Combined revascularization and microvascular free tissue transfer for limb salvage: a six-year experience

Atherosclerotic vascular disease causing extensive tissue loss of the lower extremities often results in primary amputation. Combined revascularization and free tissue transfer has been described as a method of extending limb salvage to these patients. The durability of this combined procedure remains unknown, thus the objective of this report is to describe the immediate and long-term results in a series collected over 6 years. From 1992 to 1998, 15 patients with a mean age of 60 years underwent combined revascularization and free tissue transfer. Mean ulcer size measured 45 cm(2) for a mean duration of 7.4 months preoperatively and 12 patients had exposed bone or tendon. Vascular reconstruction included popliteal (3), tibial (6), and pedal (6) bypass with concomitant myocutaneous free flap, using mostly rectus abdominis or latissimus dorsi muscle. There were no perioperative deaths. One patient suffered a nonfatal myocardial infarction. Two patients had a postoperative wound hematoma and one required vascular graft revision. Patients were followed for 4 to 75 months (mean = 23 months). Four patients have required amputations (3 early, 1 late), three of whom had preoperative renal failure. The limb salvage rate has been 72% at 36 months,

Total mandibular and lower lip reconstruction with a prefabricated osteocutaneous free flap

Large, complex bony defects can be a vexing problem for the reconstructive surgeon, especially when standard donor sites are not available or do not provide sufficient tissue. Using the concept of flap prefabrication, we demonstrated in a single patient that (1) iliac crest bone chips and bone morphogenic protein in an alloplastic mandibular tray can ossify in a heterotopic location and (2) neovascularization sufficient to support a large, custom-designed bone graft occurs within a convenient "carrier" flap. Ultimately, the fields of angiogenesis and osteogenesis research could significantly contribute to the ability of the plastic surgeon to construct the "ideal" composite prefabricated flap for complicated reconstruction.

Prospective comparison of axial computed tomography and standard and panoramic radiographs in the diagnosis of mandibular fractures

Objective data comparing sensitivity and accuracy between traditional and computed imaging techniques used for diagnosing mandibular fractures is sparse. To address the paucity of information the authors studied prospectively 33 mandibular fractures in 21 consecutive patients with standard mandibular series, panoramic tomography, axial computed tomography (CT), and coronal CT. Differences in diagnostic accuracy and sensitivity as compiled by four blinded reviewers were calculated. Although overall sensitivities of mandibular fracture detection were not statistically significant between the imaging studies, a distinction between the four methods did exist. Coronal CT was the most accurate imaging method, followed by mandibular series, panoramic topography, and axial CT. Excluding technically inadequate studies, panoramic tomography was 100% accurate and sensitive. Diagnostic accuracy and sensitivity did not correlate measurably with reviewers' impressions of the quality of a particular exam. Axial CT detected significantly fewer angle fractures than standard radiographs (60% vs. 98%, p = 0.006) and coronal CT (60% vs. 100%, p = 0.008). False-positives were unusual except for plain mandibular radiographs. The clear definition of both coronal and axial CT scans made their analysis simpler than the plain radiographs. Lack of fracture displacement was the single most important factor in missed fractures with all modalities. Despite reviewer concerns about the quality of the plain mandibular series, the high accuracy and sensitivity of this imaging technique and applicability in all patients, coupled with its low cost, make it an excellent screening exam for all patients with suspected mandibular fractures. In clinically stable and cooperative patients with mandibular trauma, panoramic radiography and coronal CT are recommended to confirm clinical suspicions when the mandibular series is equivocal. To supplement the mandibular series in the uncooperative or multisystem trauma patient, axial CT scans have not been beneficial. These diagnostic modalities do not obviate the need for a careful physical exam.

Reconstructed mandibular defects: fibula free flaps and osseointegrated implants

Twenty patients with microvascular fibula flap reconstruction of oromandibular defects were selected for implant-retained prosthodontic rehabilitation. A total of 71 osseointegrated implants were placed within the grafted fibulas. Four patients had immediate implant placement at the time of their reconstructive surgery, and the remaining 16 patients had implants placed secondarily. One patient received postoperative radiation therapy (5910 cGy) 6 weeks following reconstruction and immediate implant placement. No implants were placed in previously irradiated flaps. A minimum 6-month period of osseointegration was allowed prior to second stage surgery. Fifty-four of the 71 implants were uncovered; 46 of these implants were functional, and 3 were in the process of being restored. Among the 54 implants (15 patients) that were uncovered, only 1 failed to osseointegrate, 2 implants were reburied, and 2 were removed. The follow-up period ranged from 1 to 49 months since second stage surgery. Although a number of prosthodontic designs were used, 11 of the 15 patients were restored with removable overlay prostheses. Only those implants exposed to postoperative radiation demonstrated radiographic bone loss following functional loading.

Safe ischemia time in free-flap surgery: a clinical study of contact-surface cooling

Although the effectiveness of cooling in extending tolerable ischemia time is well-established experimentally, most free-flap surgeons are still concerned about this problem and try to limit the ischemic period to less than 1 hr. Clinically, contact-surface cooling has been used empirically to prolong the limits of ischemia time; however, its applications are unproven. It also remains unknown whether contact-surface cooling has detrimental effects on flap tissue, such as vessel spasm leading to thrombosis. The purpose of this study was to determine, in a clinical setting, if skin, muscle, and bone free flaps of considerable size could tolerate prolonged cold ischemia without adverse effects. Flap size, cold ischemia time, and surgical outcomes were studied in 189 consecutive free flaps. Microvascular thrombosis occurred in 5/378 (1.3 percent) of anastomoses. The overall flap complication/flap loss rate was 7/189 (3.7 percent). Mean ischemia time for all flaps was 2 hr and 6 min (range: 30 min to 5 hr, with one case at 6 hr and 8 min). The mean ischemia time for cases with flap complications was 2 hr 20 min, while ischemia time for cases with thrombosis averaged 2 hr 13 min. The one flap loss had an ischemia time of 1 hr 35 min. No statistically significant correlations existed between duration of ischemia time or duration of contact-surface cooling and the incidence of thrombosis, flap complication, or flap failure. Among the conclusions were that, within a 4-hr period of cold ischemia, the application of the surface-cooling technique is not detrimental to free flap surgery; thus, concern for ischemia, and especially the "no reflow" phenomenon, generally should not interfere with efficient and orderly free-flap surgery.

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

BACKGROUND

Despite numerous refinements in microsurgical technique and instrumentation, the microvascular anastomosis remains one of the most technically sensitive aspects of free-tissue transfer reconstructions.

MATERIALS AND METHODS

Concurrent with the development of microsurgical techniques, various anastomotic coupling systems have been introduced in an effort to facilitate the performance and reliability of microvascular anastomoses. The microvascular anastomotic coupling device (MACD) studied here is a high-density, polyethylene ring-stainless steel pin system that has been found to be highly effective in laboratory animal studies. Despite its availability for human clinical use over the last 5 years, reported clinical series remain rare. Our clinical experience with this MACD in 29 head and neck free-tissue transfers is reported herein.

RESULTS

Thirty-five of 37 (95%) attempted anastomoses were completed with 100% flap survival with a variety of donor flaps, recipient vessels, and clinical contexts. Two anastomoses were converted to conventional suture technique intraoperatively, and one late postoperative venous thrombosis occurred after fistulization and vessel exposure.

CONCLUSIONS

We conclude that the MACD studied here is best suited for the end-to-end anastomosis of soft, pliable, minimally discrepant vessels. Previous radiation therapy does not appear to be a contraindication to its use. Interpositional vein grafts may also be well suited to anastomosis with the device. When carefully and selectively employed by experienced microvascular surgeons, this MACD can be a safe, fast, and reliable adjunct in head and neck free-tissue transfer reconstructions, greatly facilitating the efficiency and ease of application of these techniques.

Surgical stents for composite mandible reconstruction

Surgical stents have improved and simplified our ability to predictably restore maxillomandibular relationships after composite oromandibular resections. Bimaxillary relationships are optimized, the aesthetic result is enhanced, and successful dental rehabilitation follows.

Injected liquid silicone, chronic mastitis, and undetected breast cancer

Although the use of injected liquid silicone for breast augmentation has all but ceased since its widespread use in the 1960s, patients with injected silicone are still seen with a multitude of symptoms. Silicone mastitis is a well-documented phenomenon; however, there has been a paucity of information regarding cancer detection in this group of patients. We report 2 patients who presented with chronic mastitis but on further workup were found to have breast cancer. In both patients, early cancer detection was adversely affected by the presence of free liquid silicone. In view of this and other similar case reports, we advise that simple mastectomy be recommended to those patients with breasts inspissated with liquid silicone who not only have suspicious masses but present with recurrent mastitis or a family history of breast cancer.

Clinical experience with the 3M microvascular coupling anastomotic device in 100 free-tissue transfers

The microvascular surgical anastomosis remains one of the most technically sensitive aspects of free-tissue transfers. To facilitate these often time-consuming, difficult anastomoses, various anastomotic coupling systems have been introduced. The 3M microvascular anastomotic coupling device, a polyethylene ring-pin device, was found to be highly successful in numerous animal studies. It has been available for use in human subjects for the last 4 years, but clinical experience remains sparse. Our clinical experience with the 3M coupler is reported in 100 free-tissue transfers. The average anastomotic time was 4 minutes. Mean follow-up was 8.6 months, and flap survival was 100 percent. The overall success rate for 3M (MACD) coupler use in microvascular anastomoses is 98.4 percent (121 of 123). Nine abandoned anastomoses were converted to sutured anastomoses intraoperatively. The over-all failure rate for 3M coupler anastomoses is 1.6 percent (2 of 123). We conclude that the 3M device is best suited for minimally discrepant, soft, pliable venous microvascular anastomoses and is unsuitable for end-to-side anastomoses in clinical situations. When carefully and selectively employed by a trained microvascular surgeon, the 3M coupler can be a safe, fast, and reliable adjunct for free-tissue transfers.

Preoperative assessment and surgical planning for patients undergoing immediate composite reconstruction of oromandibular defects

The rehabilitation of patients with orofacial-mandibular defects has made great strides with our ability to reliably transfer composite tissues. Unimpeded soft-tissue healing and osseous union set the stage for reliable restoration of form and function. A multidisciplinary, carefully planned, and carefully executed approach is emphasized.

The role of three-dimensional computed tomography in the evaluation of acute craniofacial trauma

Three-dimensional computed tomographic (3-D CT) reformations together with their corresponding conventional axial two-dimensional (2-D) CT images of 20 patients with facial fractures were compared with 2-D CT alone to define their usefulness in the determination of facial skeletal fracture patterns. Nine surgeons with three different levels of experience and training evaluated the presence and spatial arrangement of fractures in all 2-D CT and 3-D CT scans. Comparisons were made between their evaluations of 2-D CT alone and 2-D CT plus 3-D CT scans. Statistical analysis with Friedman's test were performed. The addition of 3-D CT did not alter the interpretation of 2-D CT in 75% of evaluations. The number and accuracy of the changes made with the aid of 3-D CT reflected the experience of the observers. Overall, there was no improvement in the accuracy of interpretations with the addition of 3-D CT.

Acrylic splints for dental alignment in complex facial injuries

Twenty-four patients with complex facial injuries were managed by wide subperiosteal exposure, precise anatomical reduction, rigid internal fixation, and immediate bone grafting when indicated, in conjunction with dental impressions, model surgery, and fabrication of dental splints to establish proper preinjury occlusion. The study population consisted of 18 men and 6 women, whose ages ranged from 18 to 49 years (mean, 30.7 yr) at the time of injury. High velocity motor vehicle accidents were responsible for facial injuries in 18 patients, gunshot wounds in 2, low velocity blunt trauma in 3, and falls in 1. All facial fractures involved the occlusion, and unstable and/or comminuted palatal/maxillary and mandibular fractures, often with edentulous segments, were the major indications for fabrication of acrylic splints. Depending on the nature of the fracture pattern, model surgery was performed on the maxillary and/or mandibular models and segmented along fracture lines. These fragments were then repositioned according to dental wear facets and preinjury occlusion. When possible, preinjury occlusal records were obtained before splint fabrication. Models were mounted on a Galetti articulator and palatal, lingual, and/or occlusal splints were fabricated. Edentulous segments were compensated for by local buildup of the splints to produce an occlusal stop. Arch bars were fixed directly to the splint with acrylic. Twenty-six splints were used in the 24 patients to establish proper occlusal relationships before internal fixation of fractures. The types of splints were palatal (n = 8), palatal-occlusal (n = 6), lingual (n = 8), lingual-occlusal (n = 1), and occlusal (n = 3).(ABSTRACT TRUNCATED AT 250 WORDS)

Computed tomography versus standard radiography in the assessment of fractures of the mandible

Twenty-nine fractures of the mandible were studied by standard radiographs and axial computed tomographic scans (hard copy). Independent reviewers analyzed each study in a blinded, non-paired fashion. When radiographic diagnostic sensitivities were compared on the basis of known surgical findings, the plain films were found to have a higher diagnostic sensitivity (89%) than the hard copy computed tomograms (64%). This difference occurred primarily with images of nondisplaced fractures in posterior portions of the mandible, and is likely the result of tomographic orientation and volume averaging. Though computed tomography has emerged as the standard diagnostic test in evaluating intracranial and maxillofacial trauma, this study demonstrates that computed tomographic scanning alone is inadequate in excluding nondisplaced fractures of the posterior mandible.

The deep inferior epigastric rectus abdominis muscle and myocutaneous free tissue transfer: further applications for head and neck reconstruction

The rectus abdominis muscle and myocutaneous free tissue transfer is a well-recognized donor site for reconstruction of complex head and neck defects. Four composite deformities were successfully managed using this donor site. The rectus abdominis myocutaneous "sandwich" flap was used for closure of a pharyngocutaneous fistula and to provide intraoral lining and external coverage for a composite mandibular defect. The rectus muscle flap was used to obliterate a compound frontal sinus injury and an orbitomaxillary defect. All flaps were based on the deep inferior epigastric vascular pedicle.

High-energy orbital dislocations: the possibility of traumatic hypertelorbitism

In a 4-year period from 1983 to 1987, 7160 patients with blunt injuries were admitted to the Maryland Institute of Emergency Medical Services Systems Shock Trauma Center. Facial injuries occurred in 10 percent of this population. High-energy fractures (characterized by computed tomography) were seen in approximately 10 percent of these patients. In this high-energy group, five cases of high-energy orbital dislocations, some representing examples of traumatic hypertelorbitism, were observed. They represent 1.5 percent of the 342 midface fractures observed and 4.8 percent of the naso-orbital ethmoid fractures observed (105 patients). One additional patient is described who was seen at the UCLA Medical Center for late repair of the condition. High-energy impacts of the upper midface created fractures of both orbits, zygomas, and nasoethmoidal regions permitting lateral transposition, enlargement, and divergence of the orbits. Interorbital, intercanthal, and interpupillary distances were increased, criteria that confirm the diagnosis of hypertelorbitism. Fifty percent of the patients were bilaterally blind, and one patient sustained unilateral blindness.

Management of the medial canthal tendon in nasoethmoid orbital fractures: the importance of the central fragment in classification and treatment

The medial canthal tendon and the fragment of bone on which it inserts ("central" fragment) are the critical factors in the diagnosis and treatment of nasoethmoid orbital fractures. The status of the tendon, the tendon-bearing bone segment, and the fracture pattern define a clinically useful classification system. Three patterns of fracture are appreciated: type I--single-segment central fragment; type II--comminuted central fragment with fractures remaining external to the medial canthal tendon insertion; and type III--comminuted central fragment with fractures extending into bone bearing the canthal insertion. Injuries are further classified as unilateral and bilateral and by their extension into other anatomic areas. The fracture pattern determines exposure and fixation. Inferior approaches alone are advised for unilateral single-segment injuries that are nondisplaced superiorly. Superior and inferior approaches are required for displaced unilateral single-segment injuries, for bilateral single-segment injuries, and for all comminuted fractures. Complete interfragment wiring of all segments is stabilized by junctional rigid fixation. All comminuted fractures require transnasal wiring of the bones of the medial orbital rim (medial canthal tendon-bearing or "central" bone fragment). If the fracture does not extend through the canthal insertion, the canthus should not be detached to accomplish the reduction.

Rigid fixation of internal orbital fractures

When large portions of the internal orbit are destroyed (two to four walls), standard bone-grafting techniques for immediate and late orbital reconstruction may not yield predictable eye position. Critical bone support is most often deficient inferomedially. CT analysis of orbital volume in cases where eye position was unsatisfactory reveals that displacement of bone grafts is one mechanism of the unsatisfactory result. Other mechanisms include undercorrection and bone-graft resorption. In order to minimize postoperative bone-graft displacement, titanium implants were used to span large defects in the internal orbit to provide a platform for bone-graft support. Twenty-six implants were placed in immediate and 12 were placed in late orbital reconstructions. More reliable bone-graft position resulted. Two late infections have occurred resulting in implant removal in a 3-year period.

Sequencing LeFort fracture treatment (Organization of treatment for a panfacial fracture)

The types of midfacial fractures and their complexity were evaluated in admissions to the Maryland Institute of Emergency Medical Service Systems (MIEMSS) during the years of 1984 to 1988. Two hundred and sixty-eight LeFort fractures were treated and followed (3.2 percent of admissions). One half (50 percent) had skull fractures and 40 patients (15 percent) had LeFort, skull and mandibular fractures. Isolated nasoethmoidal fractures were observed in 176 patients and in 107 patients (39 percent) of patients with LeFort fractures. Isolated mandibular fractures were observed in 321 patients and in 104 patients with LeFort fractures (39 percent). Eleven percent of patients had midfacial, nasoethmoidal and frontal sinus fractures. Six percent of patients had midfacial, frontal bone, frontal sinus and nasoethmoidal fractures (Cranial Base Crush Syndrome). Twenty two percent of patients had LeFort and frontal sinus fractures. Reconstruction of multiple area injuries is simplified by a highly organized treatment sequence that conceptualizes the face in two groups of two units. Each unit is divided into sections, and each section is assembled in three dimensions. Sections are integrated into units and units into a single reconstruction. Conceptually, in each unit, facial width must first be controlled by orientation from cranial base landmarks. Projection is then (and often reciprocally with width) established. Finally, facial length is set both in individual units and in the upper and lower face. Soft tissue is considered the "fourth dimension" of facial reconstruction. Bone reconstruction should be completed as early as possible to minimize soft tissue shrinkage, stiffness and scarring of soft tissues in nonantomic positions.(ABSTRACT TRUNCATED AT 250 WORDS)

Panfacial fractures: organization of treatment

Recent advances in facial trauma management have enabled the surgeon to perceive and successfully reconstruct complex panfacial injuries. Restoration of both preinjury facial aesthetics and function is now the goal. An organized approach to these injuries begins at the maxillary and mandibular arches with progression to the vertical mandible. The nasoorbital ethmoidal complex is stabilized to the cranium and bone grafted when indicated. The zygomatic complex is related medially, and orbital reconstruction performed. The facial architectural restoration is completed at the Lefort I level. Adherence to this protocol enables the surgeon to obtain reproducibly good results, even with the most extensive facial dislocations.