Breast augmentation: choosing the optimal incision, implant, and pocket plane

A retrospective study of 220 patients was performed to review surgical design in breast augmentation. Three specific issues were studied: incision site, implant variables, and pocket plane selection. The influence of these three factors on aesthetic results in both primary and secondary cases was the focus of the analysis. No attempt was made to address long-term issues such as capsular contracture or saline implant deflation rates. In 77 primary augmentation patients and 80 unilateral augmentations for symmetry in breast reconstruction, there were the following untoward results: 11 revisions for unilateral malposition, change to a different implant shape, or change to a larger implant size; four deflations of saline implants requiring replacement; and four conversions of saline to silicone gel implants. In 63 secondary cases, there were two hematomas and two infections requiring implant removal and subsequent replacement. Operative technique in breast augmentation is described, as are recommendations for each of the options associated with the three variables studied.

The premature removal of tissue expanders in breast reconstruction

The role of tissue expanders in breast reconstruction is well established. Little information exists, however, regarding the incidence and etiology of premature removal of the tissue expander before planned exchange to a permanent breast implant. The purpose of this study was to review our 10-year experience with tissue expander breast reconstruction and identify factors relating to the premature removal of the tissue expander. This study is a retrospective review of 770 consecutive patients who underwent breast reconstruction with tissue expanders over the past 10 years. Breast reconstruction was immediate in 90 percent of patients. Patients were expanded weekly, and adjuvant chemotherapy was begun during the expansion process when required. Factors potentially affecting premature expander removal (chemotherapy, diabetes, obesity, radiation therapy, and smoking) were evaluated. Fourteen patients (1.8 percent) with a mean age of 47 years (range, 38 to 62 years) required premature removal of their tissue expander. Expanders were removed a mean of 3.2 months (0.1 to 8 months) after insertion. Causes for premature removal of the tissue expander included infection (7 patients), exposure (2), skin necrosis (2), patient dissatisfaction (2), and persistent breast cancer (1). Positive wound cultures were obtained in four of the seven infected patients (57 percent), requiring expander removal for infection. Tissue expanders were removed in 11 patients for complications directly related to the expander. Among these, six (55 percent) were receiving adjuvant chemotherapy, and one was a smoker. Diabetes, obesity, other concomitant medical illnesses, and prior mantle irradiation were not associated with expander removal. Premature removal of the tissue expander was required in only 1.8 percent of the patients in this series. Infection was the most common complication necessitating an unplanned surgical procedure to remove the expander. This study demonstrates that the use of tissue expanders in breast reconstruction is reliable, with the vast majority of patients completing the expansion process.

Reconstruction of the mandible with osseous free flaps: a 10-year experience with 150 consecutive patients

Osseous free flaps have become the preferred method for reconstructing segmental mandibular defects. Of 457 head and neck free flaps, 150 osseous mandible reconstructions were performed over a 10-year period. This experience was retrospectively reviewed to establish an approach to osseous free flap mandible reconstruction. There were 94 male and 56 female patients (mean age, 50 years; range 3 to 79 years); 43 percent had hemimandibular defects, and the rest had central, lateral, or a combination defect. Donor sites included the fibula (90 percent), radius (4 percent), scapula (4 percent), and ilium (2 percent). Rigid fixation (up to five osteotomy sites) was used in 98 percent of patients. Aesthetic and functional results were evaluated a minimum of 6 months postoperatively. The free flap success rate was 100 percent, and bony union was achieved in 97 percent of the osteotomy sites. Osseointegrated dental implants were placed in 20 patients. A return to an unrestricted diet was achieved in 45 percent of patients; 45 percent returned to a soft diet, and 5 percent were on a liquid diet. Five percent of patients required enteral feeding to maintain weight. Speech was assessed as normal (36 percent), near normal (27 percent), intelligible (28 percent), or unintelligible (9 percent). Aesthetic outcome was judged as excellent (32 percent), good (27 percent), fair (27 percent), or poor (14 percent). This study demonstrates a very high success rate, with good-to-excellent functional and aesthetic results using osseous free flaps for primary mandible reconstruction. The fibula donor site should be the first choice for most cases, particularly those with anterior or large bony defects requiring multiple osteotomies. Use of alternative donor sites (i.e., radius and scapula) is best reserved for cases with large soft-tissue and minimal bone requirements. The ilium is recommended only when other options are unavailable. Thoughtful flap selection and design should supplant the need for multiple, simultaneous free flaps and vein grafting in most cases.

Current trends in breast reduction

Current trends in the development of breast reduction surgery include a few minor refinements in classic inverted-T scar methods but, more, the increased use of vertical-scar reduction mammaplasty. The benefits of the latter, which include reduced scar burden and improved long-term projection, are attractive, although the technique itself has proved to be somewhat intuitive and more difficult to master. These shortcomings can be minimized and the technique safely learned by initially applying it to patients with minor degrees of macromastia and ptosis. New modifications and alternative approaches have been introduced recently to address the problematic areas of the vertical-scar technique. A survey of members of the American Society of Plastic and Reconstructive Surgeons was undertaken at the 1998 annual meeting to review the current role of various techniques in breast reduction. The results revealed a slow acceptance of vertical-scar methods and the dominance of the inferior/central pedicle inverted-T scar method for a wide variety of macromastia types. Other issues were reviewed; they revealed the minimal role of both blood transfusion and liposuction and that more than half of breast reductions are still performed on an inpatient basis.

Efficacy of conventional monitoring techniques in free tissue transfer: an 11-year experience in 750 consecutive cases

Conventional free flap monitoring techniques (clinical observation, hand-held Doppler ultrasonography, surface temperature probes, and pinprick testing) are proven methods for monitoring free flaps with an external component. Buried free flaps lack an external component; thus, conventional monitoring is limited to hand-held Doppler ultrasonography. Free flap success is enhanced by the rapid identification and salvage of failing flaps. The purpose of this study was to compare the salvage rate and final outcomes of buried versus nonburied flaps monitored by conventional techniques. This study is a retrospective review of 750 free flaps performed between 1986 and 1997 for reconstruction of oncologic surgical defects. There were 673 nonburied flaps and 77 buried flaps. All flaps were monitored by using conventional techniques. Both buried and nonburied flaps were used for head and neck and extremity reconstruction. Only nonburied flaps were used for trunk and breast reconstruction. Buried flap donor sites included jejunum (n = 50), fibula (n = 16), forearm (n = 8), rectus abdominis (n = 2), and temporalis fascia (n = 1). Overall flap loss for 750 free flaps was 2.3 percent. Of the 77 buried flaps, 5 flaps were lost, yielding a loss rate of 6.5 percent. The loss rate for nonburied flaps (1.8 percent) was significantly lower than for buried flaps (p = 0.02, Fisher's exact test). Fifty-seven (8.5 percent) of the nonburied flaps were reexplored for either change in monitoring status or a wound complication. Reexploration occurred between 2 and 400 hours postoperatively (mean, 95 hours). All 44 of the salvaged flaps were nonburied; these were usually reexplored early (<48 hours) for a change in the monitoring status. Flap compromise in buried flaps usually presented late (>7 days) as a wound complication (infection, fistula). None of five buried flaps were salvageable at the time of reexploration. The overall salvage rate of nonburied flaps (77 percent) was significantly higher than that of buried flaps (0 percent, p<0.001, chi-square test). Conventional monitoring of nonburied free flaps has been highly effective in this series. These techniques have contributed to rapid identification of failing flaps and subsequent salvage in most cases. As such, conventional monitoring has led to an overall free flap success rate commensurate with current standards. In contrast, conventional monitoring of buried free flaps has not been reliable. Failing buried flaps were identified late and found to be unsalvageable at reexploration. Thus, the overall free flap success rate was significantly lower for buried free flaps. To enhance earlier identification of flap compromise in buried free flaps, alternative monitoring techniques such as implantable Doppler probes or exteriorization of flap segments are recommended.

Evaluation of bone height in osseous free flap mandible reconstruction: an indirect measure of bone mass

Osseous free flaps have become the preferred method of mandibular reconstruction after oncologic surgical ablation. To elucidate the long-term effects of free flap mandibular reconstruction on bone mass, maintenance or reduction in bone height over time was used as an indirect measure of preservation or loss in bone mass. Factors potentially influencing bone mass preservation were evaluated; these included site of reconstruction (central, body, ramus), patient age, length of follow-up, adjuvant radiotherapy, and the delayed placement of osseointegrated dental implants. A retrospective analysis of patients undergoing osseous free flap mandible reconstruction for oncologic surgical defects between 1987 and 1995 was performed. Postoperative Panorex examinations were used to evaluate bone height and bony union after osteotomy. Fixation hardware was used as a reference to eliminate magnification as a possible source of error in measurement. There were 48 patients who qualified for this study by having at least 24 months of follow-up. There were 27 male and 21 female patients, with a mean age of 45 years (range, 5 to 75 years). Mandibular defects were anterior (24) and lateral (24). Osseous donor sites included the fibula (35), radius (6), scapula (4), and ilium (3). There were between zero and four segmental osteotomies per patient (excluding the ends of the graft). Nineteen percent of all patients had delayed placement of osseointegrated dental implants. Initial Panorex examinations were taken between 1 and 9 months postoperatively (mean, 2 months). Follow-up Panorex examinations were taken 24 to 104 months postoperatively (mean, 47 months). The bony union rate after osteotomy was 97 percent. Bone height measurements were compared by site and type of reconstruction. The mean loss in fibula height by site of reconstruction was 2 percent in central segments, 7 percent in body segments, and 5 percent in ramus segments. The mean loss in bone height after radial free flap mandible reconstruction was 33 percent in central segments and 37 percent in body segments; ramus segments did not lose height. The central and body segments reconstructed with scapular free flaps did not lose height, but one ramus segment lost 20 percent of height. There was no loss in bone height in mandibular body reconstruction with the ilium free flap. Fibula free flaps did not significantly lose bone height when evaluated with respect to age, follow-up, radiation therapy, or dental implant placement. The retention in bone height demonstrated in this study suggests that bone mass is preserved after osseous free flap mandible reconstruction. The greatest amount of bone loss was seen after multiply osteotomized radial free flaps were used for central mandibular reconstruction. The ability of the fibula free flap to maintain mass over time, coupled with its known advantages, further supports its use as the "work horse" donor site for mandible reconstruction.

Improving safety and aesthetic results in inverted T scar breast reduction

Breast reduction using an inverted T scar skin design and a variety of glandular pedicle types is widely practiced and is the standard by which more recent limited scar techniques are judged. The inverted T procedures are attractive because they are predictable and versatile and permit great control over both the extent of reduction and the breast-shaping process. Despite these advantages, common criticisms of inverted T scar techniques include breast shape abnormalities, areolar malposition, hypertrophic scars, and poor long-term projection. Preoperative markings influence both safety and aesthetics. A method of skin marking that is based on a displacement method to determine vertical limb splay angle is described. This design concept must be modified to address certain variants, such as macromastia presenting with normal nipple position or large-diameter areolae, moderately severe macromastia, and macromastia involving radiated breasts. Safety in breast reduction is improved by paying attention to patient positioning issues, using techniques that minimize blood loss, raising flaps of appropriate thickness in the correct plane, and performing resection by observing the principles that reduce the risk of compromise of nipple and areolar circulation. Aesthetic results are improved by analyzing vertical breast meridian lengths during final breast shaping, modifying areolar shape as necessary, and carefully tailoring the medial inframammary crease. The latter is also important for minimizing the potential for scar hypertrophy. The principles presented have been refined during the course of a 12-year experience with several hundred breast reduction procedures. They contribute to improved results in inverted T scar breast reduction when practiced consistently.

A review of 716 consecutive free flaps for oncologic surgical defects: refinement in donor-site selection and technique

Free-tissue transfer has become an important method for reconstructing complex oncologic surgical defects. This study is a retrospective review of a 10-year experience with 716 consecutive free flaps in 698 patients. Regional applications included the head and neck (69 percent), trunk and breast (14 percent), lower extremity (12 percent), and upper extremity (5 percent). Donor sites included the rectus abdominis (195), fibula (193), forearm (133), latissimus dorsi (69),jejunum (55), gluteus (28), scapula (26), and seven others (17). Microvascular anastomoses were performed to large-caliber recipient vessels using a continuous suture technique; end-to-end anastomoses were preferred (75 percent). Flaps were designed to avoid the need for vein grafts. Conventional postoperative flap monitoring methods were used. These included clinical observation supplemented by Doppler ultrasonography, surface temperature probes, and pin prick testing. Buried flaps were either evaluated with Doppler ultrasonography or not monitored. The overall success rate for free-flap reconstruction of oncologic surgical defects was 98 percent. Fifty-seven flaps (8 percent) were reexplored for either anastomotic or infectious problems. Reexplored flaps were salvaged in 40 cases (70 percent). Surviving flaps resulted in a healed wound and did not delay postoperative radiation or chemotherapy. The incidence of major and minor postoperative complications was 34 percent. The mean duration of hospitalization was 20 days, and the average cost was $40,224. The results of this study support the need for only seven donor sites to solve the majority (98 percent) of oncologic problems requiring microsurgical expertise. The evolution of preferred donor sites for specific regional applications is illustrated in this 10-year experience. Technical refinements have simplified performing the microsurgical anastomoses and essentially eliminated the need for vein grafts. Conventional monitoring has led to the rapid identification of vascular compromise and subsequent flap salvage in the majority of non-buried free flaps.

Aesthetic refinement in breast reconstruction: complete skin-sparing mastectomy with autogenous tissue transfer

Aesthetic results in breast reconstruction are often compromised either by prominent scars or by the presence of an island of skin that differs in color and texture from the native breast skin. Complete skin-sparing mastectomy is a technique by which breast scars can be largely eliminated and the need for a visible skin island avoided. A circumareolar incision is used for mastectomy with a separate axillary incision if needed. Autogenous tissue is used to fill the skin envelope, and a disk of skin temporarily replaces the areola. Twenty-eight patients treated by this method were reviewed retrospectively. Prerequisites included a favorable biopsy scar location and a suitable tissue donor site. The mean patient age was 42.5 years, and the majority were reconstructed with TRAM flaps (92 percent). There was no evidence of increased morbidity or any instance of local recurrence during a follow-up period, which averaged 25.7 months. Aesthetic results were judged excellent in 12 patients, good in 11 patients, and fair in 5 patients. Insufficient tissue volume, shape asymmetry, and areolar position asymmetry were the most common factors that detracted from the quality of the results. Advantages of this method, besides the prospect of an ideal aesthetic result, include easier flap insetting and simplified subsequent revision procedures. Disadvantages include the requirement of a skilled ablative surgeon and incompatibility with conventional expander/implant methods of reconstruction.

Immediate reconstruction after complete skin-sparing mastectomy with autologous tissue

BACKGROUND

Immediate breast reconstruction with autologous tissue can re-create a breast mound that closely resembles the native breast in shape and consistency. Results are limited by scarring and color differences between flap and native breast skin. This study reviews all patients undergoing complete skin-sparing mastectomy with immediate autologous tissue reconstruction over the past 4 years.

STUDY DESIGN

Twenty-eight patients with a mean age of 43 years (range, 32-53 years) were retrospectively reviewed. Requirements for the complete skin-sparing approach included a favorable biopsy scar location, adequate areolar diameter, and suitable donor site for autologous tissue reconstruction. Ninety-two percent of patients were reconstructed with a transverse rectus abdominis musculocutaneous flap.

RESULTS

There were no instances of flap loss or local recurrence during the followup period (mean, 27 months; range, 14-48 months). Complications at the reconstruction site were minor and limited to cellulitis, periareolar skin loss, and the need for repeat skin excision because of a very close pathologic margin. Donor site complications were seen in five patients. Aesthetic results were judged as excellent or good in 75% of patients.

CONCLUSIONS

Complete skin-sparing mastectomy with immediate autologous tissue reconstruction has enhanced immediate breast reconstruction by reducing scar burden and eliminating color differences without an increased incidence of local recurrence. This procedure is limited by appropriate patient selection and technical expertise in performing the mastectomy.

Retrospective review of 400 consecutive free flap reconstructions for oncologic surgical defects

BACKGROUND

Free tissue transfer has become an important method for reconstructing complex oncologic surgical defects, allowing single stage reconstruction in most instances. The purpose of this study is to review a single center's experience with free flap reconstruction and describe trends that have evolved with respect to technique and donor site selection.

METHODS

A retrospective review of 400 consecutive free flap reconstructions performed in 396 patients over 10 years was done. Regional applications include the head and neck (63%), trunk and breast (16%), lower extremity (16%), and upper extremity (5%). Donor sites include the fibula (109), rectus abdominis (93), forearm (72), latissimus dorsi (51), scapula (26), gluteus (25), jejunum (16), and five others (8). Microvascular anastomoses were performed to large-caliber vessels using a continuous suture technique; end-to-end anastomoses were preferred. Flaps were designed to avoid the need for vein grafts. Postoperative flap monitoring included clinical observation, conventional Doppler ultrasonography, surface temperature probes, and pinprick testing.

RESULTS

The overall free flap success rate was 97%. Twenty-eight flaps (7%) were reexplored, of which seventeen were salvaged (61%). Surviving flaps resulted in a healed wound that did not delay postoperative radiation or chemotherapy. The complication rate was 14%. The mean duration of hospitalization was 21 days, with an average cost of $40,000.

CONCLUSIONS

The use of fewer, reliable donor sites to reconstruct the vast majority of oncologic defects and the simplification of the microsurgical process have contributed to the success of free tissue transfer in this series.

Long-term evaluation of bone mass in free fibula flap mandible reconstruction

BACKGROUND

Vascularized fibula transfer has become a preferred method of mandibular restoration after oncologic surgical ablation. In order to elucidate the long-term effect on fibular mass after mandibular reconstruction, change in fibular height was utilized as an indirect measure of change in bone mass over time. Other potentially influential factors in long-term bone mass preservation were evaluated; these included site of reconstruction (central, body, ramus), patient age, length of follow-up, adjuvant radiotherapy, and the delayed placement of osseointegrated dental implants.

METHODS

A retrospective analysis of patients undergoing free fibula mandible reconstruction for oncologic surgical defects between 1987 and 1993 was performed. Postoperative panorex examinations were used to evaluate fibular height and bony union after osteotomy. Fixation hardware was used as a reference to eliminate magnification as a possible source of error in measurement. Only patients with at least 24 months follow-up were included in this study.

RESULTS

There were 27 patients (15 males and 12 females) with a mean age of 43 years (range 14 to 65) included in this study. Mandibular defects were anterior (16) and lateral (11). There were between two and five segmental osteotomies per patient (excluding the ends of the graft). Thirty percent of patients had delayed placement of osseointegrated dental implants. Initial panorex examinations were taken between 1 and 9 months (mean 2) postoperatively. Follow-up panorex examinations were taken 24 to 104 months (mean 54) postoperatively. The bony union rate after osteotomy was 93%. Comparative measurements of fibular height revealed that central segments underwent a mean decrease in height by 4% (range 0% to 22%); body segments decreased in height by 7% (range 0% to 33%); ramus segments decreased in height by 5% (range 0% to 15%). In each anatomic segment, fibular height varied by 10% or less when compared with respect to patient age, length of follow-up, adjuvant radiation therapy, and the presence of osseointegrated dental implants.

CONCLUSIONS

We conclude that the retention of fibula height seen in this study indicates that fibula bone mass is preserved after free flap mandible reconstruction. Furthermore, these findings are not affected by the site of reconstruction, patient age, length of follow-up, adjuvant radiation therapy, or presence of osseointegrated dental implants. This study further supports the efficacy of vascularized fibula grafts for mandible reconstruction.

Resection and immediate microvascular reconstruction in the management of osteoradionecrosis of the mandible

BACKGROUND

Management of osteoradionecrosis (ORN) remains a difficult and challenging problem. The traditional approach using debridement, antibiotics, and occasionally hyperbaric oxygen is usually successful in treating minimal ORN. However, when bone and soft-tissue necrosis is extensive, the conservative approach usually requires intensive care over a long period of time and often yields unsatisfactory functional and cosmetic results.

METHODS

Within the past 5 years, we have used radical resection of the mandible with immediate microvascular reconstruction in the treatment of extensive ORN of the mandible. This aggressive surgical approach was used in six patients with advanced ORN of the mandible, all of whom had failed initial conservative treatment, including hyperbaric oxygen therapy in three. A fibular free graft with microvascular anastomosis was used in all patients.

RESULTS

All the patients healed primarily with minimal postoperative morbidity and excellent cosmetic results. Two patients subsequently required removal of some of their hardware. One patient had placement of osseointegrated implants with an excellent cosmetic and functional result.

CONCLUSION

Microvascular reconstruction with its own blood supply seems to expedite bone healing and limit further osteoradionecrosis of the remaining mandible. Although prevention is the primary goal in radiation injury, our experience suggests that radical resection with free microvascular reconstruction offers significant advantages to selected patients with extensive ORN of the mandible.

Current role of the radial forearm free flap in mandibular reconstruction

The radial forearm free flap was selected as a donor site in only 17 (11 percent) of 155 consecutive free flap mandible reconstructions performed over a 9-year period. It was used either as an osteocutaneous flap (58 percent), as a soft-tissue flap alone for coverage of a reconstruction plate (18 percent), to supplement another free flap (12 percent), or to salvage a previous reconstruction (12 percent). The most common underlying disease was epidermoid carcinoma (82 percent), the average patient age was 55 years, and the average length of follow-up was 13.5 months. Although there was one patient death, there were no anastomotic failures. Postoperatively, two patients experienced fracture at the donor site (12 percent), and three patients (18 percent) had hardware related problems such as exposure, infection, or both. Although early studies advocated using the osteocutaneous radial forearm flap as a preferred method in mandible reconstruction, superior donor site options such as the fibula have now relegated it to a minor role. The best remaining indication for its use today is for a limited posterior bone defect associated with a large adjacent mucosal loss. Osseointegrated implant capability is not important in this setting, and the short bone length needed for this application minimizes the potential for fracture at the donor site, a serious complication. Otherwise, the osteocutaneous radial forearm flap is not recommended for the majority of segmental mandibular defects. The radial forearm flap without bone continues to have an important supportive role in mandibular reconstruction. It is an excellent choice in this regard when used to cover a reconstruction plate, as a second free flap when soft-tissue requirements are exceptionally large, or for salvage of a previous mandible reconstruction.

Posterior pharyngeal carcinoma resection with larynx preservation and radial forearm free flap reconstruction: a preliminary report

BACKGROUND

Surgical management of selected posterior pharyngeal wall lesions can be performed with pharyngectomy, allowing for larynx preservation, with radial forearm free flap (RFFF) reconstruction.

METHODS

Retrospective review of our experience using RFFF reconstruction in 9 patients.

RESULTS

All 9 patients had a posterior pharyngectomy with larynx preservation, neck dissection (3 bilateral, 6 unilateral), and RFFF reconstruction. Six patients experienced 8 postoperative complications including one postoperative death. Only 3 patients were able to obtain all nutrition orally. Tracheotomy decannulation occurred in 4 patients and voice was maintained in all patients. American Society of Anesthesiologists score (ASA) was an accurate predictor of postoperative medical complications.

CONCLUSIONS

Posterior pharyngeal resections with larynx preservation and RFFF reconstruction can be accomplished with acceptable morbidity in healthy patients with carefully selected lesions of the posterior pharyngeal wall. However, in patients with significant co-morbidities as reflected by an ASA of 3 or more, larynx preservation and RFFF reconstruction was fraught with significant morbidity and is not recommended.

A review of 60 consecutive fibula free flap mandible reconstructions

Sixty consecutive fibula free flap mandible reconstructions were performed for oncologic defects. Patient age averaged 46.7 years. Eighty-one percent were primary reconstructions. Sixty-two percent were lateral defects; 22 percent were anterior; and the remainder had combined defects. The bone gap averaged 9.4 cm. A skin island was included with the fibula in 85 percent of patients but was actually needed in only 62 percent. Miniplate fixation was used in 96 percent. Templates derived from radiographic studies were used as an aid in shaping the fibula. Average anesthesia time was 14.54 hours; the transfusion requirement, 3 units; and hospitalization, 22 days. Fifty-nine flaps were successfully transferred. Ninety percent of skin islands raised were completely viable. Average postoperative interincisal opening was 35.2 mm. Osseointegrated implants were placed in 56 percent of suitable candidates, and all implants integrated into bone. Aesthetic results were usually good when the soft tissue defect was limited, but poor when it was extensive. Donor site morbidity was usually mild and transient. The most significant problem was delayed healing in patients closed with a skin graft. Postoperatively, all patients ambulated normally, and none used assist devices. Reoperation for donor site problems was rare. The fibula has many assets that together make it an ideal choice for the reconstruction of most mandible defects. The skin island is usually reliable if it is designed and raised properly. Donor site morbidity is largely inconsequential. The primary contraindication to the use of the fibula for mandible reconstruction is severe peripheral vascular disease.

Ultraviolet excitation fluorescence spectroscopy: a noninvasive method for the measurement of redox changes in ischemic myocutaneous flaps

In this report, we discuss application of the noninvasive technology of ultraviolet fluorescence spectroscopy to the metabolic analysis of normal and compromised myocutaneous flaps. Acute changes in tissue redox states during ischemia and reperfusion were determined analysis of changes in the fluorescence spectrum of reduced nicotinomide adenine dinucleotide (NADH). Analysis of the system for NADH fluorescence showed good correlation between excitation spectra recorded at 450 nm from pure beta-NADH and those recorded from porcine rectus abdominis myocutaneous flaps. Sequential measurements of surface fluorescence were obtained from six flaps subjected to 6 hours of warm arterial ischemia and 4 hours of reperfusion. Results were compared with spectra obtained from six contralateral nonischemic control flaps. A significant mean increase in NADH fluorescence (49 percent; p < 0.05) was demonstrated within 30 minutes of vascular occlusion. Fluorescence intensity continued to increase throughout the ischemic period, reaching 320.5 percent of baseline values at 6 hours. Reperfusion resulted in the prompt return of fluorescence intensity to baseline levels. These results show that fluorescence spectroscopy of endogenous NADH is a sensitive and reliable indicator of vascular occlusion in experimental myocutaneous flaps.

Reconstruction of extensive scalp defects with rectus free flaps

This review represents the largest reported series involving reconstruction of complex scalp and calvarial defects with rectus abdominis free flaps. Sixteen patients presented with extensive (up to 300 cm2) scalp and calvarial defects requiring free tissue transfer for closure. All of the 11 patients who underwent a rectus abdominis free flap had a technically successful microvascular transfer. The defects encountered involved a wide spectrum of complexities including extensive multilaminar defects with exposed brain and dura, irradiated fields, and infection. In our institutions, the rectus abdominis muscle has evolved as a uniquely superior donor choice for restoring extensive scalp defects for several reasons: (1) accessibility, which eliminates intraoperative patient repositioning and allows for a simultaneous two-team approach; (2) minimal donor-site morbidity; (3) vascular reliability; and (4) the ability to supply abundant, easily contoured tissue.

Conceptual considerations in mandibular reconstruction

Microsurgical free tissue transfer allows for the immediate reconstruction of any composite mandibular defect. Most patients are candidates for reconstruction, and careful preoperative planning is an important key to success. Osteocutaneous free tissue transfer is currently the reconstructive modality of choice. The type of free flap used is determined by the requirements of the defect. Techniques such as condylar autotransplantation and osseointegrated implants are important adjuncts in achieving the best aesthetic and functional result.

The role of free tissue transfer following oncologic resection in the lower extremity

The current treatment of extremity sarcomas is multimodal, consisting of limb-sparing surgery, adjuvant radiotherapy, and/or chemotherapy. This approach has decreased the need for amputations and increased the demand for coverage of large composite defects. To date, the role of microsurgery in lower extremity reconstruction after oncologic resection has not been well defined. This study reviews a single center's experience with free tissue transfer for reconstruction of the lower extremity after oncologic resection. Fifty-nine free flaps were performed in 57 patients over a 5-year period. Forty-six patients (78%) underwent primary reconstruction and 35 patients (61%) received adjuvant therapy. Overall flap success rate was 96.6%. Most flaps were soft-tissue types including musculocutaneous (78%), skin only (11%), and muscle plus skin graft (4%). Osteocutaneous flaps were uncommon. There were major complications in 12% and minor complications in 7%. This study demonstrates that free tissue transfer for lower extremity reconstruction following oncologic resection has a high success rate that is similar to other free flap applications. It has become an integral part of lower extremity sarcoma management. Free flaps permit uninterrupted adjuvant therapy and enhance the efficacy of limb salvage surgery.

Condyle transplantation in free flap mandible reconstruction

Fourteen patients requiring hemimandible resection were reconstructed with bone free flaps onto which the resected condyle was mounted as a nonvascularized graft. Postoperative mandible function, facial aesthetics, and patient symptoms were reviewed. The follow-up period ranged from 13 to 56 months (average 30.4 months). Interincisal opening ranged from 25 to 52 mm (average 37.10 mm). Opening ability inversely correlated with a need for intraoral soft tissue replacement and with the administration of postoperative radiation therapy. Eight patients were available for late study of the transplanted condyle with lateral tomograms and computed tomographic scans. Condyle volume diminished considerably in some, but this did not correlate with a decrease in function. Dual joint function and preoperative occlusion were maintained long term with this technique. Aesthetic results were enhanced by the contribution of the transplanted condyle to improved accuracy of free flap bone graft fabrication and insetting. There were neither postoperative morbidity nor abnormal symptoms due to the use of the condyle as a nonvascularized graft. This study demonstrates the effectiveness and safety of condyle transplantation in free flap mandible reconstruction.

Myocutaneous flaps in genitourinary oncology

Between January 1983 and September 1992, 32 myocutaneous flaps were fashioned in 28 patients for reconstruction following treatment of genitourinary malignancies or complex pelvic fistulas. Of the myocutaneous flaps 14 were used to obtain primary soft tissue coverage of large but otherwise uncomplicated wounds and 10 were used to cover previously irradiated resection sites. Four myocutaneous flaps were used to repair complex radiation-induced fistulas involving the bladder, vagina, urethra and rectum. Flaps were used to cover infected or nonhealing open wounds in 8 cases, 4 of which also had been previously irradiated. Myocutaneous flap donor sites were the tensor fascia lata in 11 cases, gracilis in 9, rectus abdominis in 10 and rectus femoris in 2. There was 1 major complication (flap loss) and 9 minor complications. There were no perioperative deaths. Myocutaneous flaps are an effective means of covering large groin, perineal and lower abdominal surgical defects after radical surgery.

Soft tissue coverage of mandibular reconstruction plates

Free tissue transfer was compared to pectoralis major flap coverage of mandibular reconstruction plates in a retrospective review. The study group consisted of 14 patients whose composite defects were reconstructed with metal plates covered with either pectoralis flaps (9) or soft tissue free flaps (5). Four patients in the pectoralis group (44%) had plates that extruded compared to none in the free flap group. The mean operating room time for the free flap group (721 minutes) was longer than the pectoralis group (550 minutes), but the overall hospital stay for the free flap group (20 days) was half that of the pectoralis group (39 days). The pectoralis group required more secondary procedures (88%) than the free flap group (20%). Free flaps have a higher success rate, a shorter hospital stay, and require fewer additional procedures than do pectoralis flaps. This justifies the longer operating time and greater technical complexity of free tissue transfer for reliable coverage of mandibular reconstruction plates.

Fibula free flap mandibular reconstruction

The fibula free flap is rapidly becoming the donor site of choice for mandibular reconstruction. Its versatility makes it suitable for the majority of composite mandibular defects. The indications, operative techniques, and postoperative considerations are detailed in this article. Important principles of preoperative preparation, flap design, graft shaping, and bone fixation are included.

Free flap chest wall reconstruction for recurrent breast cancer and radiation ulcers

Pedicled myocutaneous flaps are the established first choice for soft tissue coverage of major chest wall defects. In some patients, this alternative is not available because the flap itself or its blood supply may be included within the field of surgical resection, the flap may have been used previously, or the defect is too large or extends past the reach of the flap. In these patients, free flaps can be used to provide adequate soft tissue coverage. This report examines 7 women with major full-thickness chest wall defects treated with free flap soft tissue coverage. Either a rectus abdominis (6 women) or a latissimus dorsi myocutaneous free flap (1 woman) was used. There were no flap failures. Permanent protection of prosthetic material used to stabilize the chest wall was provided in all women. Only 1 woman experienced delayed wound healing. Secondary procedures were not required in any patient. Myocutaneous free flaps provide reliable single-stage soft tissue coverage for large chest wall defects that are not suited to reconstruction with pedicled myocutaneous flaps.

Osseointegrated implants and functional prosthetic rehabilitation in microvascular fibula free flap reconstructed mandibles

The mandibulectomy deformity can be alleviated by immediate mandibular reconstruction using the microvascular fibula free flap. Before the advent of microvascular reconstruction, conventional and maxillofacial prosthetic rehabilitation offered limited success after surgery due to the failure to reestablish the bony foundation and soft tissues (tongue, floor of mouth, vestibule) anatomically and physiologically. With proper multidisciplinary pretreatment planning and postoperative treatment, osseointegrated implants can be strategically placed in patients with these reconstructed mandibles to restore occlusal and masticatory function. The records of seven patients who underwent reconstructive surgery and osseointegrated implants were reviewed, with an emphasis on the variety of prosthetic designs and principles used to maximize long-term efficiency and preservation of tissues.

The treatment of lower extremity sarcomas with wide excision, radiotherapy, and free-flap reconstruction

Treatment of extremity sarcomas has evolved into a multidisciplinary approach utilizing surgery, radiotherapy, and, in some cases, chemotherapy. Limb-sparing surgery has maintained low rates of local recurrence when supplemented with early postoperative radiotherapy (brachytherapy). Leg defects that result from resection resemble those caused by trauma and appear ideally suited to free-flap reconstruction. However, the resection site is subjected to 4500 cGy of radiation given within 2 weeks of surgery. It has not been demonstrated that free flaps can endure early postoperative radiation without adverse effects. Three patients are presented with locally recurrent leg sarcomas treated by wide excision, brachytherapy, and free-flap reconstruction. All flaps survived, and the wounds healed uneventfully. This study reviews the current multidisciplinary approach to the treatment of lower extremity sarcomas and demonstrates the durability of free-flap reconstruction in the presence of early postoperative radiation therapy.

Aesthetic improvements in free-flap mandible reconstruction

Mandible reconstruction with free flaps has become a well-established technique. Efforts are now focused on obtaining superior functional and aesthetic results. Improvements in the quality of the latter are possible with a systematic approach to shaping the bone graft. Important elements in this approach have been defined based on experience in 50 consecutive cases. Preoperative studies include the lateral cephalogram and a transverse plane CT scan from which mandible templates are constructed. These templates are models of the mandible in two planes and are used to shape the bone with a high degree of precision. They allow the bone to be completely shaped while still attached by the pedicle at the donor site. The surgical specimen serves as an additional key visual reference and as a source of measurements to determine overall bone-graft length. Miniplates alone provide sufficient fixation to stabilize the bone as it is shaped segment by segment. Intermaxillary fixation is used only to prevent errors in total bone-graft length. Hemimandible and anterior defects represent two completely different bone-shaping problems. Although the bone-shaping methods described have been developed primarily with the fibula, they have been successfully applied to the scapula and radius donor sites as well.

Full-thickness cheek and lip reconstruction with the radial forearm free flap

The radial forearm free flap has proven versatility in head and neck reconstruction. It is superior to regional alternatives such as the pectoralis flap because it is thin, pliable, and predominantly hairless. A more recent application is the use of the folded forearm flap to replace both the skin and inner lining, simultaneously, in full-thickness cheek and lip defects. Nine such cases are presented in this report. Each patient had a recurrent lesion that had been reconstructed previously with local flaps, and all but one were treated with postoperative radiation therapy. The average size of the external defects after resection was 27 cm2, and of the intraoral defects, 18 cm2. All free flaps survived completely. The folded forearm flap solved the reconstructive problem for each patient in a single-stage procedure, providing good contour and a reasonable color match. The flap is easy to raise, has a long pedicle with large-diameter vessels, and has an acceptable donor site defect not associated with long-term morbidity.

The role of emergent exploration in free-tissue transfer: a review of 150 consecutive cases

One-hundred and fifty consecutive free-tissue transfers were reviewed to evaluate the role of emergent exploration in flap survival. Eleven flaps exhibited signs of circulatory failure between 1 hour and 6 days postoperatively and required return to the operating room. In eight patients the preoperative diagnosis was venous thrombosis, and in three patients it was arterial thrombosis. The average time from the first abnormal examination to exploration was 1.5 hours. There were no false-positive explorations. All 11 flaps were salvaged following correction of the cause of circulatory compromise. In eight patients this was due to inflow or outflow obstruction in the recipient vessels proximal to the anastomosis, in two patients it was due to extrinsic compression of the flap from a tight wound closure, and in one patient it was due to obstruction of the recipient vein by a drain. Primary anastomotic thrombosis was not encountered as the cause of circulatory compromise in any patient. An aggressive approach to exploration was responsible for an increase in flap survival in the entire series from 90 to 98 percent. The results of this study demonstrate the efficacy of clinical monitoring, the role of early exploration, and the durability of microvascular anastomoses.

Titanium miniplate fixation in free flap mandible reconstruction

The use of miniplate fixation in free flap mandible reconstruction was reviewed in a series of 27 patients. Flap donor sites included the radius, scapula, and fibula. The bone defect ranged from 5 to 16 cm (mean, 11.5 cm). The number of fixation sites per graft ranged from 2 to 6 (mean, 3.96). Three to 10 (mean, 5.51) titanium miniplates (Wurzburg) were used for fixation. All free flaps survived. In no patient did the plate pressure on the periosteum or the multiple screws through the bone compromise flap circulation to a critical degree. Nonunion occurred in 2 of 107 osteotomy sites. Wound healing problems that required plate removal occurred in 4 patients. In each patient the plates were retained until bone healing was complete. Intermaxillary fixation was not necessary for purposes of additional stability. Miniplates have the advantages of ease of application, decreased fixation time, and the lack of need for additional forms of fixation. Their small size and malleable nature allow precise graft contouring. This contributes to a superior aesthetic result.

Fibula free flap: a new method of mandible reconstruction

The fibula was investigated as a donor site for free-flap mandible reconstruction. It has the advantages of consistent shape, ample length, distant location to allow a two-team approach, and low donor-site morbidity. It can be raised with a skin island for composite-tissue reconstruction. Twelve segmental mandibular defects (average 13.5 cm) were reconstructed following resection for tumor, most commonly epidermoid carcinoma. Five defects consisted of bone alone, and four others had only a small amount of associated intraoral soft-tissue loss. Eleven patients underwent primary reconstructions. At least two osteotomies were performed on each graft, and miniplates were used for fixation in 11 patients. Six patients received postoperative radiation, and two patients received postoperative chemotherapy. The flaps survived in all patients. All osteotomies healed primarily. The septocutaneous blood supply was generally not adequate to support a skin island for intraoral soft-tissue replacement. The aesthetic result of the reconstruction was excellent in most patients, particularly in "bone only" defects. There was no long-term donor-site morbidity.

Local recurrent mammary carcinoma failing multimodality therapy. A solution

Chest wall recurrence following radiation and hormonal therapy is an uncommon but serious and disabling condition. A chest wall ulcer secondary to treatment for recurrence also presents the same dilemma. Over the past 35 years, the Thoracic Service at our institution has treated 35 patients for these problems by surgical resection and reconstruction. Eight patients were seen after the first recurrence, six after the second, ten after the third, and ten after the fourth. One patient had chest wall resection with mastectomy when recurrence followed radiation therapy. Following resection of the tumor, 21 patients had reconstruction using mesh or a mesh "sandwich." There were no operative deaths and no respirator need. Twenty patients are alive from five to 120 months, with a median of 50 months. One of 35 patients had chest wall recurrence. Surgical resection of recurrent mammary carcinoma resistant to all other therapy is a viable alternative for both palliation and cure.

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.

Anatomic basis of plantar flap design

Safe planes exist for plantar incisions that minimize the possibility of subcutaneous nerve injury and are therefore useful in flap design. Nerve branch orientation in the plantar subcutaneous tissue is specific and guides dissection so as to avoid producing anesthesia in weight-bearing areas. An extensive proximal plantar subcutaneous plexus exists that permits elevation of plantar flaps in a superficial plane. This is due to the major contribution that the dorsal circulation makes to the skin of the plantar surface. The blood supply to the non-weight-bearing midsole area is not from the medial plantar artery exclusively. This is a watershed area with important lateral plantar artery and dorsalis pedis artery contributions as well. It is not necessary or desirable to base plantar flaps on a myocutaneous or fasciocutaneous supply with its required deep dissection. Local plantar flaps can be designed to include sensation and abundant blood supply without the need for "subfascial" dissection. Subcutaneous sensory plantar flaps designed in accordance with these principles promise a more ideal solution for the treatment of plantar defects.

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.

Lower extremity avulsion injuries

Avulsion injuries are best treated by removal of the avulsed tissue and replacing it as a full-thickness skin graft. Additional meshed split-thickness skin grafts from a separate donor area may be necessary to complete the soft-tissue coverage. Fractures commonly accompany avulsion injuries and require appropriate treatment. The atypical avulsion injury is a special problem that occurs infrequently but results in considerable morbidity. This injury is most commonly seen in individuals run over by heavy vehicles, particularly buses. The shearing forces involved cause extensive undermining of tissues, although the external surface of these areas appears uninvolved. This results in an under-estimation of the true extent of the injury. If not recognized, there may be either delayed full-thickness necrosis of large areas of skin and subcutaneous tissue or the development of sepsis due to deep necrosis of the fat and fascia at the shear plane. If the true extent of injury is initially recognized, a dilemma exists in terms of deciding how much of the normal-appearing tissue to excise. The proper treatment plan for the atypical injury is not yet established with certainty. However, quantitative dermofluorometry has proven to be a valuable means of assessing the viability of extensively undermined areas of skin and subcutaneous tissue. This test is easily performed and can be used for serial study. Viable areas that are undermined and left in place require an early limited debridement of the undersurface to remove necrotic fascia and subcutaneous fat. This may require additional incisions for exposure. Plantar avulsions are another separate category of avulsion injury. Traditionally, the avulsed plantar surface has been sewn back into place, although this frequently resulted in the loss of this specialized tissue. It has become clear that it is possible to revascularize the plantar surface when major avulsion injuries occur. The plantar surface is thus similar to digital amputations and major scalp avulsion injuries in that replantation or revascularization is worthwhile and should be performed whenever possible. Soft-tissue loss around the ankle frequently co-exists with these injuries, and free tissue transfer may be necessary to complete soft-tissue coverage following revascularization.