Increased salvage rates with early reexploration: A retrospective analysis of 547 free flap cases.

BACKGROUND: Free flap complications are generally rare, but not negligible since they may exert paramount impact on both patients and care providers. The aim of the study was to identify risk factors for reexploration and assess predictors associated with increased salvage rates. METHODS: A retrospective cohort study was conducted for free flaps performed between 2006 and 2015. Patient demographics, indications and flap types were analyzed together with complications and time to reexploration. RESULTS: Among 547 consecutive free flaps, 11.5% required acute reexploration. Hematoma together with vascular compromise was the main cause (41.9%) for reexploration, followed by hematoma only (19.4%), venous (16.1%) and arterial (6.5%) thrombosis. Hematoma was associated with an increased risk for concomitant vascular complication (p < 0.02). The incidence of total and partial flap necrosis was 3.5% and 3.7% respectively. There was an overall 71.4% salvage rate. The median time from detection of a compromised flap to reexploration was 3.0 h. Significantly higher salvage rates were observed for cases reexplored within (82.4%) compared to after (57.1%) 3.0 h (OR 3.50 (95% CI 1.10 to 11.13, p = 0.034)). CONCLUSIONS: The current study highlights the importance of early intervention, including evacuation of hematomas that may lead to vascular compromise. Adequate monitoring of venous outflow was found necessary to improve flap salvage rates, whereas arterial complications were mainly related to persistent arterial injury in traumatized extremities with reduced salvage rates. Free flap surgery requires trained staff and immediate access to operating facilities to ensure high flap survival rates.

Perspective on contemporary burn surgery and burn care in Sweden.

Burn surgery has gone through revolutionary changes during the last century, even the most severe burns can now be safely treated. Modern surgical treatments have been followed by improvements in intensive burn care and anaesthesiology. These developments have allowed immediate surgery within 24 hours of the injury to take place in our centre, therefore obtaining advantageous results in shortening hospital stay, improving patient's functional results and simplifying the treatment itself. This treatment is economically beneficial as well. In future we count on rapid development of a new discipline, tissue engineering, which should take a greater role in burn care.

Changes in a rat facial muscle after facial nerve injury and repair.

This study describes changes in a rat facial muscle innervated by the mandibular and buccal facial nerve branches 4 months after nerve injury and repair. The following groups were studied: (A) normal controls; (B) spontaneous reinnervation by collateral or terminal sprouting; (C) reinnervation after surgical repair of the mandibular branch; and (D) chronic denervation. The normal muscle contained 1200 exclusively fast fibers, mainly myosin heavy chain (MyHC) IIB fibers. In group B, fiber number and fiber type proportions were normal. In group C, fiber number was subnormal. Diameters and proportions of MyHC IIA and hybrid fibers were above normal. The proportion of MyHC IIB fibers was subnormal. Immediate and delayed repair gave similar results with respect to the parameters examined. Group D rats underwent severe atrophic and degenerative changes. Hybrid fibers prevailed. These data suggest that spontaneous regeneration of the rat facial nerve is superior to regeneration after surgical repair and that immediacy does not give better results than moderate delay with respect to surgical repair. Long delays are shown to be detrimental.

Repair of the mandibular branch of the rat facial nerve through transmedian grafting in one or two stages. Functional evaluation.

A previous study examined the morphological outcome of axonal regeneration in the mandibular branch (ramus marginalis mandibulae) of the rat facial nerve after transmedian nerve grafting in one or two stages. The present study supplements the morphological data with a functional evaluation. Recordings of the force of tetanic muscle contractions elicited through stimulation of the mandibular branch showed that upper and lower lip data obtained from animals grafted in one stage did not differ significantly from control data. However, animals grafted in two stages exhibited significantly lower muscle forces compared to one-stage data and to control data. Electromyographic recordings of the M-response showed multiple prolonged potential fluctuations with subnormal amplitudes in grafted cases. In both groups of grafted rats, the mean voltage amplitudes recorded from the upper lip were weaker than the amplitudes seen at the angle of the mouth or the lower lip. The two-stage cases exhibited the most obvious deficit. In conclusion, the present results show that, with respect to the functional restoration achieved three months after nerve injury, repair through transmedian grafting in one stage gives better results than repair in two stages. This finding, which conforms with previous morphological data, suggests that the one-stage procedure should be considered for clinical use.

Monolingual and bilingual children's use of the mutual exclusivity constraint.

The use of the mutual exclusivity constraint was examined in three-year-old and six-year-old children who were either monolingual in English (N = 32) or bilingual in English/Urdu (N = 32) or in English/Greek (N = 32). Three tests of the constraint were used: disambiguation rejection, and restriction. On the disambiguation test, the mutual exclusivity bias was significantly more evident in five- and six-year-old monolingual children than in their same-age bilingual peers. Monolingual children were also more likely than bilingual children to reject a new name for a familiar object. However, using a restriction test, neither monolingual nor bilingual children readily accepted and restricted typical names for hybrid objects. Developmental differences were also found, as older (five- to six-year-old) monolingual children's responses on the tests were generally more consistent with the constraint than younger (three- to four-year-old) children's responses. Nevertheless, bilingual children did use the constraint, but not to the extent of monolingual children.

Repair of the mandibular branch of the rat facial nerve through transmedian grafting in one or two stages. Morphological evaluation.

This study examined by electron microscopy the normal fibre composition of the mandibular branch (MB) of the rat facial nerve and the outcome of axon regeneration in the MB after transmedian grafting in one or two stages. The average normal MB contained 2,185 axons, 17% of which were unmyelinated. The myelinated axons had a unimodal diameter distribution (range 1.5-9.5 microns, mode 4.5 microns). After superior cervical ganglionectomy, the MB lost 1/3 of the C-fibres and 10% of the myelinated axons. In neonatally capsaicin-treated rats the occurrence of unmyelinated axons was reduced by about 50%. After repair in one or two stages the MB contained more myelinated and unmyelinated axons than normal. The myelinated axons showed a unimodal size distribution with a subnormal diameter range. Statistical comparisons showed that MBs from both experimental groups were significantly abnormal with respect to total axon number as well as numbers of unmyelinated and myelinated axons. In these respects the grafted MBs did not differ significantly from each other. However, the myelinated axons in MBs from one-stage cases showed larger mean and maximum diameters compared to MBs from two-stage cases. These data suggest that the normal MB of the rat contains myelinated and unmyelinated sympathetic axons and that about half the C-fibres in the normal MB come from capsaicin-sensitive sensory neurons. The comparison of the two reparative procedures used provides evidence in favor of the one-stage alternative.