The fasciovascular flap: a new vehicle for islet transplantation.

In order to determine whether pancreatic islets could be neovascularized by a fasciovascular flap (FVP), islet transplant studies were conducted in Lewis rats. Islets from two donors were isolated by collagenase digestion and discontinuous gradient centrifugation on Ficoll. These islets were injected in syngeneic recipients either into random groin SC fat as a control, or into a flap composed of fascia and fat elevated from the groin based on the superficial inferior epigastric vessels. After two wk, islet viability was assessed by histological analysis. The degree of neovascularization of the islet tissue was evaluated with India ink injection through the vascular pedicle. Whereas control islets degenerated and did not show clear signs of neovascularization, FVP-islets showed rich neovascularization and viability as a large sheet of islet clusters. These results have demonstrated that the FVP-flap is a novel recipient site which can support a large quantity of islet tissue. This model constitutes a unique neo-endocrine pancreas flap, which can be subsequently transplanted at will to transfer the established neo-endocrine pancreas to a desired site using microvascular surgical technique.

Immediate reconstruction of full-thickness chest wall defects.

Twenty-one patients had full-thickness chest wall defects reconstructed at the New York University Medical Center in the last ten years. Marlex mesh provided chest wall stability in 5 patients. In 9 patients with radiation ulcers Marlex mesh was not required; a severe fibrotic reaction had obliterated the pleural space and prevented paradoxical motion. Partial sternal resections did not require Marlex stabilization, while a total sternectomy resulted in marked ventilatory insufficiency in a patient who would have benefited from the use of a stabilizing material. Random pattern flaps were used initially; more recently, axial pattern, myocutaneous, and myocutaneous free flaps were employed. Necrosis developed in 4 (36%) of the 11 patients with random pattern flaps, but was not seen with the newer flap techniques. Myocutaneous free flaps provided uncomplicated coverage of and stability to three large, potentially contaminated defects. It seems that with the currently available flap techniques and the methods of chest wall stabilization, immediate repair of all full-thickness chest wall defects is possible.

Surgical techniques in penile revascularization.

A review of the current status of penile artery revascularization and its methodology is presented. Microsurgical anastomosis of the inferior epigastric artery or central arteries produces good results in younger men. Older patients or those with diabetes, hypertension or who have had coronary bypass surgery do not appear to have good results.

Management of compartmental syndrome. Diagnostic and surgical considerations.

Compartmental syndrome is a condition in which swelling within a closed anatomic space increases the intracompartmental pressure to compromise the circulation and function of tissue within that space. Unless this condition is recognized early and treated by prompt surgical decompression, permanent neuromuscular deficits may result. In those instances in which early clinical evidence of this syndrome is difficult to assess, monitoring of intramuscular pressures may be valuable adjunct in the clinical evaluation of patients at risk for this syndrome. The association of compartmental syndrome with a wide variety of circumstances and the importance of an early diagnosis make it essential that all physicians be familiar with this condition. As physician awareness and recognition of this condition increase, the complications associated with it can be greatly reduced.

Clinical experience with a microvascular anastomotic device in head and neck reconstruction.

BACKGROUND: Despite numerous refinements in microsurgical technique and instrumentation, the microvascular anastomosis remains one of the most technically sensitive aspects of free-tissue transfer reconstructions. MATERIALS AND METHODS: Concurrent with the development of microsurgical techniques, various anastomotic coupling systems have been introduced in an effort to facilitate the performance and reliability of microvascular anastomoses. The microvascular anastomotic coupling device (MACD) studied here is a high-density, polyethylene ring-stainless steel pin system that has been found to be highly effective in laboratory animal studies. Despite its availability for human clinical use over the last 5 years, reported clinical series remain rare. Our clinical experience with this MACD in 29 head and neck free-tissue transfers is reported herein. RESULTS: Thirty-five of 37 (95%) attempted anastomoses were completed with 100% flap survival with a variety of donor flaps, recipient vessels, and clinical contexts. Two anastomoses were converted to conventional suture technique intraoperatively, and one late postoperative venous thrombosis occurred after fistulization and vessel exposure. CONCLUSIONS: We conclude that the MACD studied here is best suited for the end-to-end anastomosis of soft, pliable, minimally discrepant vessels. Previous radiation therapy does not appear to be a contraindication to its use. Interpositional vein grafts may also be well suited to anastomosis with the device. When carefully and selectively employed by experienced microvascular surgeons, this MACD can be a safe, fast, and reliable adjunct in head and neck free-tissue transfer reconstructions, greatly facilitating the efficiency and ease of application of these techniques.

Alginate microbead release assay of angiogenesis.

Recently, the acceleration (and retardation) of blood vessel growth has been an increasingly frequent subject of study. With its potential application to a wide range of clinical disease processes, investigation certainly remains essential and promising. While in vitro investigation is traditional, well-controlled, and objective, studying angiogenesis in vivo can be quite difficult for a number of reasons. One major reason is the inherent tissue differences associated with blood vessel growth. Because all tissues are different, certain tissues tend to be inherently more vascular than others. As such, the growth (and concentration) of blood vessels occurs at different rates and proportions depending on that specific tissue. In the past several years, most in vivo angiogenesis work has been performed in the sclera as it allows for relatively easy access and the possibility of repeated observation. The sites to which investigation of angiogenesis might be applied, however, are invariably quite different and therefore additional tissues such as solid organs, fascia, muscle, and skin need to be studied as well. How can this be performed?

Microsurgery--looking ahead.

The evolving areas of microsurgery pertinent to hand surgery are briefly described and outlined. The spectacular developments in the recent past are merely glimpses of what may yet be ahead for hand surgery. This is illustrated by a science fiction story of the management of an amputation injury in outer space in which many of the currently evolving technologies are employed.

Aesthetic reconstructions of the leg after trauma.

Lower extremity trauma often results in significant skin or contour deformities as a result of the tissues destroyed. Such deformities are poorly tolerated by most patients, especially younger women. To achieve a satisfactory aesthetic reconstruction, the surgeon must be familiar with the special anatomy of the lower extremity as well all the different reconstructive options at his or her disposal. Minor scars or contour deformities can be corrected by traditional methods of scar revision or serial excision. Tissue expanders or silicone implants have a somewhat limited role in the lower extremity as compared with elsewhere in the body. Most major defects require free flaps to replace the surface or contour. Because of the importance of aesthetic results in the legs, free flaps should be utilized more often during the original trauma surgery if their use is deemed necessary for aesthetic reasons (Case 6).

Microvascular free flap breast reconstruction.

As in other areas of reconstruction, microvascular free flaps have earned a definite role in certain breast reconstructions difficult to accomplish with conventional techniques. With improvements in techniques and survival rates, the advantages of such reconstructions have become increasingly more attractive to the patient and the surgeon.

Superior gluteal free flap breast reconstruction.

The authors substantial experience with the superior gluteal free flap for breast reconstruction indicates that this is a more difficult but important free flap for breast reconstruction. Compared with the standard transverse rectus abdominis myocutaneous (TRAM) free flap, it is a much less forgiving operation with many specific technical details. With careful attention to details on flap design, recipient vessel selection anastomsis, and flap insetting, the success rate and morbidity of the gluteal flap operation are highly acceptable. For patients unsuitable for the TRAM flap for autologous tissue reconstruction, this is a very valuable alternative. It can achieve some spectacular results in breast reconstruction in terms of volume, replacement, and projection--even in very thin patients.

Bilateral free flap breast reconstruction.

Bilateral mastectomies are relatively frequent. Free flaps from the abdomen, buttock, and lateral thigh can be used for simultaneous or staged reconstructions. The more extensive surgery is well rewarded by the permanent and gratifying results achieved. For patients unsuitable for implants or who have had failed implant reconstructions, such autologous tissue reconstructions are important alternatives.

Reconstruction of foot injuries.

Foot injuries constitute a spectrum of problems that can be classified by severity. The development of successful techniques for the treatment of lower leg injuries has made the severity of a concomitant foot injury a key factor in determining the overall salvageability of the leg. A more complete classification of foot injuries is therefore needed and has been proposed. Preoperative assessment of foot injuries differs in the acute versus the delayed presentation. The acute case requires evaluation of wound conditions, exposed structures, and associated proximal injuries. The chronic injury requires gait analysis, study of weight-bearing patterns by Harris mat prints, skeletal evaluation, mapping of plantar sensation, and, in some cases, angiography. Thorough knowledge of foot anatomy is essential for developing a rational plan for treatment. The significance and course of the medial calcaneal nerve and the anatomy of the plantar nerves have not been fully appreciated in most reports on the treatment of foot injuries. The recognition of the proximal plantar subcutaneous plexus blood supply has modified the understanding of plantar flap design. It has simplified and improved the safety of dissection of sensate plantar flaps. A plethora of both local and distant flap options exist for the treatment of foot injuries. The foot is divided into four major areas based on different requirements for reconstruction and the types of flaps available. These areas are the proximal plantar area; the malleoli, Achilles tendon, and posterior (non-weight-bearing) heel area; the distal plantar area; and the dorsum. The options for coverage have been discussed in detail, and a summary of the reconstructive strategy by area has been presented in Table 3. Complex (type III) injuries are special injuries owing to their severity and multiple components. They require a careful initial evaluation for both feasibility and advisability of extremity salvage. Treatment of these injuries consists of bony stabilization and soft-tissue debridement followed by flap coverage.

The evolution of the surgical management of severe lower extremity trauma.

A hundred years ago, the question of whether to amputate a severely injured extremity could be answered rather easily and did not pose a serious dilemma. However, the increasing reconstructive capabilities have permitted the retreat to amputation to be made less frequently and occasionally create a dilemma concerning the best means of securing optimal function for the traumatized extremity. The surgeon must carefully balance the extent of trauma with the likelihood that his or her reconstructive efforts would surpass the functional results afforded by prompt amputation and prosthetic fitting. Although the mechanisms of limb destruction have changed in the past 2 centuries, the fundamental dilemma confronting the trauma surgeon has remained unchanged. In the words of Samuel D. Gross: "The cases which may reasonably require and those which may not require interference with the knife are not always so clearly and distinctly defined as not to give rise, in very many instances, to the most serious apprehension ... that, while the surgeon endeavors to avoid Scylla, he may not unwittingly run into Charybdis, mutilating a limb that might have been saved, and endangering life by the retention of one that should have been promptly amputated."

Lower extremity nerve injuries.

The surgical and anatomic features pertinent to lower extremity nerve injury are reviewed. The common problems associated with specific nerve lesions are discussed and reparative recommendations are offered. A more informed, aggressive approach to lower extremity nerve repair is suggested.

Microvascular free flaps in breast reconstruction.

There is no longer any doubt that free flaps can achieve the best breast reconstruction. Proof is the rapidly increasing popularity of the method. Its many advantages, the indications for each flap, and the technical refinements are presented.

Principles of flap prefabrication.

Clinical flap prefabrication can be classified according to the basic technique of plastic surgery used for the prefabrication. There are currently three methods: (1) delay or expansion; (2) grafting; and (3) vascular induction by staged transfer. Illustrative cases are given to point out the advantages and indications for each method. A fourth, still experimental, method is based on cell biology advances that are looming on the horizon and may have revolutionary future clinical applications.

Vascularized calvarial flaps.

Vascularized calvarial transfers offer many advantages. In this article the anatomic (soft tissue, vascular, osseous) basis of flap design is summarized, and the technical details of two calvarial flaps, the temporoparietal and the frontoparietal, are presented.

Breast reconstruction by superior gluteal microvascular free flaps without silicone implants.

The author's experience with 10 gluteus maximus myodermal free flap breast reconstructions is reviewed against the current methods of reconstruction using silicone implants, latissimus dorsi flaps, regional skin flaps, and rectus abdominis myodermal flaps. The superior gluteal free flap can achieve a reliable, permanent, and aesthetic reconstruction of the breast without silicone implants. The softness, projection, natural appearance, and patient satisfaction are excellent compared with other methods. It is particularly useful in patients who object to the use of artificial implants, are not suitable for regional flaps, or have disappointing results from previous reconstructions. Technical modifications of the flap design and selection of the recipient vessels are important.

Managed care's attempts to capture aesthetic surgery.

Managed care organizations recently have attempted to add aesthetic surgery to their line of available services. To better understand the challenges posed by these actions, all members of the American Society for Aesthetic Plastic Surgery were surveyed about managed care overtures to aesthetic plastic surgeons, their responses, and the likely responses of their patients. The goal was to examine both the supplier and consumer ends of the aesthetic surgery market to determine the likely effects of managed care's attempts to capture aesthetic surgery. A total of 632 plastic surgeons returned the surveys (response rate, 54.5 percent). Twenty-two percent reported being approached by managed care organizations about joining a panel of aesthetic surgeons. Approximately one-quarter of the plastic surgeons said they would participate in aesthetic surgery panels developed by managed care organizations. Characteristics significantly associated with willingness to participate were solo practice structure, a low percentage of practice revenues from aesthetic surgery, and a very competitive practice environment. Plastic surgeons believed that their colleagues would be even more willing to acquiesce to managed care aesthetic surgery; more than one-third said that 25 to 50 percent of their colleagues would join, and nearly one-third thought that more than half would participate. Plastic surgeons believed that many of their patients would also participate in managed care aesthetic surgery. Twenty-four percent thought that more than half of their patients would choose an aesthetic surgeon through their managed care organization if that organization developed a network for aesthetic surgery. This figure increased to almost 40 percent if the organization would deny coverage for complications resulting from nonpanel surgeons, and to 41 percent if the organization would offer price discounts. This survey shows that most plastic surgeons are against managed care aesthetic surgery. But it also shows that some plastic surgeons will participate, and that most plastic surgeons think many of their colleagues and patients will do likewise. This means that managed care organizations have the potential to make inroads in aesthetic surgery on both the supplier and consumer ends of the market. To prevent managed care from capturing aesthetic surgery, plastic surgeons must anticipate the likely business strategy of managed care. To this end, they must understand the steps involved in the creation of a new service business and offer organized countermeasures against each of them.

Anatomic basis of plantar flap design: clinical applications.

Closure of plantar defects with local rotation flaps was studied in 10 patients with 11 plantar defects. Ages ranged from 15 to 66 years, and the average defect was 3.0 X 3.6 cm. Two patients were diabetics. Etiology was variable and included trauma, tumors, and breakdown in patients with anesthetic plantar surfaces. Plantar flaps were designed superficial to the plantar fascia based on the proximal plantar subcutaneous plexus blood supply. Sensation was provided by including the medial calcaneal nerve territory within the flap and by performing a limited intraneural dissection of the medial and lateral plantar nerves. Flaps were medially based, although laterally based designs are also possible when sensation is absent. The follow-up period averaged 20.8 months. Patients with normal sensation preoperatively had full sensation postoperatively and were able to bear weight on the flap without limitation. There was minor breakdown in one patient with incomplete sensation. One patient developed a hematoma. Sensate plantar flaps can be designed superficial to the plantar fascia. These flaps are durable and allow normal weight-bearing on the reconstructed surface.