The proximal first dorsal metacarpal artery free flap for reconstruction of complex digital defects.

We describe our experience and outcome with the 'Proximal first dorsal metacarpal artery free flap'. Ten consecutive cases utilizing the proximal first dorsal metacarpal artery free flap for complex digital defects were studied. Surgical technique, patient demographics, and flap outcome data were collected. Patient satisfaction was analysed using a questionnaire. All defects healed successfully with no loss of free flaps. The short-pedicle proximal first dorsal metacarpal artery free flap enables primary closure of the donor site up to 2 cm of width (in nine of the ten donor sites). The flap is a reliable and versatile alternative in selected cases of complex digital injuries.

The efficacy of magnesium sulfate on resolving surgically provoked vasospasm of the flap pedicle in an experiment.

BACKGROUND: Vasospasm frequently accompanies manipulation of small vessels during free flap surgeries and replantations. The purpose of this experimental study was to evaluate the effect of magnesium sulphate on vasospasm provoked by surgical manipulation (axial tension) on the flap pedicle. This kind of surgical manipulation of the vessel cannot be studied in a clinical environment without putting flap viability into risk. MATERIAL AND METHODS: Forty male Wistar rats weighing around 300 g each were classified in two experimental groups (n=20 in each). In the treatment group (group A) Magnesium Sulphuricum 10% (Biotika, Czech Republic) was applied; the second group (group B) served as a control. The vasopasm was provoked by pulling the pedicle of the right groin flap of the rat. The peripheral blood perfusion of the flap was continuously measured using laser-Doppler recording. In the study group, magnesium sulphate was applied topically on the flap pedicle to relieve vasospasm, and duration of the vasospasm was compared to the control group. RESULTS: A statistically significant difference (p=0.01) between the groups was found. The duration of vasospasm was significantly shorter in the treatment group A. CONCLUSIONS: We conclude that in an experimental environment magnesium sulphate is effective in relieving surgically provoked vasospasm of the flap pedicle. This finding is in accordance with our clinical observations.

The effect of blood around a flap pedicle on flap perfusion in an experimental rodent model.

BACKGROUND: The vasospasm has been studied to a considerable extent in the neurosurgical literature. Little experimental and basic scientific literature about vasospasm of flap pedicle is available in the field of reconstructive microsurgery. The purpose of the study was to investigate the effect of presence of blood around the pedicle on a flap perfusion. MATERIAL AND METHODS: Blood flow through a right groin flap was continuously measured using Laser Doppler flowmetry on 40 male Wistar rats. A segment of the flap's pedicle was surgically cleared of adventitia and bathed in blood. The blood used was either collected from the tail of the rat (group A) or from the bleeding branch of the pedicle itself (group B). The differences between the signal amplitudes before and after exposure of the pedicle to blood were recorded. RESULTS: The presence of blood around the pedicle resulted in a significant decrease in perfusion of the flap in both groups. However, no significant differences in the duration of impaired blood flow between the groups were observed. CONCLUSIONS: In conclusion, the presence of blood around the vascular pedicle may cause a significant decrease in the perfusion of a flap, while the origin of the blood does not appear to be an important factor.

Arterialized venous free flaps--a reconstructive alternative for large dorsal digital defects.

Venous free flaps should be considered as potential reconstructive options for large dorsal digital defects with exposed bone, joint and/or extensor tendons, if local flaps are inadequate or unusable. We describe our experience of thirteen venous free flaps in twelve patients with large dorsal digital defects. Our survival rate for these flaps is comparable to the published data. The forearm donor site was closed primarily in all cases with minimal morbidity. The flaps should be monitored with Doppler devices as clinical evaluation is misleading secondary to the venous congestion inherent in these flaps. This reconstructive option has become a well-established procedure in our hands and is the alternate reconstructive method of choice for large dorsal digital defects where local flaps are not usable or inadequate due to complex hand injuries or multiple finger defects.

The preservation of a spare hemi-abdominal flap in unilateral breast reconstruction with abdominal free flap in high risk patients.

BACKGROUND: Unilateral breast reconstruction with a free abdominal TRAM or DIEP flap restores the shape of the amputated breast with acceptable donor site morbidity. In patients with small breasts and ample lower abdominal tissue this can be achieved by using only a hemi-abdominal flap. In these cases, the contra-lateral flap is usually discarded, but it could potentially be left in situ as a "spare" hemi-abdominal flap, especially in patients at high risk for contra-lateral breast cancer or flap failure. We report our early experience with this preservation technique. MATERIAL AND METHODS: The authors report two cases of unilateral breast reconstruction with hemi-abdominal DIEP free flaps in women at high risk for contra-lateral breast cancer and/or flap failure, who opted not to have prophylactic contra-lateral mastectomies. They consented to having the unused "spare" hemi-abdominal deepithelialized flap left in situ in case the need for a secondary flap arose. RESULTS: The "spare" hemi-abdominal flap was used for immediate reconstruction as an SIEA free flap when the first patient's original flap necrosed secondary to microcirculation problems. The second patient's spare flap was left in situ by burying it after de-epithelialization. CONCLUSIONS: We believe that patients undergoing unilateral breast reconstruction who are at high risk for contra-lateral breast cancer and/or free flap failure, and who choose not to undergo an immediate contra-lateral prophylactic mastectomy, should have the "spare" hemi-abdominal flap buried. This tissue could be used as a potential bailout flap in cases of original flap failure or for contralateral breast reconstruction at a later date.

Outcomes in a series of 103 retroperitoneal sarcomas.

AIMS: To report the effect on outcome of selection in patients receiving intra-operative electron beam radiation (IOERT) and external beam radiation therapy (EBRT). METHODS: One hundred and three patients treated for primary RS were studied. Median follow-up was 27 months. Clinical presentation, tumor characteristics, and treatment methods were analyzed to determine impact on survival and recurrence and if selection was occurring. RESULTS: Mean age was 55+/-17 years. Mean tumor size was 15+/-6cm and 88 were high-grade. Complete gross tumor resection (CR) occurred in 62 patients and improved survival vs. both debulking (p=0.0005) and biopsy (p<0.0001). The 5- and 10-year survival rates were 62% and 52% for those with CR vs. 29% and 20% after incomplete resection. Among the 62 CR patients, there was selection to receive additional EBRT+/-IOERT in patients with high-grade tumors (p=0.005) and/or microscopically positive margins (p=0.011). In these high-risk patients there was a trend for IOERT to further augment survival vs. EBRT alone and to increase the time to both local and distant recurrences (p=0.036). CONCLUSIONS: Complete gross resection is the primary form of curative treatment for retroperitoneal sarcomas. Selection led to patients with high-risk tumors receiving additional radiation therapy. There appears to be a beneficial effect of IOERT plus EBRT in these high-risk patients after complete tumor resection.

The effect of surgery and grade on outcome of gastrointestinal stromal tumors.

HYPOTHESIS: Gastrointestinal stromal tumors (GIST) are aggressive, rare, and difficult-to-cure gastrointestinal tumors. We believe that the clinical behavior of these tumors can be predicted by reproducible prognostic factors. DESIGN AND SETTING: A retrospective review of all patients (N = 70) with GIST treated at a tertiary care center from 1973 to 1998. PATIENTS: Adequate data for evaluation were available for 69 patients. Male-female distribution was 40:29. Median age was 60 years. Median follow-up duration was 38 months. MAIN OUTCOME MEASURES: Tumor grade, stage, and histologic subtype at presentation; effect of grade, surgery and adjuvant therapy on recurrence, salvage, and survival. RESULTS: Tumor distribution included 61% in the upper, 23% in the middle, and 16% in the lower digestive tract, with a median tumor size of 7.9 cm (range, 1.8-25 cm). Tumors with more than 1 mitosis per 10 high-power fields constituted 57% of neoplasia in the series. Distant disease at initial visit occurred in 49% of patients. Complete gross resection occurred in 59% of patients. After complete resection, the 5-year survival rate was 42%, compared with 9% after incomplete resection (hazard ratio = 0.27, P<.001). Neither radiation nor chemotherapy demonstrated any significant benefit. Among 39 patients who were disease free after complete resection, 2% developed lymph node recurrence, 25% developed local recurrence, and 33% developed distant recurrences (54% liver, 20% peritoneum). By multivariate analysis the risk of local and/or distant metastases was significantly increased for tumors with more than 1 mitosis and size larger than 5 cm (P<.05). Multivariate analysis in all 69 patients revealed that incomplete resection, age greater than 50 years, non-smooth muscle histological feature, tumor with more than 1 mitosis, and tumor size larger than 5 cm significantly decreased survival. CONCLUSION: Complete gross surgical resection is presently the only means of cure for GIST. Tumors with more than 1 mitosis and a size larger than 5 cm have an especially poor prognosis, with decreased survival, and increased local and/or distant recurrence.