to the source artery. Statistical cluster analysis of perforator distributions was performed to determine the regions in which cutaneous perforators are consistently found. The scapular and radial forearm flaps could be divided into up to three well-perfused segments. The analysis predicted the possibility of dividing the lateral arm flap into as many as seven segments while maintaining perfusion. Clinical applications of this method for preoperative flap design and elevation as well as final results are shown.

Case report: sequential vascular connection of free flaps in the upper extremity.

Devastating hand injuries often require multiple microvascular reconstructions. We report a patient in whom two flaps were used for late reconstruction of a devastating hand injury involving devascularization of the right hand, severely comminuted fractures of the hand and forearm, and multiple tendon avulsions. We believe the sequential vascular connection of free flaps offers the best method of reconstruction in this severe case, allowing composite tissue transfer, monitoring of the osseous flap, and optimal positioning of the two free tissue transfers.

Anatomy of the intermetacarpal ligaments of the carpometacarpal joints of the fingers.

In this study, the structure of the retaining ligaments between the proximal metacarpal bones of the fingers was defined. Anatomic dissections were performed on 10 fresh cadavers. Four separate ligaments were found: a dorsal metacarpal ligament, a palmar metacarpal ligament, and 2 interosseous ligaments oriented in a V-shaped configuration. The V-shaped interosseous ligaments were found to be the strongest; along with the palmar and dorsal intermetacarpal ligaments, they form a very strong connection between the bases of the adjacent metacarpals.

The temporal branch of the facial nerve: how reliably can we predict its path?

A thorough examination of the temporal branch of the facial nerve was performed to characterize precisely the number of rami crossing the zygomatic arch and their location with respect to bone and soft-tissue landmarks. Fresh cadaver dissection was performed in 12 facial halves, dissecting the facial nerve superiorly from the stylomastoid foramen to identify all branches crossing the zygomatic arch. There were a median of three (range two to four) rami of the temporal branch crossing the lower aspect of the zygomatic arch, with distinct anterior and posterior divisions identified in each dissection. In 8 of the 12 dissections, one or more separate middle divisions of the nerve also were seen at the inferior aspect of the zygomatic arch. Superior to the zygomatic arch, frequent interconnections were noted between all divisions of the temporal branch, but no connections were noted to other branches of the facial nerve. Previous descriptions of the course of the temporal branch based on soft-tissue landmarks most closely correlated with nerve rami that were found in the present study to be located within the anterior division of the nerve. On crossing the inferior aspect of the zygomatic arch, the anterior and middle divisions of the temporal branch were located a median of 12 and 4 mm anterior to the articular eminence, respectively; the posterior division ranged in location from 10 mm posterior to 7 mm anterior to the articular eminence. The range over which rami of the temporal branch crossed the inferior aspect of the zygomatic arch was equally divided anterior and posterior to the articular eminence and covered up to 50 percent of the total length of the zygomatic arch. The present study confirms that the temporal branch is not a single nerve branch but consists of multiple rami that cross the zygomatic arch anywhere for over half the length of its inferior border. Techniques for localizing the nerve based on reference points from two soft-tissue landmarks are therefore unreliable.

A dynamic analysis of changes in the nasolabial fold using magnetic resonance imaging: implications for facial rejuvenation and facial animation surgery.

An anatomic study was performed on living subjects using magnetic resonance imaging (MRI) to distinguish the relative contribution of skin, subcutaneous tissue, and muscle to dynamic changes in the nasolabial fold during facial animation and aging. MRI scans with the face in repose and then holding a full smile were performed in both young and old adult subjects. Anatomic landmarks were identified, and measurements characterizing their position were made on the MRI console. MRI resulted in excellent image resolution of facial tissue planes. Comparison between young and old subjects with the face in repose demonstrated that progressive thickening of the dependent portion of the check fat pad and overlying skin, with no appreciable change in the muscle plane comprising the levators of the upper lip, resulted in a deeper and more acute nasolabial fold in older subjects. In both age groups there was significant shortening of the mimetic muscles with smiling, with the lateral mimetic muscles drawn closer to the underlying facial bones. This was accompanied by redistribution of the cheek fat pad, thereby maintaining projection of surface landmarks within the cheek mass in young subjects with smiling. These findings indicate that in order to diminish the nasolabial fold, surgery for facial rejuvenation should be directed to the skin and subcutaneous tissue planes superficial to the mimetic muscles to the upper lip. In order to recreate a natural nasolabial fold during surgery for facial reanimation, contraction of the levator muscles to the upper lip should result in redistribution of the cheek fat pad without change in surface projection of the cheek mass or upper lip; this can only be accomplished if the reconstructed levator muscle is positioned deep to the cheek fat pad, with its insertion toward the deep (mucosal) surface of the upper lip.

Magnetic resonance imaging scanning in the diagnosis of zone II flexor tendon rupture.

This study was undertaken to determine the usefulness of magnetic resonance imaging (MRI) in the diagnosis of flexor tendon rupture in patients who had prior surgery. Magnetic resonance imaging scans were performed on 11 digits (16 tendons) with the clinical diagnosis of flexor tendon rupture. Clinical suspicion correlated with MRI and surgical findings. Clinical examination yielded a 60% accuracy in diagnosis. MRI differentiated rupture from adhesions with a 100% accuracy rate. The MRI scan is a valuable tool in diagnosing tendon ruptures and may help reduce the incidence of unnecessary tendon explorations.

Complications and salvage of an ectopically replanted thumb.

The ectopic replantation of a thumb is described after a mutilating hand injury. The case was followed by a series of complications and surgical procedures to treat these complications. Through perseverance and multiple microsurgical procedures the patient attained a functional hand. The patient's psychological and physical course is described.

Anatomic considerations in transconjunctival blepharoplasty.

To better identify the anatomy of the lower eyelid in relation to the transconjunctival approach to blepharoplasty, 20 fresh cadaver lower eyelids were dissected. Cross-sectional cuts of fresh cadaver specimens also were made and examined by whole-organ photomicrographs of the entire lower eyelid and its associated soft-tissue structures. These were correlated with magnetic resonance imaging studies in the living patient. Measurements were made of the relationship of the lid margin, tarsal plate, infraocular fat (including the three traditional fat compartments), inferior oblique muscle, and eyelid (on stretch). Our findings suggest that a transconjunctival incision closer to the fornix, directed toward the infraorbital rim, allows the surgeon a direct and safe approach to the fat compartments. No distinct anatomic compartmentalization of the periorbital fat as traditionally described was found. There was a consistent extension of the lateral pad, lateral to the lateral canthus of the eye. There are also accumulations of fat outside the orbital septum in the cheek and beneath the orbicularis muscle that contribute to the fullness of the lower eyelid and which cannot be addressed by the transconjunctival approach.

Combination latissimus dorsi and groin free flap with double microvascular transfer.

A combined free tissue transfer using the skin and muscle supplied by the thoracodorsal artery and the superficial circumflex iliac artery (groin flap) was transferred to reconstruct a large lower extremity soft-tissue defect. The combination of these two flaps allowed coverage of a large tissue defect, more reliable coverage than either of these flaps alone, and direct donor site closure.

Tissue humoral response to intact and ruptured silicone gel-filled prostheses.

Biopsies of the fibrous capsule in 31 women undergoing explanation of gel-filled breast prostheses and in 3 women with silicone gel-associated granulomas were tested for the presence of IgG, IgM, IgA, C3 complement, and fibrin using fluorescent antisera. Of a total of 41 prostheses removed, 9 were found to be ruptured but contained within the fibrous capsule or immediately adjacent to it. In the 3 women undergoing granuloma excision only, the sites were the arm (2) and the chest/axilla (1). In one patient, IgG, C3, and fibrin were detected in the capsule of an intact prosthesis. C3 and fibrin were present in the capsule surrounding one ruptured prosthesis. Fibrin was detected in the capsule of one other patient. Bilateral capsules surrounding intact prostheses removed from 4 patients with collage-vascular diseases were negative for C3, fibrin, and immunoglobulins, as were the 3 granulomas from distant sites. Hematoxylin and eosin stains revealed a typical foreign-body response to gel in almost all cases. Both T- and B-cell lymphocytes are present in the infiltrate surrounding silicone gel. In this study, chronic exposure to silicone gel-filled prostheses did not result in antibody deposition or complement activation in the fibrous capsule or in the tissue surrounding gel droplets.

Changes of the midface with age.

To understand how to re-create the youthful look, one must understand which tissues change with age, the direction of that change, and the amount of that change. This article discusses the subjective and objective results of a study of the evolution of the midface with aging.

Anatomy of the midface.

Surgical procedures for the midface and nasolabial fold demand that the surgeon possess a magnified knowledge of the facial anatomy and its structural relationships. With this knowledge, the surgeon limits complications while achieving better results. This article reviews the anatomy of the midfacial subcutaneous soft tissues.

The brachioradialis forearm flap: anatomy and clinical application.

The blood supply to the brachioradialis muscle and the skin of the forearm was studied in latex-injected arms. The dominant perforator to the muscle arose from the brachial artery (27.3 percent), radial recurrent artery (33.3 percent), or radial artery (39.4 percent). In all cases, adequate perforators exist from the radial artery so that transfer as either a muscle or musculocutaneous free flap based on this vessel is possible. In 10 arms the septocutaneous perforators from the radial artery were dissected to determine the relationship between the forearm and brachioradialis flaps. Transfer of the brachioradialis muscle as a free flap or combined with the radial artery forearm flap based on the radial artery and either the venae comitantes and/or the cutaneous veins is feasible. Four clinical cases demonstrate the usefulness of this flap.