Use of intraoperative fluorescent angiography to assess and optimize free tissue transfer in head and neck reconstruction.

PURPOSE: Composite tissue defects in the head and neck region present unique challenges. Definitive head and neck reconstruction of these cases is often complicated by complex 3-dimensional defects that may require multiple flap or chimeric flap procedures. These advanced techniques can have serious repercussions should poor perfusion of the flap cause flap failure, which can be devastating. MATERIALS AND METHODS: A retrospective review was completed for those complex reconstructions using free tissue transfers and fluorescent indocyanine green angiography (Lifecell SPY Elite imaging, Lifecell Corporation, Bridgewater, NJ) at Walter Reed National Military Medical Center over a 24-month period. Data analyzed included flap type (myocutaneous, osteocutaneous, or fasciocutaneous), flap success and failure rates, and complications. These also were compared with data from the institution before the study period and the incorporation of SPY technology. RESULTS: Sixty-one free flaps, including 11 head and neck flaps, were performed. The head and neck flaps included 1 latissimus, 3 gracilis, 1 vastus lateralis, 4 anterior lateral thigh, and 2 fibular flaps. The overall success rate was 98.4%; 1 flap was lost (1.6%) and 2 flaps developed partial flap necrosis (3.3%). Where SPY Elite was used, there was no unpredicted partial flap necrosis. The only total flap loss was related to a hypercoagulable condition. CONCLUSIONS: Free tissue transfer can be technically challenging, especially in complex head and neck reconstruction. An algorithmic approach using SPY Elite imaging aids in pedicle location, angiosomal assessment, anastomotic flow visualization, and cutaneous and osteocutaneous flap perfusion assessment. This objective tool can assist the reconstructive surgeon in avoiding perfusion-related complications and total and partial flap losses, thus improving patient outcomes.

Wound management and nutrition for optimal wound healing.

The process of wound healing is complicated and requires optimization of wound bed conditions locally through wound management and systemically through proper nutritional care. Although there are a variety of local and systemic factors that can adversely influence healing, the wound environment can be treated through proper dressings to decrease necrotic debris, bacterial load, and foreign bodies. In addition, maintaining or improving patient nutritional status will help the body to supply the necessary building blocks and cellular response for healing to take place.

Pattern and mechanism of traumatic limb amputations after explosive blast: experience from the 07/07/05 London terrorist bombings.

BACKGROUND: Traumatic amputation of limbs caused by bomb blast carries a high mortality; we present our experience of 07/07 London terrorist bombing that resulted in a large number of survivors with amputated limbs. We think that the unique underground bombing, the shape of the carriages, and the enclosure by the underground tunnel caused amputation of the limb by the channeling of the blast wave as a result of the device being floor based, which resulted in lower-limb amputation without other fatal primary blast injuries. We present our results of the traumatic amputation in the fatalities and survivors as well as the possible mechanism and protective measure that could save lives. METHODS: Data for traumatic amputations were collected from several sources and made anonymous. Traumatic amputations were specifically classified in both the survivors and the fatalities. RESULTS: Our results have shown that 24.5% of those with traumatic amputations will survive. Most of the lower-limb amputations occurred in the shaft of the long bones. Only one person with an upper limb amputation survived the injuries. CONCLUSION: This study does not support the previously held belief that traumatic amputations from a bomb blast results from simple avulsions by the blast winds. However, it reinforces the belief that the principal mechanism of primary traumatic amputation of the limbs in such circumstances occurs primarily [corrected] from the direct coupling of blast waves, resulting in a fracture of the long bone rather than at a joint. This study is unique because it looks at the effects of blast at a very close range (<2 m) at the four London bombing scenes. LEVEL OF EVIDENCE: Epidemiological study, level V.

Tympanic membrane rupture in the survivors of the July 7, 2005, London bombings.

OBJECTIVE: The goal of this study was to analyze the prevalence of tympanic membrane rupture in the survivors of the London bombings of July 2005 and to assess whether tympanic membrane rupture provides a useful biomarker for underlying primary blast injuries. STUDY DESIGN: Cross-sectional study. SUBJECTS AND METHODS: Survivors of the 4 blasts of London bombings on July 7, 2005. Data were gathered from medical records and the London's Metropolitan Police evidence documenting the injuries sustained by 143 survivors of the blasts. All patients with tympanic membrane rupture or primary blast injury were identified. Analysis was made of distance against prevalence of tympanic membrane rupture. Correlation between tympanic membrane rupture and other forms of primary blast injury was then assessed. RESULTS: Results from the 143 survivors showed a 48% prevalence of tympanic membrane rupture across all 4 sites. Fifty-one patients had isolated tympanic membrane rupture with no other primary blast injuries. Eleven patients had tympanic membrane rupture and other primary blast injuries, but only one of these was an initially concealed injury (blast lung). CONCLUSIONS: Tympanic membrane rupture in survivors of the London bombings on July 7, 2005, had a high prevalence affecting half of patients across a range of distances from the blasts. Tympanic membrane did not act as an effective biomarker of underlying blast lung. In a mass casualty event, patients with isolated tympanic membrane rupture with normal observations and chest radiography can be monitored for a short period and safely discharged with arrangement for ear, nose, and throat follow-up.