[POSSIBLE REACTION TO SUTURE MATERIALS].

INTRODUCTION: The use of sutures is a common practice in plastic surgical procedures. The potential risk of developing an allergic reaction to suture materials exists. To the best of the authors' knowledge, this is the first case reported in the literature of such a reaction in aesthetic breast surgery. The aim of this review is to raise the awareness of possible allergic and infective or inflammatory reactions to the suture material and to expand the knowledge of the management and interventions which are critical for patient safety and satisfaction. More research is needed to study this challenging topic.

De Novo Reconstruction of a Hybrid Patella by Staged Fabrication of a Microvascular Bone Transplant with an Osteointegrated Prosthetic Socket.

Total patellectomy is sometimes unavoidable but usually results in severely impaired function, pain, and instability in the affected knee. Any patellar prosthetic solutions rely on a certain amount of remaining bone and therefore are not applicable after total patellectomy. Traditionally, reconstruction of a neopatella by avascular or allogeneic bone grafts is hampered by mechanical failure, resorption, or infection. We developed a new, 3-stage approach to reconstruct a hybrid patella composed of a revascularized scapula tip transplant fabricated with a prosthetic socket. The procedure is safe and provides optimal healing and prosthetic osteointegration through viable bone and dynamic stability to the considerable load a patella has to bear in unrestricted mobility. The technique also demonstrates successful integration of orthopedic prosthetic devices into current flap fabrication concepts.

Patient-specific reconstruction plates are the missing link in computer-assisted mandibular reconstruction: A showcase for technical description.

INTRODUCTION: Preoperative planning of mandibular reconstruction has moved from mechanical simulation by dental model casts or stereolithographic models into an almost completely virtual environment. CAD/CAM applications allow a high level of accuracy by providing a custom template-assisted contouring approach for bone flaps. However, the clinical accuracy of CAD reconstruction is limited by the use of prebent reconstruction plates, an analogue step in an otherwise digital workstream. TECHNICAL REPORT: In this paper the integration of computerized, numerically-controlled (CNC) milled, patient-specific mandibular plates (PSMP) within the virtual workflow of computer-assisted mandibular free fibula flap reconstruction is illustrated in a clinical case. Intraoperatively, the bone segments as well as the plate arms showed a very good fit. Postoperative CT imaging demonstrated close approximation of the PSMP and fibular segments, and good alignment of native mandible and fibular segments and intersegmentally. Over a follow-up period of 12 months, there was an uneventful course of healing with good bony consolidation. CONCLUSION: The virtual design and automated fabrication of patient-specific mandibular reconstruction plates provide the missing link in the virtual workflow of computer-assisted mandibular free fibula flap reconstruction.

The functional peroneus brevis as a third muscle component in the osteomyocutaneous fibula free-flap system.

Up to now, the peroneus brevis muscle was harvested as a non-functional pedicled muscle flap for defects around the ankle and the anterior lower leg. It has a reliable dual segmental vascularisation from the peroneal and the anterior tibial artery and a long, single motor nerve entering proximally. We report of a free microvascular transfer of the peroneus brevis as a neurotised functional muscle component in a composite osteo-musculo-cutaneous flow-through fibula flap. The flap components were used to reconstruct extensive radial and soft-tissue defects in a severely damaged forearm, whereas the peroneus brevis nerve was coapted to the proper flexor carpi radialis (FCR) motor nerve to counterbalance ulnar abduction, as all radial abductors were lost in the injury. Thirteen months later, the arm was fully reconstructed and an active radial abduction of 15° by the contracting peroneus muscle was achieved. Donor-site complications were absent. The peroneus brevis can expand the versatility of the peroneal-vessel-flap system as a third muscular component in four possible ways: a) addition of plain muscle bulk in the middle- and lower third of the fibula if left attached to the bone, b) as a reinnervated functional muscle as presented here, c) as a distally based muscle component if released from its origin from the middle third of the fibula and pedicled on its distal segmental branches from the peroneal vessels or d) as a distally pedicled osteomuscular flap permitting individual placement of a middle fibula segment.

Surgical angiogenesis with short-term immunosuppression maintains bone viability in rabbit allogenic knee joint transplantation.

BACKGROUND: Vascularized composite allotransplantation has the potential for reconstruction of joint defects but requires lifelong immunosuppression, with substantial risks. This study evaluates an alternative, using surgical angiogenesis from implanted autogenous vessels to maintain viability without long-term immunotherapy. METHODS: Vascularized knee joints were transplanted from Dutch Belted donors to New Zealand White rabbit recipients. Once positioned and revascularized microsurgically, a recipient-derived superficial inferior epigastric fascial flap and a saphenous arteriovenous bundle were placed within the transplanted femur and tibia, respectively, to develop a neoangiogenic, autogenous circulation. There were 10 transplants in group 1. Group 2 (n = 9) consisted of no-angiogenesis controls with ligated flaps and arteriovenous bundles. Group 3 rabbits (n = 10) were autotransplants with patent implants. Tacrolimus was used for 3 weeks to maintain nutrient flow during angiogenesis. At 16 weeks, the authors assessed bone healing, joint function, bone and cartilage mechanical properties, and histology. RESULTS: Group 1 allotransplants had more robust angiogenesis, better healing, improved mechanical properties, and better osteocyte viability than ligated controls (group 2). All three groups developed knee joint contractures and arthritic changes. Cartilage thickness and quality were poorer in allograft groups than in autotransplant controls. CONCLUSIONS: Surgical angiogenesis from implanted autogenous tissue improves bone viability, healing, and material properties in rabbit allogenic knee transplants. However, joint contractures and degenerative changes occurred in all transplants, regardless of antigenicity or blood supply. Experimental studies in a larger animal model with improved methods to maintain joint mobility are needed before the merit of living joint allotransplantation can be judged.

Knee joint transplantation combined with surgical angiogenesis in rabbits--a new experimental model.

PURPOSE: We have previously described a means to maintain bone allotransplant viability, without long-term immune modulation, replacing allogenic bone vasculature with autogenous vessels. A rabbit model for whole knee joint transplantation was developed and tested using the same methodology, initially as an autotransplant. MATERIALS/METHODS: Knee joints of eight New Zealand White rabbits were elevated on a popliteal vessel pedicle to evaluate limb viability in a nonsurvival study. Ten additional joints were elevated and replaced orthotopically in a fashion identical to allotransplantation, obviating only microsurgical repairs and immunosuppression. A superficial inferior epigastric facial (SIEF) flap and a saphenous arteriovenous (AV) bundle were introduced into the femur and tibia respectively, generating a neoangiogenic bone circulation. In allogenic transplantation, this step maintains viability after cessation of immunosuppression. Sixteen weeks later, X-rays, microangiography, histology, histomorphometry, and biomechanical analysis were performed. RESULTS: Limb viability was preserved in the initial eight animals. Both soft tissue and bone healing occurred in 10 orthotopic transplants. Surgical angiogenesis from the SIEF flap and AV bundle was always present. Bone and joint viability was maintained, with demonstrable new bone formation. Bone strength was less than the opposite side. Arthrosis and joint contractures were frequent. CONCLUSION: We have developed a rabbit knee joint model and evaluation methods suitable for subsequent studies of whole joint allotransplantation.

First experiences with simultaneous skeletal and soft tissue reconstruction of noma-related facial defects.

Noma victims suffer from a three-dimensional facial soft-tissue loss. Some may also develop complex viscerocranial defects, due to acute osteitis, chronic exposure, or arrested skeletal growth. Reconstruction has mainly focused on soft tissue so far, whereas skeletal restoration was mostly avoided. After successful microvascular soft tissue free flap reconstruction, we now included skeletal restoration and mandibular ankylosis release into the initial step of complex noma surgery. One free rib graft and parascapular flap, one microvascular osteomyocutaneous flap from the subscapular system, and two sequential chimeric free flaps including vascularized bone were used as the initial steps for facial reconstruction. Ankylosis release could spare the temporomandibular joint. Complex noma reconstruction should include skeletal restoration. Avascular bone is acceptable in cases with complete vascularized graft coverage. Microsurgical chimeric flaps are preferable as they can reduce the number and complexity of secondary operations and provide viable, infection-resistant bone supporting facial growth.

The role of fabricated chimeric free flaps in reconstruction of devastating hand and forearm injuries.

Devastating hand and forearm injuries almost exclusively need free flap transfer if reconstruction is attempted. Early active and passive motion is only possible with aggressive, early, and comprehensive reconstruction. Despite recent advances in compound flaps, in selected cases it might be wise to harvest several smaller flaps and microsurgically combine them to one "chain-linked" flap "system." Four microsurgically fabricated chimeric free flaps were used in four patients for complex hand and forearm injuries. The combinations were sensate anterolateral thigh (ALT) flap plus sensate extended lateral arm flap (2x), ALT plus free fibula, and ALT plus functional musculocutaneous gracilis muscle. All flaps survived completely. Functional rehabilitation was possible immediately after flap transfer. There were no donor-site complications except two widened scars. The microsurgical fabrication of chimeric free flaps, as well established in head and neck reconstruction, can be successfully adapted to massive hand injuries as well. Individual placement of selected tissue components, early comprehensive reconstruction, and reduction of the number of operations are beneficial in cases that need more than one free flap.

Thumb salvage with skin grafted medial femoral corticoperiosteal free flap.

A 23-year-old man suffered a severe crush injury with fracture of his left thumb base phalanx and destruction of his extensor pollicis longus tendon. Immediate plate stabilisation and soft tissue coverage was performed; however, a recalcitrant pseudarthrosis developed in this compliant non-smoker despite three revisions with avascular iliac crest grafts for interphalangeal joint arthrodesis, corticocancellous bone application and hardware exchange. An attempt to improve thumb vascularity and soft tissue cover with a pedicled Foucher flap as well as through extracorporeal shock wave therapy failed. Bone healing and subsequent thumb salvage were finally achieved with a free vascularised medial femoral condyle (MFC) bone flap, which was covered directly with a full-thickness skin graft. Both bony and soft tissue healing went well and after 3 months the patient returned to work. This case demonstrates that skin grafting the periosteal surface of the MFC flap is safe and results in a thin skin-bone compositae transplant which also might be very useful for indications other than hand surgery.

Prefabricated supraclavicular flap as a salvage procedure for a failed microvascular hypopharyngeal defect closure in a tetraplegic patient.

Delayed hypopharyngeal perforations in tetraplegics are a rare but potentially life-threatening complication of anterior cervical spine instrumentation. To date, no established treatment regimen exists for these situations. A patient with traumatic tetraplegia sub-C4 was admitted to the hospital 14 days after anterior spinal fusion with an infected hypopharyngeal perforation. After hardware removal, the spine was restabilized with a composite free osteomusculocutaneous fibula with the flexor hallucis longus muscle closing the mucosal defect. However, it was lost because of external venous compression. After 54 days, definitive reconstruction was achieved with a delayed supraclavicular artery flap. Follow-up endoscopy showed a closed and mucosalized defect. Composite free flaps are intriguing for complex hypopharyngeal and spine defects; however, they can undergo fatal external compression due to postoperative swelling in this area. Supraclavicular flaps might serve as a rescue alternative, offering unimpaired neck mobility that is crucial for tetraplegics, adequate tenuity for the hypopharynx, and reliable blood supply without large vessels in the field.

The muscular and the new osteomuscular composite peroneus brevis flap: experiences from 109 cases.

BACKGROUND: Pedicled peroneus brevis muscles are proven flaps for defect coverage around the ankle, foot, and distal lower leg. Some of these defects--such as postosteitic hollowed out calcaneal bones--may profit from a simultaneous vascularized bone transplantation. The authors' experiences with 109 successive muscular and newly developed osteomuscular peroneus flaps are outlined for small to medium combined defects in this region. METHODS: One hundred nine patients with various soft-tissue and skeletal defects underwent reconstruction with proximally (n = 10) or distally pedicled (n = 98) or free microvascular transplanted (n = 1) peroneus brevis flaps. Eight patients received a composite flap of the peroneus brevis muscle with an attached lateral split fibula segment. RESULTS: In 72.5 percent of the cases, a stable defect closure was achieved without significant secondary procedures. In 16.5 percent, further operations such as secondary wound closure or flaps were necessary, most often because of the avascular loss of the 1 to 3 cm of the distal flap tip. Nine flaps (8.3 percent) were lost completely. Seven of eight osteomuscular flaps demonstrated stable bony healing, and full weight bearing was achieved. No relevant donor-site complications were seen. CONCLUSIONS: The peroneus brevis is a valuable flap for defect closure around the ankle and lower leg. It can be harvested together with a vascularized split fibula segment, representing a simple alternative to several free composite flaps. Its complication rate can be lowered significantly if the proximal 3 cm of the muscle origin (i.e., the flap tip in distally pedicled flaps) is discarded during dissection and delicate hemostasis is performed.

Surgical angiogenesis: a new approach to maintain osseous viability in xenotransplantation.

BACKGROUND: Large segmental osseous defects are challenging clinical problems. Current reconstructive methods, using non-viable allografts, vascularized autografts or prostheses have significant rates of serious complications and failure. These include infection, stress fracture and non-union (frozen structural allogenic bone); loosening and implant failure (prosthetic replacement); limited availability, poor match of size and shape and donor site morbidity (vascularized autograft bone). In the future, microvascular transplantation of living allogenic or xenogenic bone could solve some of these issues, combining the advantages of living bone autografts (capability of primary osseous healing, remodeling, and fracture resistance) with the ability to match size and shape, provide immediate stability and avoid donor site morbidity. Xenotransplants would be particularly attractive, as they could be readily available, if long-term bone survival could be achieved without unacceptable morbidity. Here, we present a preliminary study to evaluate a new and unique method to maintain xenogenic bone circulation without need for long-term immune modulation that depends upon generation of a neo-angiogenic circulation within the transplanted bone from recipient-derived vessels. Thus, only short-term immunosuppression would be required to achieve bone survival. METHODS: One hundred and forty-one hamster femora were microsurgically transplanted to rats, restoring nutrient vessel circulation with standard microvascular anastomoses. At the same time, a host-derived arteriovenous bundle (AVB) was placed within the medullary canal. Two independent variables were evaluated: use of tacrolimus/cyclophosmamid immunosuppression (IS) and patency of the implanted AVB. Rats were therefore randomized to four groups; group 1-no IS + patent AVB; group 2-no IS + ligated AVB; group 3-IS + patent AVB; group 4-IS + ligated AVB. Rats were sacrificed after 1 or 2 weeks. We evaluated bone blood flow (microsphere entrapment), neoangiogenesis (microangiography and quantification of capillary density), bone necrosis rate (osteocyte counts) and nutrient pedicle rejection (microsurgical anastomotic patency). Statistical Analysis was performed with two-way ANOVA with Bonferroni adjustment. Differences were considered significant when P < 0.05. RESULTS: Capillary density was significantly increased with a patent intramedullary AVB (groups 1/3) compared to groups with ligated AVBs (groups 3/4). Capillary sprouting was predominantly restricted to the endosteal layer. Most nutrient pedicles (78.7%) stayed patent in groups with IS (groups 3 and 4). Consequently, bone blood flow was significantly higher in groups 3 and 4 compared to groups 1 and 2. Similarly, a patent AV bundle improved flow in group 1 when compared to group 2. The bone necrosis rate was not influenced by the presence of patent AVBs but was significantly reduced in groups 3 and 4. CONCLUSIONS: Surgical angiogenesis occurs when patent arteriovenous bundles are placed in the medullary canal of xenogenic bone and leads to increased bone blood flow. Bone viability was not significantly influenced by neoangiogenesis. Although capillary sprouting was restricted to the endosteal layer in this short term study, more complete cortical revascularization might be observed in a long-term study. Such a study should further evaluate whether these new vessels supply sufficient blood flow to maintain long-term bone viability and allow remodeling.

Host-derived neoangiogenesis with short-term immunosuppression allows incorporation and remodeling of vascularized diaphyseal allogeneic rabbit femur transplants.

The purpose of this study was to demonstrate that living bone allotransplants can incorporate, remodel, and maintain mechanical properties without long-term immunosuppression in a fashion comparable to living autotransplants. For this, viability is maintained by repair of nutrient vessels and neovascularization from implanted host-derived vasculature. Microsurgically revascularized femoral diaphysis allotransplants were transferred from young male New-Zealand-White (NZW) into 4 groups of male Dutch-Belted (DB) rabbits. Short-term immunosuppression by tacrolimus (IS, groups 4 and 5) and host-derived neovascularization (NV) from implanted fascial flaps was used to maintain viability (groups 3 and 5) as independent variables. Group 2 received neither IS nor NV. Vascularized pedicled autotransplants were orthotopically transplanted in group 1. After 16 weeks, transplants were evaluated using radiologic, histologic, biomechanical, and histomorphometric parameters. Vascularized bone allotransplants treated with both short-term IS and host-derived NV (group 5) healed in a fashion similar to pedicled autotransplants (group 1). Their radiographic scores were higher than other groups. Groups with patent fascial flaps (3 and 5) showed significantly greater neoangiogenesis than ligated controls (2 and 4). Tacrolimus administration did not affect neoangiogenesis. Elastic modulus and ultimate stress were significantly greater in autogenous bone than in allotransplanted femora. Biomechanical properties were not significantly different among allotransplants. Bone turnover was decreased with IS, but increased with NV by the implanted fascial flaps. Living allogeneic femoral allotransplants treated with short-term IS and host-derived neoangiogenesis can lead to stable transplant incorporation in this rabbit model. The combination of both factors optimizes bone healing. Transplant mineralization is improved with neoangiogenesis but diminished with IS.

Early free active versus dynamic extension splinting after extensor indicis proprius tendon transfer to restore thumb extension: a prospective randomized study.

PURPOSE: Transfer of the extensor indicis proprius tendon to the distal extensor pollicis longus (EPL) tendon is a standard operation to restore thumb extension. However, several postoperative hand therapy regimens exist. The previously described early dynamic extension splinting protocol has become our standard, and we now compare it with an early active protocol in a prospective randomized study. METHODS: Twenty-one patients with a closed EPL tendon rupture in zones T4 and T5 were treated with an extensor indicis proprius tendon transfer and were randomly divided into 2 postoperative physical therapy regimens: one group (DY) was treated with a dynamic protocol using a rubber-band system, and the other group (AC) was allowed an early active thumb extension with limited flexion. All patients were evaluated for active range of motion (ROM) of the thumb and for grip and tip-pinch strength 3, 4, 6, and 8 weeks postoperatively. Long-term outcomes were not evaluated. RESULTS: Three weeks postoperatively, DY group patients demonstrated a significantly better active ROM in the interphalangeal joint than that of the AC group patients. DY group patients achieved 72% of contralateral joint active ROM compared with 49% of contralateral joint active ROM achieved in the AC group. However, no significant difference was found during further course of study resulting in a final mean interphalangeal joint active ROM of 69 degrees (range, 45 degrees to 110 degrees) in group DY and of 58 degrees (range, 40 degrees to 75 degrees) in group AC. The mean grip strength and tip-pinch strength did not differ significantly after 8 weeks with patients achieving 66% and 73%, respectively, of the contralateral side in group DY and 63% and 71%, respectively, of the contralateral side in group AC. Three complications--one due to rupture (DY group), one due to adhesion, and one due to inadequate joint motion secondary to poor tendon tensioning at the time of initial surgery (both AC group)--occurred during a 1-year follow-up. CONCLUSIONS: Considering the small group sizes, both regimens (dynamic vs early active) achieved comparable clinical results. The early active protocol does not have a notably higher complication rate but fails to accelerate rehabilitation. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic III.

Isometric tetanic force measurement method of the tibialis anterior in the rat.

Tetanic force measurements of rat tibialis anterior (TA) muscles have been described, but with a variety of stimulation parameters. This study presents a novel functional method of force measurement of the rat TA muscle and describes the optimization of stimulation parameters. Bilateral TA muscles in 10 male Lewis rats were attached to a force transducer after the corresponding hindlimb was fixed. Preload, stimulus intensity, duration, and frequency were optimized for each individual muscle and the isometric maximal tetanic muscle force was measured. The mean left side tetanic force as a percentage of the right was 100.0 +/- 4.4% and was statistically equivalent. Large standard deviations between sides (35-50%) were observed in the optimized parameters (preload, stimulus intensity, duration, and frequency). Optimization of the variables affecting isometric tetanic force resulted in reproducible and reliable side-to-side measurements of the TA muscle in the rat model.

Transplantation of a vascularized rabbit femoral diaphyseal segment: mechanical and histologic properties of a new living bone transplantation model.

A new vascularized bone transplantation model is described, including the anatomy and surgical technique of isolating a rabbit femoral diaphyseal segment on its nutrient vascular pedicle. The histologic and biomechanical parameters of pedicled vascularized femoral autotransplants were studied following orthotopic reimplantation in the resulting mid-diaphyseal defect. Vascularized femur segments were isolated in 10 rabbits on their nutrient pedicle, and then replaced orthotopically with appropriate internal fixation. Postoperative weightbearing and mobility were unrestricted, and the contralateral femora served as no-treatment controls. After 16 weeks, the bone flaps were evaluated by x-ray (bone healing), mechanical testing (material properties), microangiography (quantification of intraosseous vasculature), histology (bone viability), and histomorphometry (bone remodeling). Bone healing occurred by 2 weeks, with further callus remodeling throughout the survival period. Eight transplants healed completely, while two had a distal pseudarthrosis. Microangiography demonstrated patent pedicles in all transplants. Intraosseous vessel densities were comparable to nonoperated (control) femora. We found ultimate strength and elastic modulus to be significantly reduced when compared to normal controls. Viable bone, increased mineral apposition rate, and bone turnover were demonstrated in all transplants. The method described, and the data provided will be of value for the further study of isolated segments of living bone, and in particular, for investigations of reconstruction of segmental bone loss in weight-bearing animal models. This study also provides important normative data on living autologous bone flap material properties, vascularity, and bone remodeling. We intend to use this method and data for comparison in subsequent studies of large bone vascularized allotransplantation.

The superficial inferior epigastric artery fascia flap in the rabbit.

In reconstructive surgery, fascial flaps provide thin, pliable tissue for mucosal closure or serve as a highly vascularized support for skin grafts. Their angiogenic potential is used for experimental neovascularization of avascular tissue grafts. However, most fascial flaps in animal surgery have random pattern design with short reach. As a pilot study for a femur revascularization project in rabbits, a new axial fascial flap is described based on the superficial inferior epigastric (SIE) vessels. They were used in this species previously only as ligated bundles or in fasciocutaneous flaps. The topographical anatomy of the SIE-vessels, lower abdominal fascia, and panniculus carnosus are outlined. The angiogenic capabilities are demonstrated microangiographically by abundant vessel formation in a femur allograft. Used in a pedicled fashion, this flap is an alternative to femoral and saphenous vessels for prefabrication or revascularization procedures in the lower abdomen, genital area, and thigh. Distant recipient sites seem possible with microsurgical transfer.

Severe tacrolimus toxicity in rabbits.

OBJECTIVES: Tacrolimus is an effective immunosuppressant, safely administered in clinical practice by monitoring blood levels. In experimental transplants, many dosage regimens have been reported, often without such determinations. Anorexia and organ toxicity commonly occur. We report the toxic effects of tacrolimus in rabbits receiving intramuscular injections (1 mg/kg/d) and the subsequent dosage modifications that resulted in improved animal survival without toxic effects. MATERIALS AND METHODS: To obtain nontoxic drug concentrations in the blood, 3 dosage regimens were required. Drug concentrations were targeted using therapeutic human values as a guide (range, 5-20 ng/mL). First, a group of 12 Dutch-Belted rabbits received vascularized femoral allografts and were treated with intramuscular dosages of tacrolimus (1 mg/kg/d) for 14 days. Subsequently, dosage reductions in 10 more rabbits, to 0.2 mg/kg/d for 14 days, were necessary. Finally, another group of 20 rabbits was treated with 0.08 mg/kg for 3 days, and then every other day thereafter. Weight loss > 30%, cardiopulmonary failure, and/or creatinine levels > 221 micromol/L were the criteria approved by our local Institutional Animal Care and Use Committee for euthanizing the animals. Treated animals were compared with 20 nonimmunosuppressed controls that underwent the same operation. RESULTS: At an intramuscular dosage of 1 mg/kg/d, the mean tacrolimus blood level was 90.7 ng/mL. Ten of the 12 animals in the original group died or required euthanasia. At necropsy, renal failure, cardiac abnormalities, and pulmonary edema were found. The tacrolimus dosage of 0.2 mg/kg/d produced a mean tacrolimus blood level of 17.6 ng/mL; however, 8 of the subsequent 10 rabbits died when given this dosage. Ultimately, the 0.08 mg/kg regimen in 20 rabbits permitted survival of 18 animals with a mean tacrolimus blood level of 6.8 ng/mL. None of 20 nonimmunosuppressed controls died after surgery. CONCLUSIONS: For successful immunosuppression, Dutch-Belted rabbits require intramuscular tacrolimus dosages lower those required in other rabbit breeds. This has not been reported previously. The 0.08 mg/kg/d dosage combined with intermittent drug level monitoring permits survival without significant complications.

Primary and secondary procedures in functional and aesthetic reconstruction of noma-associated complex central facial defects.

BACKGROUND: Most defects resulting from noma involve the lateral and anterolateral aspects of the face and are often combined with severe functional deficits. A subgroup, commonly called "central noma," is composed of defects of the upper lip, maxillary soft tissues, premaxilla, nasal cartilaginous infrastructure, and soft tissues. In contrast to unilateral involvement of the face, central noma does not affect opening of the jaw; however, it results in severe mutilation, with disfiguring three-dimensional defects erasing any individual traits from a face. The common surgical approach to centrofacial noma defects has been single-stage reconstructive procedures using locoregional flaps, but this approach often leads to disappointing outcomes in complex cases. METHODS: The authors' concept for complex central noma defects is a staged approach using free flaps for soft-tissue reconstruction of the upper lip and maxillary vicinity. This approach serves as a versatile base for introducing locoregional flaps for later functional and aesthetic refinements. A secondary procedure includes total nose reconstruction with a free cartilage framework and forehead flaps. RESULTS: In this series (n = 53), free radial forearm (n = 4), anterolateral thigh (n = 1), and parascapular (n = 7) flaps proved suitable for the central face in terms of pedicle length, tissue pliability, and bulk. All free flaps survived completely. Three total nose reconstructions by forehead flaps were performed successfully as a secondary step. CONCLUSION: Being of limited use for subtotal or total reconstruction of the outer nose, microvascular tissue transfer preserves local and regional donor sites--particularly the forehead--for secondary reconstruction.