Microsurgery in the burn population - a review of the literature

The management of patients suffering from burn injury poses unique challenges for the reconstructive surgeon, both in the acute and delayed settings. Once resuscitative measures are optimized and hemodynamic stability is achieved, early burn debridement and coverage is performed. Traditionally, this consists of excision of devitalized tissue and subsequent coverage using split thickness skin grafts. However, in certain instances, and depending on the extent and nature of the burn injury, skin grafting (or even local tissue rearrangement) may not be a reasonable option. in these cases, free tissue transfer may provide a viable reconstructive alternative. While free flap reconstruction is rare in burn surgery, particularly in the acute setting, burn injuries that expose vital structures, such as tendon, nerve, bone, or deep vessels, require robust flap coverage. in the delayed setting, unsightly scar formation and contracture often occurs secondary to skin graft coverage. These significant patient morbidities are often amenable to free tissue transfer as well. This review article discusses the indications, applications, and problems with free flap surgery for burn injuries in both the acute and delayed setting, and summarizes the available literature on microsurgical free tissue transfer for burn management.

An innovative procedure for the treatment of primary and recurrent capsular contracture (CC) following breast augmentation

BACKGROUND

Capsular contracture (CC) is the most frequently reported complication following alloplastic breast augmentation. At present, none of the available preventive measures are effective, and various treatment modalities have been advocated. Reduction of the inflammatory process is critical for successful treatment. Late intracapsular glucocorticosteroid (GC) injections have been somewhat effective for the treatment, but the fine balance between the effectiveness of therapeutic GC dosages and their potential serious side effects is of utmost importance.

OBJECTIVES

The authors investigate whether instillation of a rapid-acting water-soluble GC in the implant pocket during the early proliferative phase of wound healing is more effective than delayed instillation during the remodeling phase.

METHODS

Between 2003 and 2009, 33 consecutive patients presenting with CC (Baker grades III and IV) were managed by capsulectomy with implant replacement and corticosteroid therapy immediately as well as 2 to 3 days later through an indwelling catheter left in place for that period. This delayed but early administration is a novel technique for GC injection.

RESULTS

Complete correction of the contracture with no recurrence was achieved in all patients with a follow-up range of 2 to 10 years.

CONCLUSIONS

This GC administration technique avoids the potential complications of long-term, slow corticosteroid release. It has a targeted anti-inflammatory effect, probably at a critical stage of the healing process, and could effectively prevent CC following alloplastic breast augmentation.

Nutritional and Pharmacological Modulation of the Metabolic Response of Severely Burned Patients: Review of the Literature (Part III)*

Severe burn patients are some of the most challenging critically ill patients, with an extreme state of physiological stress and an overwhelming systemic metabolic response. Increased energy expenditure to cope with this insult necessitates mobilization of large amounts of substrate from fat stores and active muscle for repair and fuel, leading to catabolism. The hypermetabolic response can last for as long as nine months to one year after injury and is associated with impaired wound healing, increased infection risks, erosion of lean body mass, hampered rehabilitation, and delayed reintegration of burn survivors into society.Reversal of the hypermetabolic response by manipulating the patient's physiological and biochemical environment through the administration of specific nutrients, growth factors, or other agents, often in pharmacological doses, is emerging as an essential component of the state of the art in severe burn management. Early enteral nutritional support, control of hyperglycaemia, blockade of catecholamine response, and use of anabolic steroids have all been proposed to attenuate hypermetabolism or to blunt catabolism associated with severe burn injury. The present study is a literature review of the proposed nutritional and metabolic therapeutic measures in order to determine evidence-based best practice. Unfortunately, the present state of our knowledge does not allow the formulation of clear-cut guidelines. Only general trends can be outlined which will certainly have some practical applications but above all will dictate future research in the field.

Nutritional and Pharmacological Modulation of the Metabolic Response of Severely Burned Patients: Review of the Literature (Part II)*

Severe burn patients are some of the most challenging critically ill patients, with an extreme state of physiological stress and an overwhelming systemic metabolic response. Increased energy expenditure to cope with this insult necessitates mobilization of large amounts of substrate from fat stores and active muscle for repair and fuel, leading to catabolism. The hypermetabolic response can last for as long as nine months to one year after injury and is associated with impaired wound healing, increased infection risks, erosion of lean body mass, hampered rehabilitation, and delayed reintegration of burn survivors into society. Reversal of the hypermetabolic response by manipulating the patient's physiological and biochemical environment through the administration of specific nutrients, growth factors, or other agents, often in pharmacological doses, is emerging as an essential component of the state of the art in severe burn management. Early enteral nutritional support, control of hyperglycaemia, blockade of catecholamine response, and use of anabolic steroids have all been proposed to attenuate hypermetabolism or to blunt catabolism associated with severe burn injury. The present study is a literature review of the proposed nutritional and metabolic therapeutic measures in order to determine evidence-based best practice. Unfortunately, the present state of our knowledge does not allow the formulation of clear-cut guidelines. Only general trends can be outlined which will certainly have some practical applications but above all will dictate future research in the field.

Nutritional and pharmacological modulation of the metabolic response of severely burned patients: review of the literature (part 1)

Severe burn patients are some of the most challenging critically ill patients, with an extreme state of physiological stress and an overwhelming systemic metabolic response. Increased energy expenditure to cope with this insult necessitates mobilization of large amounts of substrate from fat stores and active muscle for repair and fuel, leading to catabolism. The hypermetabolic response can last for as long as nine months to one year after injury and is associated with impaired wound healing, increased infection risks, erosion of lean body mass, hampered rehabilitation, and delayed reintegration of burn survivors into society. Reversal of the hypermetabolic response by manipulating the patient's physiological and biochemical environment through the administration of specific nutrients, growth factors, or other agents, often in pharmacological doses, is emerging as an essential component of the state of the art in severe burn management. Early enteral nutritional support, control of hyperglycaemia, blockade of catecholamine response, and use of anabolic steroids have all been proposed to attenuate hypermetabolism or to blunt catabolism associated with severe burn injury. The present study is a literature review of the proposed nutritional and metabolic therapeutic measures in order to determine evidence-based best practice. Unfortunately, the present state of our knowledge does not allow the formulation of clear-cut guidelines. Only general trends can be outlined which will certainly have some practical applications but above all will dictate future research in the field.

Numeric expression of aesthetics and beauty

Debate over what constitutes beauty, particularly beauty of the human body, has raged since philosophy began. Interested scholars have debated the meaning of beauty for centuries. However, it seems that numbers and the resulting numeric relationships play a fundamental role in the classification of the human body, and that a harmonic profile or body shape is produced only at certain definite numeric relationships. The beauty of individual features depends on "ideal" proportions, and it is suggested that expressing beauty in terms of geometry is possible. As the demand for aesthetic surgery has increased tremendously over the past few decades, it is becoming essential to be able to assess the possible satisfaction that can be expected after an aesthetic surgery procedure and to determine the beauty of the final result as precisely as possible.

Marjolin's Ulcer of the Scalp: a Reconstructive Challenge

In the year 1828 Jean-Nicolas Marjolin described the formation of ulcers specifically in chronic burn scars, and in 1903 De Costa coined the term "Marjolin's ulcer", applying it to tumours arising in simple leg ulcers. The causes of this condition are described, as also treatment protocols, and a case report is presented.

Armed conflict and burn injuries: a brief review*

Burns and fire disasters are sad but common and obligatory components of armed conflicts, and with the increasing sophistication of weaponry and of chemical and nuclear devices the problem is not set to disappear; on the contrary. Indeed, with the (fortunate) decrease of major international wars but with the (unfortunate) increase of smaller ethnic and sectarian but equally treacherous conflicts, burns are bound to remain a constant problem. Yet the profession is ill prepared for such dark challenges.

Microvascular soft-tissue coverage and distraction osteosynthesis for lower-extremity salvage

In our attempts to salvage massive lower-extremity injuries, even in the presence of severe peripheral vascular pathology, adequate soft-tissue coverage is no longer a limiting factor due to recent advances in microvascular composite tissue transfer. Restoration of tibial continuity without shortening has emerged as the last obstacle in the formidable task of salvaging lower extremities with grade III B and III C defects. Proposed solutions to this problem include conventional free cancellous bone-grafting applicable to small defects only, vascularized bone grafts, or shortening of the leg with subsequent elongation using the Ilizarov technique. We present our experience with 3 consecutive cases of lower-limb salvage, utilizing a new approach in which microsurgical soft-tissue reconstruction has been combined with bony reconstruction by distraction osteosynthesis. Bone transport by distraction osteosynthesis under a free flap performed while preserving the initial limb length throughout the treatment period proved to be superior to other methods in selected cases and is presented as a new technique for the management of problematic lower-limb injuries.

Pharmacologic partial salvage of a failing free flap with recombinant tissue plasminogen activator (rt-PA)

Despite all the technical improvements in microvascular surgery and the experience gained in clinical practice, thrombosis at the site of microanastomosis remains a significant problem and a continuous source of frustration to most microsurgeons. Early recognition of vascular complications and prompt reexploration with vascular revision remain an essential and standard conduct for salvage. However, in situations where conditions for no-reflow have been established due to severe vasospasm or prolonged ischemia time, it becomes obvious that surgical reexploration alone is not enough to salvage a failing flap or a replanted limb. In such situations, the loss of the revascularized tissues seems to be inevitable. The authors describe their experience in partially salvaging a failing free flap with recombinant tissue plasminogen activator (rt-PA), reversing an established state of no-reflow. Pharmacologic manipulation of the complex and variable factors influencing anastomotic patency in microvascular tissue transfer seems to offer a new hope for preventing failures, as well as for salvaging failing flaps. It appears also that free-tissue transfer failure is not an all-or-none phenomenon.

Balloon compression of the intramaxillary sinus for intractable post-traumatic bleeding from the maxillary artery. Case report

We present a case of severe intractable epistaxis after midfacial trauma in which the bleeding was identified as coming from the descending palatine artery, a branch of the maxillary artery. It could not be controlled by simple packing, and was stopped by inserting a balloon into the maxillary sinus, tamponading the injured vessel in the sphenopalatine fossa (pterigopalatine fossa). We describe an easy and practical emergency manoeuvre to control bleeding from inaccessible branches of the maxillary artery and to prevent rebleeding after embolisation.

Local recombinant tissue plasminogen activator (rt-PA) thrombolytic therapy in microvascular surgery

Vascular thrombosis remains a dreaded complication of any microvascular procedure, be it composite tissue transfer or replantation of amputated limbs or parts. Despite the tremendous advances in microvascular-related technologies and the accumulated surgical skills, failures caused by occlusion of anastomosed vessels remain a continuous source of frustration to all microsurgeons alike. Several anticoagulation and antiplatelet protocols have been proposed to be used in conjunction with microvascular surgery. More recently, thrombolytic drugs such as urokinase, streptokinase, and thrombolysin have been introduced, yet their systemic effect on hemostasis remains an undesirable side effect. We present our experience with local intra-arterial, intravenous, and soft-tissue injection of recombinant tissue plasminogen activator rt-PA in replantation surgery in three consecutive patients. Arterial thrombi are managed by intra-arterial rt-PA infusion with the catheter placed proximal to the arterial anastomosis. Venous thrombi are best lysed by infusing rt-PA in an engorged vein of the replanted limb. In replanted digits, direct intravenous infusion is not possible. In such situations, injection of rt-PA in the pulp soft tissues may result in successful salvage. We believe this agent also has a role in microvascular composite tissue transfer in preventing free flap failures as well as in salvaging failing flaps.

Microsurgical free tissue transfer: a valuable reconstructive procedure--review of 75 cases

A total of 75 cases of microsurgical composite tissue transfer to reconstruct defects of the head and neck, trunk, upper and lower extremities performed at the American University of Beirut Medical Center between January 1992 and December 1997 were evaluated in a retrospective study. There was a failure rate of 6.6% and a complication rate of 13.3%. Our results show that free tissue transfer can be considered as a safe and viable treatment option in a wide variety of clinical situations including early soft tissue coverage of complex extremity wounds, limb sparing procedures for malignant neoplasms, reconstruction of the head and neck area, treatment of chronic osteomyelitis, and finally reconstruction of the foot in patients with severe diabetic neuropathy and peripheral vascular disease. A brief discussion of the history of microvascular free tissue transfers as well as their value in modern reconstructive surgery is also presented.

Muscle transposition flap for salvage of exposed peripheral prosthetic vascular grafts

Infection of prosthetic vascular grafts, although infrequent, is a dreadful complication in vascular surgery. It is a challenge for the surgeon and is life- and limb-threatening to the patient. Conventionally, infection involving a foreign body is eradicated by removing the foreign body. Despite its theoretical appeal, this solution is fraught with danger--a high mortality rate that ranges between 10% and 30%, a high rate of protracted postoperative morbidity, and a limb amputation rate as high as 70%. The salvage of infected prosthetic vascular grafts by prompt soft-tissue coverage with transposition muscle flaps in 3 consecutive patients treated during a period of 12 years is the subject of this report.

Necrotising infection of the orofacial tissues in neonates (noma neonatorum). Case report

Noma neonatorum should be differentiated from noma, in that it is typically a disease of seriously ill premature infants whose birth weight was low, and is caused by Pseudomonas aerugenosa septicaemia. We know of only two case reports of noma neonatorum involving newborn infants born at full term, so we report here another case of noma neonatorum in a neonate born at full term. In addition we describe the differences between noma neonatorum and noma (cancrum oris), a clinically related entity.

Perinipple round-block technique for correction of tuberous/tubular breast deformity

A one-stage surgical correction of tuberous and tubular breast deformities is described. An intraareolar donut of pigmented skin is deepithelialized to correct the associated mega areola, allowing, at the same time, a port of entry for insertion of a retroglandular breast implant. The exposed areolar dermis is then telescoped inward and stretch-anchored to an imaginary circular line situated beneath the breast skin areola junction, thus pushing the breast tissue against the implant and the chest wall and correcting the deformity. The round-block technique is then utilized to approximate the skin edges, resulting in a minimal scar, totally inconspicuous, confined to the immediate perinipple area.

Early microvascular reconstruction of Gustilo type III-C lower extremity wound. Case report

Current algorithms for lower limb injuries recommend amputation for most Gustilo type III-C injuries with a limb salvage index score of 6-8 or more. Recent improvements in the timing and technique of microvascular flaps with the reduction in bone healing time as a result of better fixation devices and early bone grafting make the option of limb salvage after such severe injuries a valid and acceptable therapeutic approach. We present a case of severe shot gun injury to the leg with a limb salvage index score of 9 that was successfully salvaged by vascular reconstruction followed three days later with a microvascular osteocutaneous scapular flap anastomosed to the divided limbs of a preliminary arteriovenous fistula that had been constructed at the time of the initial vascular repair. The patient was able to walk unaided one year after the injury.

Ulnar collateral ligament rupture of the first metacarpophalangeal joint: a frequently missed injury in the emergency department

Between July 1991 and December 1995, 28 patients elected to consult one of the senior authors for a second opinion or were referred to him by their family physician after being reassured and discharged from our emergency department with the simple diagnosis of "soft tissue contusion" to the thumb. Physical examination and stress radiographs of these patients revealed a missed injury to the ulnar collateral ligament (UCL) of the first metacarpophalangeal joint in 18 patients (64.3%), 12 of whom required surgical repair. Apparently, UCL injuries are frequently underestimated in our emergency department, although the real number is unknown because some patients may have decided to seek further treatment elsewhere. In addition to the numerous trivial injuries that are frequently seen in any emergency department, emergency physicians have the added responsibility of detecting those injuries that require referral to a specialist.

Local intravenous thrombolysis with recombinant tissue plasminogen activator for salvage of forearm replantation

Microvascular anastomoses are at risk of thrombosis, especially when repairing avulsed or crushed tissues, or when ischemia time is prolonged. When all surgical techniques to avoid thrombosis of the microanastomoses fail, thrombolytic agents may play a role in dissolving the thrombus and preventing rethrombosis. The authors present a case in which recombinant tissue plasminogen activator (rt-PA) was locally infused to salvage thrombosed venous microanastomoses after replantation of an amputated forearm. They also review the effects of different thrombolytic agents, and emphasize the benefits of rt-PA and its promising role in microsurgery.

Vascularized fascial patch for repair of suboccipital dural defect

Advanced knowledge about cutaneous vascularity has enabled the development of axial flaps such as fasciocutaneous, septocutaneous, and musculocutaneous flaps. It has also laid the foundation for microsurgical free flaps. The newly emerging concept of angiosomes sheds yet more light on the complexity and multiplicity of peripheral blood supply. We describe the use of an extended vertical trapezius flap carrying a segment of latissimus dorsi muscle with the underlying paraspinal fascia to close an infected and irradiated posterior fossa craniectomy and dural defect. This flap illustrates the elevation of an angiosomal block of tissues as an axial flap vascularized by the alternative major blood supply of one of its constituents. The potentials of this "angiosomal flap" are explored. A brief review of dural defect repair is also presented.

Giant cell tumor (osteoclastoma) of the mandible: a diagnostic dilemma and a therapeutic challenge

A recurrent giant cell lesion of bone 4.5 years after initial curettage from the mandibular body is described in a 40-year-old premenopausal female patient. Giant cell tumor is exceedingly rare in this location and histologically may be indistinguishable from giant cell reparative granuloma. The treatment rationale for this particular patient was extrapolated from the treatment of giant cell tumor in other more commonly involved bones. En bloc resection is indicated irrespective of the grade or stage of the tumor, provided satisfactory reconstruction can be achieved. The morbidity from tumor treatment should never, in any case, exceed the morbidity from the tumor itself.

Bacille Calmette-Guérin (BCG)-itis of the hand: a potential hazard for health workers

The bacille Calmette-Guérin vaccine has been used widely for several decades in tuberculosis prophylaxis. More recently, it has been used therapeutically in the management of neoplastic diseases such as malignant melanoma and urinary bladder tumors. Complications of the b. Calmette-Guérin vaccine and therapy are widely reported in the literature. However, its potential hazard to health workers is not well described. We present a case of b. Calmette-Guérinitis on the extensor surface of the left ring finger of a surgical resident following an accidental prick with a contaminated syringe while installing intravesical b. Calmette-Guérin to a patient being treated for a bladder tumor. A brief review of tuberculous hand infection is presented together with its recommended treatment. A review of the various usages of b. Calmette-Guérin is also presented, stressing the various reported complications.

Fibrohistiocytic sarcoma of the thumb treated by wide resection and immediate free flap reconstruction. Case report

A 29 year old surgical resident presented with a fibrohistiocytic sarcoma over the thumb of his dominant right hand. The tumour was widely excised including the ulnar neurovascular bundle. The resultant defect was immediately reconstructed with a sensory forearm free flap from the opposite upper extremity. The patient was then given a curative dose of cobalt-60 radiotherapy starting in the fourth postoperative week. With a comprehensive regimen of physiotherapy and splinting, the patient regained an almost full range of movement in his right thumb and was able to resume his regular duties in the operating theatre two months after his operation. Soft tissue sarcomas of the hand are a real therapeutic challenge. Adequate control of the tumour in most instances requires amputation because limb sparing procedures require soft tissue coverage not available locally or achieved easily. In addition, preservation of a hand, or parts of it, with poor functional capacity, is not helpful.

Lingual thyroid: tongue-splitting incision for transoral excision

Two patients presenting to the Central Military Hospital of Beirut with symptomatic lingual thyroid are reported. I131 thyroid scanning revealed the lingual thyroid to be the only functional thyroid tissue present in each patient. Subsequent CT scanning demonstrated the large size of these ectopic thyroids causing significant mechanical obstruction. These were excised transorally using a posterior midline tongue-splitting incision and reimplanted in the rectus abdominis muscles. Details of this modified tongue-splitting surgical approach are described. A brief review of the literature concerning lingual thyroid and its surgical treatment is also presented as well as three patients operated on for lingual thyroid at the American University of Beirut Medical Centre between 1975 and 1994 using an external neck incision.

Preliminary arteriovenous fistula for free-flap reconstruction in the diabetic foot

We present our experience at the American University of Beirut Medical Center with two diabetic patients suffering from large necrotic and infected foot ulcers. Both patients were ambulatory at the time of presentation despite their extensive wounds and were believed to have a useful limb with adequate protective sensation worth saving. Below-knee amputation was prevented in both cases by successful soft-tissue coverage of the ulcers using microvascular composite-tissue transfer a few days after performing a preliminary arteriovenous fistula with a long vein graft loop. The flap vessels were anastomosed end-to-end to the arterial and venous limbs of the divided arteriovenous loop. This reconstructive technique of difficult diabetic wounds of the lower extremity, though in two stages, may be safer than one long procedure in a high-risk patient. It is technically easier than long interpositional vein grafts at the same time as free-flap transfer or microvascular anastomoses with small and diseased vessels. It definitely provides more chance of success as larger vessels are used to supply the flap. It permits distension of the vein graft at normotensive physiologic pressures and allows testing the arterial anastomosis as well as the venous flow before final flap transfer. Above all, it allows extreme freedom in performing tension-free anastomoses away from the infected wound.

Microsurgical composite tissue transfer: an expanding horizon in reconstructive surgery

Seven cases of microsurgical composite tissue transfer to reconstruct defects of the upper and lower extremities performed at the American University of Beirut Medical Center between January 1992 and July 1993 are evaluated in a retrospective study. These cases illustrate the various clinical situations where free flaps can be used to an advantage. A brief discussion of the history of microvascular free flap transfers as well as their value in modern plastic and reconstructive surgery is also presented.