Hemangiomas, vascular malformations, and lymphovenous malformations: classification and methods of treatment.

A total of 207 patients with hemangiomas, vascular malformations, and lymphovenous malformations were treated by the same surgeon from 1980 to 1990. Thirty-seven patients with true hemangiomas underwent surgical treatment. Only those hemangiomas which caused functional or developmental disturbances or those with complications were treated; many more were allowed to regress spontaneously. Sixty-five patients with low-flow and 16 with high-flow vascular malformations were treated by using a variety of surgical approaches. In low-flow lesions, sclerosant therapy can be extremely effective, either alone, in small lesions, or combined with surgical resection or embolization, in larger lesions. Preoperative embolization and surgical excision are the treatment of choice in high-flow malformations. Twenty-seven patients with lymphovenous malformations had only surgical excision with a high success rate. Sixty-two patients with acquired "senile hemangiomas" underwent a single local excision with excellent results. When indicated, angiography has been of great value as a diagnostic procedure to provide information about the vascular dynamics and the extent of these lesions, although magnetic resonance imaging is now being used more frequently for this purpose. Selective angiography also was used as a therapeutic modality when embolization was part of the treatment protocol. A new classification based on clinical, histologic, and vascular flow characteristics of these lesions has been used to simplify the present nomenclature and to help in selection of the most appropriate treatment. It has the added value of being in the language of the radiologist, who should be a member of the vascular anomalies team.

Orbitotemporal neurofibromatosis: classification and treatment.

In localized orbitotemporal neurofibromatosis, the treatment depends very much on the type and severity of the orbital involvement and on the functional state of the eye. The condition can be conveniently divided into three groups, each requiring different treatment: (1) orbital soft-tissue involvement with a seeing eye, (2) orbital soft-tissue and significant bony involvement with a seeing eye, and (3) orbital soft-tissue and significant bony involvement with a blind or absent eye. A total of 24 patients with a maximum of 12 years recurrence-free follow-up are presented.

Reconstruction of the extremity with the dorsal thoracic fascia free flap.

The dorsal thoracic fascia is the anatomic layer that contains the blood supply to the scapular and parascapular fasciocutaneous flaps. The cutaneous vascular territory of the circumflex scapular artery and its parascapular branches is well known. During the past 8 years, the authors have employed the dorsal thoracic fascia free flap for extremity reconstruction in 17 patients (upper extremity, n = 9; lower extremity, n = 8). The indications for using this free flap included primary coverage after trauma (n = 10), resurfacing of "unstable" scar (n = 3), coverage of plantar foot ulceration (n = 3), and coverage of an exposed lower extremity distal arterial bypass graft (n = 1). The large anatomic boundaries of this flap, the consistent vascular anatomy, and the thin yet durable quality of the tissue make this flap an excellent choice for the reconstruction of upper and lower extremity defects.

The accuracy of duplex ultrasonography in the planning of skin flaps in the lower extremity.

The septocutaneous perforators represent one of the major sources of the blood supply to the skin of the lower extremity. Despite several well-described anatomic accounts, the location of lower leg septocutaneous perforators, as they originate from each of the three main infrapopliteal vessels in the leg, remains inconsistent as a result of individual anatomic variations. With the aid of duplex ultrasonography (color Doppler imaging), preoperative, mapping and size determination of these perforators can be provided. The skin paddle can then be designed to lie exactly over these perforators, ensuring blood supply to the skin paddle. The location and distribution of medial septocutaneous perforators in the leg, which originate from the posterior tibial artery, were mapped using anatomic dissections (29 lower extremities). These findings were then compared with duplex ultrasonographic data in 9 living volunteers (18 lower extremities). The medial septocutaneous perforators were chosen for this study because they course directly over the posterior tibial artery, making their location difficult to assess with standard Doppler techniques. The hand-held Doppler is incapable of distinguishing flow originating from the perforators versus the posterior tibial artery. No significant difference existed between cadaver and duplex distributions. "Large" perforator vessels (> 1 mm outer diameter) were evenly distributed with a central tendency at 140 to 150 mm from the medial malleolus. The distribution of "small" perforator vessels (< 1 mm outer diameter) was skewed. Fifty percent were found within 80 mm of the medial malleolus and the remainder spread proximally in the leg.(ABSTRACT TRUNCATED AT 250 WORDS)

The gastrocnemius muscle as a free-flap donor site.

Despite the fact that the pedicled gastrocnemius flap has been used clinically for almost two decades, precise data on its neurovascular anatomy are lacking. A detailed knowledge of the neurovascular anatomy of this flap may encourage its more extensive use as a donor site by the means of microvascular free-tissue transfer. The femoral or popliteal artery in 27 fresh cadavers was injected with radiopaque contrast material to study the gross vascular supply of 54 medical and 50 lateral gastrocnemius muscles. The intramuscular vascular anatomy also was analyzed in 29 medial and 24 lateral gastrocnemius muscles using x-ray technique. Depending on the number of the sural arteries that supply the gastrocnemius muscle, flaps were classified as type 1 or type 2. Type 1 muscle bellies (lateral or medial gastrocnemius muscle belly) are supplied by one sural artery, while in type 2 muscles two arteries supply one muscle belly. Eighty-five percent of medial and 84 percent of lateral gastrocnemius muscle bellies had single vascular pedicles (type 1). The point of origin of the sural artery(s) permitted us to further classify the blood supply to the muscle bellies as subtypes A, B, and C. Intramuscular vascular anatomy is characterized as either a single vessel (dominant type) or two vessels (nondominant type). A single motor nerve, from the tibial nerve, accompanied the primary vascular pedicle into each muscle belly. When there were two vascular pedicles supplying one muscle belly, only one motor nerve accompanied the major pedicle.(ABSTRACT TRUNCATED AT 250 WORDS)

A cadaver investigation of the blood supply of the galeal frontalis flap.

The vascular anatomy of the galeal frontalis flap was studied in 12 fresh cadavers by an intraarterial dye injection technique. Special attention was directed to the length limit of this flap. The general belief that the galeal frontalis flap has a robust vascularity by means of the supratrochlear and supraorbital arteries was not demonstrated in this study. In the medial half of the forehead, superficial branches of both arteries penetrated the frontalis muscle immediately above the supraorbital rim and ran superficially in the subcutaneous tissue. In the lateral half, some of the superficial branches of the supraorbital artery traveled with the frontalis muscle and anastomosed with the frontal branch of the superficial temporal artery. Deep branches of the supratrochlear and supraorbital arteries showed an axial distribution on the periosteum only for a short distance. One or two branches of the supraorbital artery were found to take a superficial course within the subgaleal layer, pierce the frontalis muscle, and anastomose with the superficial temporal artery. These findings suggest that the galeal frontalis flap should be elevated in the lateral forehead. The preservation of the periosteum with the flap is recommended in order to ensure the temporoparietal extension.

Penetration of the skull base by dissecting keratocyst.

The extensive destructive potential of the keratocyst has been well recognized but penetration of the keratocyst into the skull base is rare. 3 cases showing such aggressive behavior and rare location were seen and treated; 2 are reported in this paper. Both cases illustrate the importance of early radical treatment once the aggressive nature of keratocyst is recognized.

Management of locally aggressive sinus disease using craniofacial exposure and the galeal frontalis fascia-muscle flap.

Histologically, benign sinus diseases can behave aggressively, potentially causing sight- and life-threatening conditions requiring surgical treatment. Four patients illustrating acute and chronic infection, single and multiple sinus polyposis, and mucoceles are presented and discussed to illustrate how the principles of craniofacial exposure, resection, and reconstruction may be employed to treat aggressive sinus disease. The bicoronal and buccal sulcus approaches minimize visible scarring; wide exposure of the orbital contents and dura reduce the risk of excessive bleeding, neurologic complications, and orbital volume derangements. Immediate cranial bone grafting and the well-vascularized galeal-frontalis myofascial flap obliterate the dead space and isolate the extradural space from contaminated facial cavities, diminishing the risk of infection. The craniofacial surgical approach is particularly appropriate for the management of aggressive frontoethmoidal and multiple sinus involvement because it allows the treatment of sinus cavities under direct vision and complete resection of sinus disease.

Microvascular anastomotic thrombosis in experimental diabetes mellitus.

An experimental model was developed to investigate the effects of glycemic control and pentoxifylline administration on microvascular anastomotic patency rates in streptozotocin-induced diabetic rats. Diabetes was confirmed by blood glucose levels of more than 300 mg/dl prior to administering insulin and/or pentoxifylline. Microvascular anastomoses of the femoral artery and vein were performed 4 weeks after induction of diabetes. Subsequently, the comparative rates of anastomotic thrombosis in diabetic and nondiabetic groups with or without insulin or pentoxifylline administration were assessed by direct visualization of the anastomotic sites after 4 days. The results suggest that hyperglycemia impairs the post-operative patency of microvascular venous anastomoses. The diabetic animals maintained under insulin regimens that tightly controlled their serum glucose levels (100 to 200 mg/dl) experienced patency rates similar to those of nondiabetic controls (p < 0.05). Pentoxifylline improved microvenous patency at all levels of hyperglycemia studied, suggesting a possible hemorrheologic mechanism for microvascular venous anastomotic thrombus formation in diabetic animals.

Reconstruction of extensive defects of the cranium using free-tissue transfer.

Fourteen patients with large tissue deficits in the calvarium and orbits were reconstructed using microvascular free-tissue transfer (15 flaps). The etiology of these defects was skin neoplasms (seven), osteomyelitis (four), burn (two), and trauma (one). The free flaps used were the latissimus dorsi muscle flap with a split-thickness skin graft (seven), latissimus dorsi myocutaneous flap (two), rectus abdominis myocutaneous flap (three), radial forearm fasciocutaneous flap (two), and split-iliac crest flap (one). There was one postoperative death, one flap failure, two recurrences of neoplasm, and one loss of bone grafts and flap from infection. The free flaps can offer good results in patients undergoing wide resection in the cranium and orbits providing immediate repair with acceptable cosmetic result, minimized morbidity, and short hospitalization. However, immediate reconstruction following tumor resection carries a danger of positive margins discovered on permanent histologic sections or the difficulty in detecting recurrence underneath a bulky free flap.

Long-term results of weight-bearing foot reconstruction with non-innervated and reinnervated free flaps.

Twenty one patients underwent reconstruction of the weight-bearing portion of the foot with 22 free flap transfers: 12 free flaps were skin-grafted muscle flaps and 10 were fasciocutaneous flaps. Twelve flaps were reinnervated by nerve coaptation (n = 10) or an 'onlay' nerve graft (n = 2). Follow-up ranged from 1.5 to 7 years (mean 38.5 months). Five flaps (23%) developed full thickness ulcers that required surgical treatment. All ulcers occurred in patients who had an underlying neuropathy. Most complications occurred early in the series. No significant difference was found in the incidence of complications and functional outcome between fasciocutaneous and skin-grafted muscle flaps. There was no significant difference between reinnervated and non-innervated flaps. Both fasciocutaneous and skin-grafted muscle flaps, whether reinnervated or non-innervated, can be successfully used for weight-bearing foot reconstruction. Neither type of flap should be considered permanent in the presence of peripheral neuropathy. Appropriate selection of patients, extensive education about foot care and frequent follow-up visits are essential to maintain a healthy, intact flap and reconstructed foot.

A comparison of single-stage versus gradual fronto-parietal advancement in terms of extradural dead space and bone deposition.

This study was designed to investigate the differences between single-stage and gradual advancement of cranial vault in adult cats. Fifteen animals underwent fronto-parietal craniotomy including the roof of the frontal sinus. They were randomly assigned to three experimental groups; single-stage advancement (n = 5), gradual distraction with intact dura-bone attachments (n = 5), and gradual distraction after separation of the dura from the fronto-parietal bone segment (n = 5). Development of an extradural dead space and new bone formation were evaluated with CT scans at 1, 4 and 12 weeks. After sacrificing the animals at 12 weeks, midsagittal frozen sections and decalcified coronal sections of the heads were obtained. The single-stage advancement group developed an extradural dead space which communicated with the frontal sinus. The advanced bone segment, which was exposed to the air-filled dead space, showed bony resorption. Both groups of gradual advancement showed enlargement of the cranial cavity and frontal sinus. As the dura and brain were stretched superiorly, no extradural dead space was produced. Although the distraction gap demonstrated deposition of new bone in both gradual advancement groups, the bone formation was less pronounced in distraction after separating the dura from the bone segment. In conclusion, gradual distraction of a fronto-parietal bone prevents extradural dead space formation regardless of whether the dura is kept attached to or it is separated from the distracted bone segment. Devascularization of the bone segment by dissecting off the dura, however, decreases new bone formation, and thus may increase a risk of relapse.

Midface advancement in sheep by gradual distraction: a 1-year follow-up study.

PURPOSE: The purpose of this study was to find a solution to the unsatisfactory postoperative maxillary relapse after major maxillary advancement or inferior repositioning of the maxilla. MATERIALS AND METHODS: Major midface advancement by gradual distraction was performed on three young adult sheep over 21 days. Using an external device, the midface was advanced 36 mm in the nasofrontal area and 43 mm in the lateral aspect of the maxilla. The apparatus remained as an external fixation device for 6 weeks after the distraction to allow better ossification. After removal of the device, a 1-year clinical and radiographic follow-up was conducted. RESULTS: Direct measurements between the markers showed 2- to 3-mm relapse after 1 year. Radiologic measurements demonstrated that the relapse occurred during the first 3 months after removal of the distraction apparatus. CONCLUSION: It was concluded that midface advancement by gradual distraction may obviate the need for bone grafting and offer a greater movement of bone segments with good skeletal stability.

The cervical tube pedicle flap: uses in facial reconstruction.

Most reconstructive surgeons will not commonly need to use the transverse cervical tube pedicle flap in facial reconstruction but this straightforward and simple technique can be very useful in certain instances. Some of the techniques of reconstructive surgery which have stood the test of time should not be forgotten even when the most recent reconstructive options are available.

Extradural dead space following cranial bone advancement.

The extradural dead space produced after enlargement of the intracranial space or after reduction of the volume of the intracranial contents persists for an unknown period of time. To investigate this further, an extradural dead space was surgically created by advancement of parietal bones in 9 adult rabbits. By design, there was no connection with the paranasal sinuses. To determine outcome of the dead space, three-dimensional computed tomographic and histological studies were performed. The brain volume decreased in the first 3 months after surgery and remained constant for up to 9 months. The extradural volume increased in the first 4 weeks postoperatively, gradually decreasing in size with time. The brain failed to eliminate the extradural dead space by rearrangement or expansion. An osseous cavity filled with fluid and connective tissue was formed within the dead space. The fluid within it remained, even 9 months after surgery. This could be a potential environment for bacterial invasion if there was a connection with the nasopharynx.

Galeo-pericranial flaps in the forehead: a study of blood supply and volumes.

Despite their extensive use in anterior cranial base reconstruction, very little is understood about the blood supply of galeo-pericranial flaps derived from the forehead region. The goal of this study was to define the extent of the reliable axial blood supply and to determine the volumes of these flaps. The blood supply to anteriorly based galeo-pericranial flaps depends entirely upon the deep branches and a variable component of the superficial branches of the supraorbital and the supratrochlear vessels. The axial component of the blood supply to these flaps is 20-70 mm. The extent of "random' pattern blood supply distal to this could not be adequately assessed. The volumes of various galeo-pericranial flaps range from 3 to 48 cc. The well vascularized proximal portions of galeo-pericranial flaps may well serve the reconstructive needs of the anterior cranial base. Use of more distal portions of these flaps should be undertaken with caution. Some increase in bulk and vascularity may be achieved if the pericranial and the galeal-frontalis myofascial flaps are harvested as a single unit, the composite galeal-frontalis-pericranial flap. Due to the vascular and volume limitations of galeo-pericranial flaps, consideration should be given to the use of microvascular free tissue transfers in instances where large soft tissue defects and a large "dead space' occur.

Effect of monophasic blood flow on the patency of microvascular anastomoses.

The effect of monophasic blood flow on the patency of microvascular anastomoses in the rat femoral artery was evaluated by the authors. An experimental model of monophasic blood flow was created in the rat femoral artery to simulate that seen in patients with peripheral vascular disease. Microvascular anastomoses were performed, and the patency at the first hour and 24 hr later was determined. The studies demonstrated that microarterial anastomotic patency was the same when performed in vessels with monophasic or triphasic flow patterns. The authors conclude that monophasic blood flow is not an absolute contraindication for free-tissue transfer.

Midface advancement by gradual distraction.

Midface osteotomy was performed on 5 young adult sheep aged 10-12 months. In 4 animals midface advancement by gradual distraction was performed using an external device; one animal served as a control. The midface was advanced by 2 mm per day for 21 days. The amount of advancement was 36 mm in the nasofrontal area and 43 mm on the lateral aspect of the maxilla. After the period of active distraction the midface was maintained with external fixation for an additional 6 weeks to allow for ossification. Radiographs were obtained immediately postoperatively, after 21 days of distraction, and at the end of the 6 week fixation period. New bone formation in the distracted area was obvious radiographically, clinically and histologically. In conclusion, midface advancement by osteotomy and gradual distraction is possible in the sheep model and may offer controlled correction of deformity, obviating the need for the bone grafting.