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Zeiderman MR, Nuño M, Sahar DE, Farkas LM. Trends in flap reconstruction of pelvic oncologic defects: Analysis of the national inpatient sample. J Plast Reconstr Aesthet Surg 2021; 74:2085-2094. [PMID: 33455867 DOI: 10.1016/j.bjps.2020.12.067] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2020] [Revised: 12/07/2020] [Accepted: 12/19/2020] [Indexed: 11/15/2022]
Abstract
BACKGROUND Flap reconstruction of radiated pelvic oncologic defects decreases perineal wound-healing complications. How widely and how often reconstructions are performed, and how technical mastery and improved perioperative care has affected outcomes, is unknown. Our objective is to 1) provide a comprehensive evaluation of national trends in flap reconstruction of pelvic oncologic defects and 2) compare complications and length of stay (LOS) in patients with/without reconstruction. METHODS The National Inpatient Sample (NIS) database was queried (1998-2014) for patients diagnosed with cancer, primarily of the rectum and anus, who underwent abdominoperineal resection (APR) or pelvic exenteration (PE). Differences in complications and LOS were compared between patients with flap reconstruction versus primary closure. Regional and hospital outcomes were also analyzed. RESULTS The cohort included 117,923 adult patients; 3,673 (3.1%) underwent flap reconstruction. Flap reconstruction rates increased from 0.8% in 1998 to 9.8% in 2014. Extirpative procedures decreased 37.4% from 1998 to 2014. Flap reconstruction decreased risk of wound breakdown (OR 0.87; p = 0.0029) and need for secondary closure of dehiscence (OR 0.82; p = 0.0023) between periods 1998-2009 and 2010-2014. Median LOS was higher for flap patients (median [IQR] of 9.8 [7.2,14.8] vs. 7.9 [6.1-11.0; p < 0.0001) and decreased over time. CONCLUSIONS The use of flap reconstruction for pelvic oncologic defects increased from 1998 to 2014, with a reduction in LOS. Following flap reconstruction, overall complications are higher, but wound breakdown and dehiscence requiring reclosure are decreasing, suggesting technique maturation. We anticipate flap reconstruction rates will increase with further improvement in patient outcomes.
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Affiliation(s)
- Matthew R Zeiderman
- Department of Surgery, Division of Plastic & Reconstructive Surgery, University of California, Davis USA; Department of Surgery, Division of Colon & Rectal Surgery, University of California, Davis USA.
| | - Miriam Nuño
- Department of Surgery, Division of Plastic & Reconstructive Surgery, University of California, Davis USA; Department of Surgery, Division of Colon & Rectal Surgery, University of California, Davis USA; Department of Public Health Sciences, Division of Biostatistics, University of California, Davis USA
| | - David E Sahar
- Department of Surgery, Division of Plastic & Reconstructive Surgery, University of California, Davis USA
| | - Linda M Farkas
- Department of Surgery, Division of Colon & Rectal Surgery, University of California, Davis USA; Department of Surgery, Division of Colon and Rectal Surgery, University of Texas Southwestern Medical Center USA.
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Giese H, Meyer J, Unterberg A, Beynon C. Long-term complications and implant survival rates after cranioplastic surgery: a single-center study of 392 patients. Neurosurg Rev 2021; 44:1755-1763. [PMID: 32844249 PMCID: PMC8121727 DOI: 10.1007/s10143-020-01374-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 08/10/2020] [Accepted: 08/19/2020] [Indexed: 11/29/2022]
Abstract
Cranioplasty (CP) is a standard procedure in neurosurgical practice for patients after (decompressive) craniectomy. However, CP surgery is not standardized, is carried out in different ways, and is associated with considerable complication rates. Here, we report our experiences with the use of different CP materials and analyze long-term complications and implant survival rates. We retrospectively studied patients who underwent CP surgery at our institution between 2004 and 2014. Binary logistic regression analysis was performed in order to identify risk factors for the development of complications. Kaplan-Meier analysis was used to estimate implant survival rates. A total of 392 patients (182 females, 210 males) with a mean age of 48 years were included. These patients underwent a total of 508 CP surgeries. The overall complication rate of primary CP was 33.2%, due to bone resorption/loosening (14.6%) and graft infection (7.9%) with a mean implant survival of 120 ± 5 months. Binary logistic regression analysis showed that young age (< 30 years) (p = 0.026, OR 3.150), the presence of multidrug-resistant bacteria (p = 0.045, OR 2.273), and cerebrospinal fluid (CSF) shunt (p = 0.001, OR 3.137) were risk factors for postoperative complications. The use of titanium miniplates for CP fixation was associated with reduced complication rates and bone flap osteolysis as well as longer implant survival rates. The present study highlights the risk profile of CP surgery. Young age (< 30 years) and shunt-dependent hydrocephalus are associated with postoperative complications especially due to bone flap autolysis. Furthermore, a rigid CP fixation seems to play a crucial role in reducing complication rates.
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Affiliation(s)
- Henrik Giese
- Department of Neurosurgery, University of Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.
| | - Jennifer Meyer
- Department of Neurosurgery, University of Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Andreas Unterberg
- Department of Neurosurgery, University of Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Christopher Beynon
- Department of Neurosurgery, University of Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
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Xue H, Yang Z, Liu J, Wang X, Bi Z, Liu P. Continuous dural suturing for closure of grade 3 leaks after tumor removal via an endoscopic endonasal approach. Neurosurg Rev 2019; 44:373-380. [PMID: 31832806 DOI: 10.1007/s10143-019-01199-w] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2019] [Revised: 10/11/2019] [Accepted: 10/24/2019] [Indexed: 11/25/2022]
Abstract
Cerebrospinal fluid (CSF) leakage is a major complication after extended endonasal transsphenoidal surgery (EETSS), which is commonly used in the treatment of anterior skull base tumors. Dural suturing and graded reconstruction are promising techniques to further decrease the incidence of postoperative CSF (poCSF) leakage. The effect of continuous dural suturing in endoscopic surgery was investigated in this retrospective study. A total of 79 EETSS patients were included; the procedures were performed for subdural tumor removal by a single endoscopic neurosurgical team. Comparisons were applied between patients who did and did not undergo endoscopic dural suturing after tumor removal. Multivariate logistic regression analysis was performed to identify variables that significantly influenced the incidence of poCSF leakage. In all, 79 adult patients developed Esposito's grade 3 intraoperative high-flow CSF leakage. Ten patients (12.7%) experienced poCSF leakage. One of the 36 patients who underwent intraoperative dural suturing developed poCSF leakage, compared with nine of 43 patients who did not undergo dural suturing (p = 0.016). Regression analysis showed that dural suturing could significantly decrease the incidence of poCSF leakage (p = 0.049, OR 0.108, 95% CI 0.013-0.899). Prophylactic lumbar drainage could also help decrease the CSF leakage rate. Dural suturing under endoscopy is a promising and effective method for application in skull base reconstruction after subdural skull base tumor removal. With future progress, lumbar drainage and even nasoseptal flap placement could be replaced in certain groups of patients undergoing EETSS.
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Affiliation(s)
- Hai Xue
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Disease, Beijing, China
| | - Zhijun Yang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Disease, Beijing, China
- Department of Neural Reconstruction, Beijing Neurosurgery Institute, Capital Medical University,, Beijing, China
| | - Jian Liu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Department of Neurosurgery, The Second Hospital of Dalian Medical University, Dalian, China
| | - Xingchao Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Disease, Beijing, China
- Department of Neural Reconstruction, Beijing Neurosurgery Institute, Capital Medical University,, Beijing, China
| | - Zhiyong Bi
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Disease, Beijing, China
| | - Pinan Liu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.
- China National Clinical Research Center for Neurological Disease, Beijing, China.
- Department of Neural Reconstruction, Beijing Neurosurgery Institute, Capital Medical University,, Beijing, China.
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Bonda DJ, Manjila S, Selman WR, Dean D. The Recent Revolution in the Design and Manufacture of Cranial Implants: Modern Advancements and Future Directions. Neurosurgery 2015; 77:814-24; discussion 824. [PMID: 26171578 PMCID: PMC4615389 DOI: 10.1227/neu.0000000000000899] [Citation(s) in RCA: 68] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Large format (i.e., >25 cm) cranioplasty is a challenging procedure not only from a cosmesis standpoint, but also in terms of ensuring that the patient's brain will be well-protected from direct trauma. Until recently, when a patient's own cranial flap was unavailable, these goals were unattainable. Recent advances in implant computer-aided design and 3-dimensional (3-D) printing are leveraging other advances in regenerative medicine. It is now possible to 3-D-print patient-specific implants from a variety of polymer, ceramic, or metal components. A skull template may be used to design the external shape of an implant that will become well integrated in the skull, while also providing beneficial distribution of mechanical force in the event of trauma. Furthermore, an internal pore geometry can be utilized to facilitate the seeding of banked allograft cells. Implants may be cultured in a bioreactor along with recombinant growth factors to produce implants coated with bone progenitor cells and extracellular matrix that appear to the body as a graft, albeit a tissue-engineered graft. The growth factors would be left behind in the bioreactor and the graft would resorb as new host bone invades the space and is remodeled into strong bone. As we describe in this review, such advancements will lead to optimal replacement of cranial defects that are both patient-specific and regenerative.
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Affiliation(s)
- David J. Bonda
- Department of Neurological Surgery, University Hospitals Case Medical Center, 10900 Euclid Avenue, Cleveland, OH 44106
| | - Sunil Manjila
- Department of Neurological Surgery, University Hospitals Case Medical Center, 10900 Euclid Avenue, Cleveland, OH 44106
| | - Warren R. Selman
- Department of Neurological Surgery, University Hospitals Case Medical Center, 10900 Euclid Avenue, Cleveland, OH 44106
| | - David Dean
- Department of Plastic Surgery, The Ohio State University, 460 West 12th Ave., 10th Floor, Rm. 1004, Columbus, OH 43210
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Jiafeng L, Xiaodan L, Jianming S. [Total auricular reconstruction with single big expander at dual plane through incision at remnant ear]. Zhonghua Zheng Xing Wai Ke Za Zhi 2015; 31:251-254. [PMID: 26665922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
OBJECTIVE To investigate the feasibility and advantages of total auricular reconstruction with single big expander at dual plane through incision at remnant ear. METHODS 52 patients with microtia were treated. Through incision at remnant ear, one big expander (150 ml) was implanted in the post-auricular area beneath the superficial facial in the hairless area, and above the superficial fascia in the area with hair. In the second stage, total auricular was reconstructed with autologous cartilage framework and expanded skin. Skin graft was not necessary. Another 32 paitents with single big expander above the superficial fascia were used as control. The downward shift distance of expanders, the appearance of auriculocephalic sulcus and complication were recorded in order to assess the effect of these two methods. RESULTS The downward shift distance of expanders in the dual plane group (0.7 ± 0.3) cm were lower than that in the control group (1.3 ± 0.4) cm, showing significant difference (P < 0.05). After a follow-up period of 6-12 months, shallow auriculocephalic sulcus was presented in 5 patients of the dual plane group and 12 patient of the control group. The shallow auriculocephalic sulcus was cut to make it deeper and covered with full skin graft. CONCLUSIONS Dual plane skin expansion could reduce the downward shift distance of expander. Adequate skin on the upper part of expander could make satisfactory auriculocephalic sulcus.
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Abstract
Severely disfiguring facial injuries can have a devastating impact on the patient's quality of life. During the past decade, vascularized facial allotransplantation has progressed from an experimental possibility to a clinical reality in the fields of disease, trauma, and congenital malformations. This technique may now be considered a viable option for repairing complex craniofacial defects for which the results of autologous reconstruction remain suboptimal. Vascularized facial allotransplantation permits optimal anatomical reconstruction and provides desired functional, esthetic, and psychosocial benefits that are far superior to those achieved with conventional methods. Along with dramatic improvements in their functional statuses, patients regain the ability to make facial expressions such as smiling and to perform various functions such as smelling, eating, drinking, and speaking. The ideas in the 1997 movie "Face/Off" have now been realized in the clinical field. The objective of this article is to introduce this new surgical field, provide a basis for examining the status of the field of face transplantation, and stimulate and enhance facial transplantation studies in Korea.
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Affiliation(s)
- Seok-Chan Eun
- Department of Plastic and Reconstructive Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Korea
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Cigna E, Lo Torto F, Parisi P, Felli A, Ribuffo D. Management of microanastomosis in patients affected by vessel diseases. Eur Rev Med Pharmacol Sci 2014; 18:3399-3405. [PMID: 25491614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
OBJECTIVE In the last 10 years with the advances in microsurgery of techniques and materials the indications for free tissue transfer have considerably been increased. But, there are still some limitations and drawbacks. Among risk factors associated with flap failure, atherosclerosis can affect both the flap and the recipient vessels of free microvascular tissue transfers. The purpose of this paper is to discuss about the pathogenesis of Monckeberg's sclerosis, and the topics that must be taken into consideration when performing microsurgery in these patients. METHODS PubMed database was searched using Mesh. The following terms was added to the search builder: Monckeberg's sclerosis, free flap. The Boolean operator "AND" was selected. All the selectable Mesh headings for "Monckeberg's sclerosis" and "free flap" were included. RESULTS Almost all the literature works about microsurgery in Monckeberg's sclerosis patient show the importance of an accurate preoperative and postoperative evaluation and of a proper surgical technique. CONCLUSIONS When adequate preoperative evaluation, surgical technique and postoperative monitoring are performed, even severe atherosclerosis should not be considered an absolute contraindication for microvascular surgery.
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Affiliation(s)
- E Cigna
- Department of Surgery "P. Valdoni", U.O. of Plastic Reconstructive and Aesthetic Surgery, "Sapienza" University of Rome, Rome, Italy.
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Carlesimo B, Lo Torto F, Rossi A, Marcasciano M, Ruggiero M. Long-term result of bilateral pectoralis major muscle advancement flap in median sternotomy wound infections. Eur Rev Med Pharmacol Sci 2014; 18:3767-3772. [PMID: 25555865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
OBJECTIVE Deep sternal wound infection (DSWI) is an uncommon but serious complication of open heart surgery being characterized by a high mortality rate and a considerable economic weight. Repair of sternal defects, compromised with infection, can be achieved in several ways. The aim of our study is to report our case load in the management of sternal wound infection. PATIENTS AND METHODS In this study, we will report our twelve-year case load with bilateral pectoralis major advancement flap as the sole treatment modality for deep sternal wound infection. RESULTS This surgical approach has given excellent results in terms of resolution of the infection of the sternum, with few complications and a good cosmetic result. CONCLUSIONS We propose bilateral pectoralis major advancement flap as the first choice treatment for deep sternal wound infection.
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Affiliation(s)
- B Carlesimo
- Department of Plastic and Reconstructive and Aesthetic Surgery, Sapienza University of Rome, Rome, Italy.
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Askew DA, Wilkinson D, Schluter PJ, Eckert K. Skin cancer surgery in Australia 2001–2005: the changing role of the general practitioner. Med J Aust 2007; 187:210-4. [PMID: 17708722 DOI: 10.5694/j.1326-5377.2007.tb01201.x] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2007] [Accepted: 07/19/2007] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To describe changing patterns of skin cancer surgery by Australian general practitioners and make comparisons with specialists. DESIGN AND SETTING Analysis of Medicare Australia item number reports for skin cancer excisions and for flap and graft repairs between 2001 and 2005. MAIN OUTCOME MEASURES GPs' and specialists' rates of non-melanoma skin cancer (NMSC) excisions, melanoma excisions, flap repairs and graft repairs; excision to flap ratios. RESULTS NMSC excisions in Australia increased from 338 712 (2001) to 451 628 (2005), a mean annual increase of 1.11/1000 population (P = 0.04); GPs did 51.1% of excisions in 2001, increasing to 54.4% in 2005, representing a higher mean annual rate increase than in specialists (P = 0.003). Nationally, melanoma excisions increased from 20 414 (2001) to 25 580 (2005); GPs did 34.3% of excisions in 2001, increasing to 35.8% in 2005--a similar mean annual rate increase to that in specialists (P = 0.25). Total flap repairs increased from 58 550 (2001) to 80 742 (2005); GPs did 21.3% of flap repairs in 2001, increasing to 26.9% in 2005--a similar mean annual rate increase to that in specialists (P = 0.83). Nationally, the excision to flap ratio for GPs fell from 14 : 1 (2001) to 12 : 1 (2005); in Queensland the ratio fell from 14 : 1 to 9 : 1 over the same period. CONCLUSION GPs excise the majority of skin cancers, and the proportion excised by GPs is increasing. GPs are increasingly using skin flaps for repair, suggesting substantial changes to patterns of treatment, especially in Queensland.
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Affiliation(s)
- Deborah A Askew
- Discipline of General Practice, School of Medicine, University of Queensland, Brisbane, QLD, Australia.
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Russo G, Rotondo M, Punzo A, Di Napoli D. Excimer Laser Assisted Non-occlusive Anastomosis (ELANA). Our experience with a training model in vivo. J Neurosurg Sci 2007; 51:11-6. [PMID: 17369786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/14/2023]
Abstract
AIM In this study the ELANA Technique has been reproduced in our experimental laboratory in order to verify its feasibility and reproducibility, the percentage of patent anastomosis in acute at different steps along the learning curve of the surgical team, specific problems related to the surgical technique. METHODS In 20 rabbits New Zealand 4kg body weight the training model in vivo proposed by Tulleken and coworkers has been reproduced, realizing 40 ELANA anastomosis. The model consists in the realization of two different end-to-side anastomosis on the abdominal aorta of each experimental animal, assisted by a special designed suction/excimer laser catheter, then connected by an end-to-end suture. After a few hours the animals are sacrificed and the by-pass site withdrawn and examined in order to verify the percentage of patency in acute. RESULTS In the first 5 animals (group A), the anastomosis were realized using a jugular vein graft and the procedure results successful in only 3 cases out of ten (30%). For the following experiments - groups B, C and D where an aorta artery graft was used, the percentage of arterial flap retrieval was respectively 50%, 60% and 80%. CONCLUSIONS ELANA is a feasible fascinating microsurgical technique for the realization of high flow, non-occlusive anastomosis. The rate of success results progressively higher along the learning curve of the surgical team. In our opinion, before the application of the ELANA technique on humans, a period of propaedeutic training in vivo on laboratory animals is essential for the dedicated team.
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Affiliation(s)
- G Russo
- Unit of Neurosurgery, AORN A. Cardarelli, Naples, Italy. giuseppe.russo@ospesdale/cardarelli.it
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Abstract
Limb reimplantation techniques using composite free-tissue transfer and microsurgical salvage of traumatized extremities have become standard reconstructive methods. Mechanisms for working with free-tissue transfers have advanced, specifically in regard to the use of thin-wire fixators: combining microsurgical techniques and thin-wire fixators helps in salvaging limbs that otherwise might be amputated. Also, combining the Ilizarov method with microsurgical techniques for limb salvage provides a new use for flaps. A further development in the use of flaps is the application of free-tissue transfers to preserve amputation levels in the war-injured. So-called fillet flaps serve as "spare parts" and can be customized for specific recipient sites. The so-called perforator flap makes use of feeder vessels, thus providing cutaneous and other composite flaps without sacrificing major vessels. Finally, the advent of the sural flap has made it possible to avoid microsurgical reconstruction but still provide adequate, well-vascularized cover, particularly in the distal third of the leg.
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Affiliation(s)
- L Scott Levin
- Plastic Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
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Abstract
INTRODUCTION A 10-year experience with breast reconstruction in a university hospital was recently reviewed. The purpose of this study was to determine the subtypes of breast reconstructive procedures and to evaluate the frequency and change in technique over time of free TRAM (transverse rectus abdominis muscle) flap breast reconstruction performed at one institution. Trends in the development of the procedure over this period were also reviewed. MATERIALS & METHODS Between November 1994 and September 2004, a 10-year retrospective chart review was conducted. The indications for mastectomy and reconstruction were determined. The median age was 48 (range 31-66). The range of follow-up was 2 to 71 months, with a median of 19.5 months. The mean follow-up was 23.5 months. Outcome data were grouped into 2 consecutive 5-year periods (period 1: 1994-1998; period 2: 1999-2004) and evaluated for changes over time in techniques and outcome. Statistical analysis (Decision Analyst, Inc., STATS Statistics software, version 1.1, 1998) was performed using the difference between 2 proportions module to assess the probability of a significant difference in the data for period 1 and period 2 parameters. RESULTS Over a 10-year period, 117 patients underwent breast reconstruction. This consisted of 12 pedicle procedures (11.3%), including 1 bipedicle flap (0.9%) and 2 bilateral pedicle procedures (1.8%). There were 3 latissimus dorsi pedicle flaps (2.8%). Sixteen patients (15.1%) received tissue expander or implant reconstructions. Of the 117 patients, 79 underwent free flap breast reconstruction. Of the 79 free-flap patients, 22 (27.8%) had bilateral procedures, for a total of 101 free flaps performed in these 79 patients. Fifty-two patients underwent immediate reconstruction (65.8%) and 25 were delayed (31.6%) reconstructions using either deep inferior epigastric artery perforator (DIEP) flaps (4 = 3.9%) or free TRAM flaps (97 = 96.0%). A muscle-sparing technique was used in 43 of the 97 free TRAM flaps (44.3%). The preferred vascular inflow was the internal mammary artery, which was used in 66 out of 101 flaps (65.3%). The rate of anastomotic revision (arterial and venous) was 4.9%. The majority of cases used a 2.5-mm venous coupler (65.3%). In 2 of the free TRAM cases, there was insufficient volume to establish the patients preexisting volume. Therefore, at the patient's request, immediate implants were used to augment the reconstruction. The average hospital stay was 8.13 days, and the average intensive care stay was 4.59 days. When assessed for trends over time, we noted a reduction in our hospital length of stay and our ICU length of stay. CONCLUSION The experience with free tissue breast reconstruction reveals predominant use of the TRAM flap. This is justified by the reliability of this flap and the advances in achieving esthetic breast reconstruction. Additionally, we have begun performing DIEP free-flap reconstructions. Our clinical practice has evolved concurrent with standards of care, as noted by the increase in use of muscle-sparing techniques and the reduction in the use of dextran. We do not routinely use therapeutic anticoagulation in our cases. Our hospital length of stay and average intensive care length of stay have also decreased over time, consistent with a system-wide effort to increase the efficiency of healthcare delivery.
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Affiliation(s)
- Mark A K Knight
- Aesthetic and Plastic Surgery Institute, The University of California, Irvine, CA, USA
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Affiliation(s)
- Douglas A Kohl
- Eye Associates of Boca Raton, 950 NW 13th Street, Boca Raton, FL 33486, USA
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Affiliation(s)
- F Bootz
- Klinik und Poliklinik für Hals-, Nasen-, Ohrenheilkunde/Chirurgie, Bonn
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Abstract
The first terminology consensus on perforator flaps, reached in 2001, was reviewed and further simplified following the Sixth International Course on Perforator Flaps.
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Affiliation(s)
- Phillip N Blondeel
- Department of Plastic and Reconstructive Surgery, University Hospital Gent, De Pintelaan 185, 2K12C B-900 Gent, Belgium.
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Abstract
OBJECTIVE Patients with severe peripheral occlusive disease may present especially challenging problems because of previous bypass surgery, location of ulcers, or extremely poor runoff. We used the radial artery with its overlying skin flap as a bypass conduit, called the radial artery flow-through (RAFT) graft in 10 such patients. METHODS From November 1999 to January 2002, 10 patients had limb-threatening ischemia at presentation. All had severe inframalleolar vascular occlusive disease. Four patients had undergone previous conventional bypass procedures. Two grafts remained patent, but distal ulcers failed to heal. Eight patients were men. Seven patients had diabetes mellitus. All patients but one had nonhealing ulcers. In most cases, a composite femoral-tibial bypass graft was constructed by sewing the RAFT graft end-to-end to either the greater saphenous vein or, in one patient, to a polytetrafluoroethylene graft. In all cases, the radial venous comitans were sewn to a nearby superficial vein. In 5 patients the skin paddle was positioned to cover the ulcer; in the remaining patients the skin paddle was used to close the foot incision over the distal anastamosis. Postoperative graft surveillance was performed with Duplex scanning or contrast medium-enhanced angiography. RESULTS Thromboses developed in 2 grafts during follow-up. In 1 of these patients below-knee amputation was performed. Another patient required below-knee amputation because of continuing infection in the foot despite a patent RAFT graft. In 1 patient thrombosis developed in the vein graft, but the RAFT graft extension remained patent. All other RAFT grafts were patent in their entirety at 15 (+/-6) months. CONCLUSIONS The RAFT graft is a new option for treating limb-threatening ischemia. The skin paddle may be useful in selected patients for wound coverage.
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Affiliation(s)
- Victoria J Teodorescu
- Division of Vascular Surgery, The Mount Sinai Medical Center, New York, NY 10029-6574, USA.
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Losken A, Carlson GW, Bostwick J, Jones GE, Culbertson JH, Schoemann M. Trends in unilateral breast reconstruction and management of the contralateral breast: the Emory experience. Plast Reconstr Surg 2002; 110:89-97. [PMID: 12087236 DOI: 10.1097/00006534-200207000-00016] [Citation(s) in RCA: 107] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Recent trends in breast reconstruction have transitioned toward the skin-sparing type of mastectomy and immediate reconstruction using autologous tissue. This study was designed to document trends in the management of patients with unilateral breast cancer and to determine how they influence management of the contralateral breast. All patients who underwent unilateral breast reconstruction at Emory University Hospitals from January of 1975 to December of 1999 were reviewed. The cohort was stratified by timing of reconstruction (immediate versus delayed), method of reconstruction, and mastectomy type (skin-sparing versus non-skin-sparing). The methods of reconstruction included implant, latissimus dorsi flap, and transverse rectus abdominis musculocutaneous (TRAM) flap. Contralateral procedures to achieve symmetry included augmentation, mastopexy, augmentation/mastopexy, and reduction. A total of 1394 patients were evaluated, including 689 delayed and 705 immediate reconstructions. Sixty-seven percent of delayed-reconstruction patients (462 of 689) had a symmetry procedure performed on the opposite breast, compared with 22 percent for the immediate-reconstruction patients (155 of 705) (p </= 0.001). The percentage of times a contralateral procedure was performed was highest for implant reconstructions (89 percent delayed and 57 percent immediate) and lowest for TRAM flap reconstructions (59 percent delayed and 18 percent immediate). Augmentation mammaplasty was the most common symmetry procedure for implant reconstruction (41 percent), whereas reduction was the most common procedure for autologous tissue reconstruction (57 percent). Immediate unilateral breast reconstructions were stratified into non-skin-sparing mastectomy (n = 205) and skin-sparing mastectomy (n = 500). Thirty-four percent of patients with a non-skin-sparing mastectomy defect (70 of 205) underwent a contralateral breast procedure, compared with 17 percent of patients with a skin-sparing mastectomy defect (85 of 500) (p = 0.001). The percentage of times a contralateral procedure was performed in immediate reconstruction, stratified by mastectomy and reconstruction type, was only significant for TRAM flap reconstructions (25 versus 11 percent). Trends in the management of unilateral breast cancer from delayed to immediate reconstruction and from implants to autologous tissue have reduced the incidence of contralateral symmetry procedures. Reduction mammaplasty is the most common symmetry procedure used for autologous tissue reconstruction, with augmentation predominating when implants are used. The type of mastectomy also effects the management of the opposite breast, with skin-sparing mastectomy further reducing the incidence of contralateral procedures in immediate TRAM flap reconstruction, compared with non-skin-sparing mastectomy.
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Affiliation(s)
- Albert Losken
- Division of Plastic and Reconstructive Surgery, Emory University School of Medicine, Atlanta, GA 30322, USA
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18
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Abstract
The failure of macro-implantation of the upper limb must not be considered as the end of a therapeutic method, but instead as a step in the functional rehabilitation of the upper limb. From a group of 24 patients that have been operated with a macro-implantation of the upper limb, we have seen 11 patients for who the reimplantation had failed. We have studied the surgical procedure of those failures, the mid-term evolution (prosthesis and operations), and a long-term evolution with the functional future of those patients. A surgical procedure with latissimus dorsi flap was necessary in six cases, in one hand to maintain a sufficient length of the stump for prosthesis and the other hand to preserve the articulation of the elbow. Nine patients on 11 were able to be "apparated" by a myoelectric prosthesis for the amputation below the elbow (seven cases), by prosthesis for the amputation above the elbow (two cases). On a long period of time (average time 51 months) only four patients had a permanent use of their prosthesis (myoelectric type). For us, the functional rehabilitation of the upper limb need two important elements: first a good quality of the stump with a sufficient length, and second an important motivation from the patient to live with his "new hand".
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Affiliation(s)
- A K Gosain
- Department of Surgery, Medical College of Wisconsin, Milwaukee 53226, USA
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Jonasse Y, Werker PM. [Fifty years of plastic surgery in the Netherlands. IX. Reconstructive surgery illustrated by breast reconstruction]. Ned Tijdschr Geneeskd 2000; 144:1152-6. [PMID: 10876693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
Abstract
The earliest reports on reconstructive surgery are more than two thousand years old. However, the most significant developments took place in the past four decades. At the beginning of the 21st century we are able to perform reconstructions with a moderate functional and good cosmetic result and limited donor site morbidity. The reconstructive options regarding the mammary region include application of mammary implantation only, and techniques in which autologous tissues are applied, with or without implantations. Autologous tissue is used in transposition of the M. latissimus dorsi, in application of the myocutaneous flap of the M. rectus abdominis ('transverse rectus abdominis myocutaneous flap' (TRAM flap)), which is refined in the 'deep inferior epigastric artery perforator' (DIEP) flap procedure.
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Affiliation(s)
- Y Jonasse
- Afd. Plastische, Reconstructieve en Handchirurgie, Universitair Medisch Centrum Utrecht
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21
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Préaux J. [Rieger's nasal flap. History, technical refinements and indications]. ANN CHIR PLAST ESTH 2000; 45:9-16. [PMID: 10783507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
Abstract
Rieger's flap, described by Rieger as a nasal rotation flap, has often been given other names and descriptions in the literature. We consequently felt an overview of the development, characteristics and technique of Rieger's flap was in order, with the goal of helping surgeons use it to best avail. Rieger's flap is irreplaceable for reconstructing defects of the lower third of the nose located on or near the midline. Variants of Rieger's flap can be used to treat defects located higher up on the nose. Four cases are reported to illustrate these indications.
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Affiliation(s)
- J A Werner
- Department of Otorhinolaryngology, University of Kiel, Germany.
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23
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Affiliation(s)
- J O Kucan
- Southern Illinois University School of Medicine, Springfield, USA
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24
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Cariou JL. [1984-1994: ten years of skin flaps. Improvements and conceptual developments. Development of vascular concepts, classification and clinical concepts]. ANN CHIR PLAST ESTH 1995; 40:447-525. [PMID: 8579300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
After a brief review of definitions and semantics, the author recalls the state of the art before 1984 concerning arterial and venous cutaneous blood supply. Studies and concepts published since 1984 include those of Nakajima, who distinguished six types of cutaneous arteries, Gumener, who emphasized the vascular entity represented by the subcutaneous connective tissue, and Taylor. This author, after many studies on the whole body, defined forty arterial and venous cutaneous territories, border-arteries and veins oscillating at the borders of these territories, as well as a number of neurovascular entities (neurocutaneous arteries and veins). In terms of haemodynamics, the concepts of anatomical, haemodynamic and potential arterial cutaneous territories, the concepts of arteriosome and venotome and the concept of low venous pressure zones are analysed. These anatomical and concepts haemodynamic are the basis for the feasibility and reliability of the various cutaneous, musculocutaneous and fasciocutaneous flaps. A number of classifications for these various flaps have been proposed since 1984: a theoretical classification (Kunert's), classifications according to vascular systematization, including Nakajima's classification, and many others. The author proposes a practical classification which should allow a better understanding and better national and international exchange. In parallel, the design and indications of various types of flaps have also advanced since 1984. Skin flaps without a systematized blood supply do not correspond to random flaps. Musculocutaneous flaps have advanced in three directions: partial muscular harvesting when the objective of the flap is essentially cover, an increase of the skin flap surface area; substitution, in certain anatomical regions, of the concept of fasciocutaneous flap for that of musculocutaneous flap, particularly in thoracolumbar and anterior thoracic regions. The author notes the progress in fasciocutaneous flaps: distal pedicle leg flaps, development of decreased cutaneous morbidity resulting in fasciosubcutaneous flaps and proximal or distal fascial (or fascio-adipose) pedicle fasciocutaneous island flaps, progress of normal flow or reverse flow island septocutaneous flaps on the main vessels of the limbs towards to similar types of island flaps on secondary vessels, especially in peri-articular sites. The other clinical concepts analysed include grafted fascial flaps, grafted adipose and fascioadipose flaps, neurocutaneous flaps, "tailormade" flaps and chimeric flaps. This progress in vascular and clinical concepts of skin cover flaps over the last ten years is illustrated by many examples of skin cover, particularly involving the posterior aspect of the heel.
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Affiliation(s)
- J L Cariou
- Service de Chirurgie Plastique, Chirurgie Maxillo-Faciale et Stomatologie, Hôpital d'Instruction des Armées Bégin, Saint-Mandé
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25
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Kojima T. [Recent advance and future of plastic and reconstructive surgery]. Nihon Geka Gakkai Zasshi 1995; 96:355-61. [PMID: 7666850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Plastic and reconstructive Surgery has progressed very rapidly in the past decade. It is because of free vascularized composite tissue transfer based on progress of microsurgery and anatomical study of blood circulation to skin, fascia, muscle, bone and joint. Adding to this, many new techniques and concepts including craniofacial surgery, laser surgery, tissue expansion method, microvascular coupling device and computer assisted surgery appeared to the field of reconstructive surgery. In this article these main fields of plastic and reconstructive surgery are commented about its present situation and future aspect.
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Affiliation(s)
- T Kojima
- Department of Plastic and Reconstructive Surgery, Jikei University School of Medicine, Tokyo, Japan
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Aubert H, Bertrand G, Orlando S, Benguigui F, Acocella G. [Deep rotated connective tissue flap for the reconstruction of the interdental papilla]. Minerva Stomatol 1994; 43:351-7. [PMID: 7984133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
The LCPR or Rotated Connective Flap is a simple mucogingival surgery technique that permits the to recreate, of an interdental papilla by the contribution of the vascularized connective pedicle. Keeping a good vascularization of the flap by its pedicle and its good recovering by some superficial flaps, seems to insure a long dated stability of the reconstruction.
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Affiliation(s)
- H Aubert
- UFR di Odontologia di Bordeaux II, Dipartimento di Parodontologia, Università degli Studi di Firenze
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27
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[Forum: flaps for covering the the upper limbs.. 1973-1993, 20 years of flaps]. ANN CHIR PLAST ESTH 1994; 39:269-376. [PMID: 7717659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
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28
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Affiliation(s)
- G W Carlson
- Emory University School of Medicine, Atlanta, Georgia
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Abstract
Two groups of patients with squamous cell carcinoma of the oral cavity and oropharynx treated by radical surgery were studied. Special emphasis was placed on analysing changing trends in reconstruction and the management of the mandible and their influence on complication rates, length of hospital stay and tumour control rates. Group 1 consisted of 97 patients treated between 1980 and 1984 and Group 2 consisted of 153 patients treated between 1987 and 1991. Anatomical distribution of cancers and clinical stages were similar in the two groups. The major trends identified were: (i) the increasing use of free flaps for reconstruction (0 in Group 1, 41% in Group 2); (ii) more conservative mandibular resection and the increasing use of mandibular swing procedures (1% in Group 1, 16% in Group 2) rather than segmental mandibular resection (44% in Group 1, 13% in Group 2); (iii) fewer procedures per patient (2.6 per patient in Group 1, 1.2 per patient in Group 2); and (iv) a decrease in mean duration of hospital stay from 34 to 16 days and fewer complications. Patients in Group 2 also had a lower rate of local recurrence of cancer when compared with patients in Group 1 (19 vs 29%).
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Affiliation(s)
- C J O'Brien
- Department of Head and Neck Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
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30
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Anthony JP, Huntsman WT, Mathes SJ. Changing trends in the management of pelvic pressure ulcers: a 12-year review. Decubitus 1992; 5:44-7, 50-1. [PMID: 1596351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
The purpose of this study was to evaluate the effect of a preferential shift toward increased use of muscle flap coverage for surgically treated Stage IV pelvic pressure ulcers. Patients treated from 1979-1990 were studied since 1979. Muscle flap use increased from 57% to 100% of surgically treated cases. Over this same period the number of operations per ulcer declined from 1.9 to 1.1 and the time to complete healing dropped from 12.8 to 4.8 weeks. While other factors (including advances in supportive care) have also played a role, increasing use and familiarity with muscle flap has been largely responsible for these improvements.
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Abstract
Studies done on the skin's blood circulation have also resulted in the development of new, more complex flaps. This complexity has made a standardized classification of flaps no longer possible. As a result of this, we have tried to analyze the inner system of flaps. This analysis has made a connection between the construction and the vascular structure of the flaps evident. Based on the fundamental construction and basic vascular structure, we are able to divide the flaps into three elementary types. All the complex flaps are composed of these three elementary types. This composition takes place in the form of a parallel connection or in the form of a sequential connection of the elementary types or both. To ensure the adequate blood supply of a flap, it is necessary to maintain the continuity of the elementary vascular patterns.
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Affiliation(s)
- P Kunert
- Department of Plastic Surgery, Alten Eichen Hospital, Hamburg, Germany
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Buncke HJ, Lineaweaver WC, Buncke GM, Oliva A, Alpert BS. Microsurgery: directions for the 1990s. Hand Clin 1991; 7:471-9. [PMID: 1939354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Speculating on the possible advances of microsurgery in the 1990s has encompassed discussion of transplantation technique, biochemistry, monitoring, and nerve and motor reconstruction. This article, however, is by no means exhaustive, and many other discoveries and innovations may come from areas not discussed here. The only clearly incorrect possibility concerning microsurgery in the 1990s is that nothing exciting will happen.
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Affiliation(s)
- H J Buncke
- Microsurgical Replantation Transplantation Department, Davies Medical Center, San Francisco, California
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33
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Abstract
The development of extremity replantation and reconstructive microsurgery was initially carried out independently among the pioneering centers throughout the world. The comparative development of these techniques is outlined. With the fast growth of microsurgical procedures, many of the U.S. residency programs have incorporated microsurgery training into the curriculum.
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Affiliation(s)
- W P Cooney
- Department of Orthopaedics, Mayo Medical School, Rochester, MN 55905
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