Modified extraperitoneal endoscopic separation of parts for abdominal compartment syndrome.

BACKGROUND: Standard therapy for abdominal compartment syndrome (ACS) is laparotomy and temporary abdominal wall closure with significant morbidity. The component separation technique allows for difficult abdominal closure. We studied a modified extraperitoneal endoscopic separation of parts technique on an animal model of ACS. METHODS: Twelve anesthetized pigs were instrumented for measurement of central venous pressure, arterial pressure, pulmonary artery pressure, pulmonary capillary wedge pressure, cardiac output, and intraabdominal pressure (IAP). ACS to 25 mmHg was created by infusing saline into an intraabdominally placed bag. Animals were divided in two equal groups. Pigs in group A underwent minimally invasive resection of the nerves supplying the rectus muscles bilaterally. Pigs in group B underwent minimally invasive modified component separation technique bilaterally. Change in IAP and other physiological parameters were recorded. RESULTS: (Group A) IAP increased significantly from 7.3 mmHg +/- 3.8 to 25.2 mmHg +/- 1.5 with infusion of saline. Following nerve transection on the right side there was a nonsignificant decrease in IAP from 25.2 mmHg +/- 1.5 to 22.3 mmHg +/- 1.4 and following nerve transection on the left side there was a further decrease in IAP to 20.3 mmHg +/- 1.9. (Group B) IAP increased significantly from 3.8 mmHg +/- 0.4 to 24.7 mmHg +/- 0.5 with infusion of saline. Following separation of parts on the right side there was a significant decrease in IAP from 24.7 mmHg +/- 0.5 to 15.0 mmHg +/- 1.7 and there was a further decrease in IAP to 11.3 mmHg +/- 1.4 following separation of parts on the left side. The only significant change in the physiological parameters measured was observed in CVP in both groups. CONCLUSION: We present a porcine model of extraperitoneal endoscopic release of abdominal wall components as a treatment option for ACS.

Soft-tissue reconstruction for recalcitrant diabetic foot wounds.

Thirty-three consecutive patients with plantar soft-tissue defects were managed by a single surgeon (EDN) with reconstruction by a medial plantar artery (MPA)-based flap. Foot defects resulted from a combination of abnormal weightbearing distribution and neuropathy secondary to diabetes mellitus in all patients. A retrospective study of diabetic patients from 1984 to 1997 with foot defects reconstructed with a MPA-based flap were reviewed. Thirty-three patients (age 55 +/- 9) with an average tissue deficit of 13 +/- 9 cm2 had MPA reconstruction of the heel (n = 8), midfoot (n = 23), and forefoot (n = 2). The mean follow-up was 19 months (range, 3 months-5 years). There were four minor complications, including marginal flap necrosis or localized infection, although all healed uneventfully. There were six major complications resulting in loss of the flap and proximal amputation. Out of seven patients, there were 12 rerotations of the previously rotated flap. Various techniques for reconstruction of plantar foot defects have been described in the literature. Utilizing glabrous skin for reconstruction of these defects is appealing for its unique shear and pressure-resisting properties. Surgical management of diabetic foot defects with the medial plantar artery flap is an effective means of soft tissue reconstruction.

Free vascularized bone graft.

This article reviews free vascularized bone grafts. Indications for use, advantages, and disadvantages of free vascularized versus nonvascularized bone grafts as well as applications to foot and ankle surgery are presented. A single case report is also presented.

Aggressive use of free flaps in children for burn scar contractures and other soft-tissue deficits.

Free flap reconstruction in children is often undertaken with trepidation due to a variety of perceived technical difficulties and variable reports of success. The present report examines the efficacy of free tissue transfer in children, with particular attention given to the use of fasciocutaneous flaps in burn reconstruction. Over a 12-year period, 38 free flaps were done on 30 patients with an average age of 10 years (range, 16 months-17 years). Twenty-five flaps were done for burn deformities; 6 were done for chronic back wounds; 2 each were done for chronic lower extremity wounds, lower extremity traumatic defects, and a craniofacial deformity; and 1 flap was done following the resection of a large thigh vascular malformation. The vast majority of the flaps (84%) were fasciocutaneous: 13 groin, 9 scapula, 5 radial forearm, and 4 others. The mean hospital stay was 10 days and there were 11 major complications (29%). Five of 6 flaps were salvaged by reoperation following vascular thrombosis. Six flaps were unsuccessful (84% total success). Three of these flaps were aborted intraoperatively due to technical difficulties, while 3 others were lost postoperatively due to cellulitis, thrombosis, and patient-inflicted flap removal. During follow-up (range, 1-103 months), 39% of patients underwent a minor secondary revision of the flap reconstruction. This series demonstrates the efficacy of free tissue transfer in children in providing the majority of these patients with a successful, one-stage reconstruction with morbidity similar to that reported for adult patients. Moreover, the use of fasciocutaneous free flaps for pediatric burn reconstruction is shown to provide a durable and aesthetically superior treatment of these difficult problems.

Liposuction-assisted revision and recontouring of free microvascular tissue transfers.

Liposuction has become a widely accepted and utilized technique that allows the aesthetic surgeon to improve regional definition and contour. Although the techniques of liposuction have now been extended to a variety of noncosmetic procedures as well, the application of this technique in the area of reconstructive surgery has lagged. To ascertain the applicability and effectiveness of liposuction for the revision of free microvascular tissue transfers we undertook a retrospective analysis of our free flap reconstruction cases that were revised and recontoured using liposuction. From this review of 12 cases we found liposuction to be a safe and effective technique for the delayed revision of free flap reconstructions of the head and neck region and lower extremity.

Free-tissue transfer in elderly patients.

A retrospective survey was undertaken to evaluate the success of free-tissue transfer (free flap) in the elderly. During a 70-month period, 199 free flaps were performed in 151 patients at the Western Pennsylvania Hospital, 60 of these involving 47 patients over the age of 60. Primary coverage rates differed significantly between the elderly and younger age groups (68.5 versus 85.3 percent, respectively); however, eventual coverage rates (92.6 versus 96.3 percent), minor complication rates (34.0 versus 34.6 percent), mortality rates (2.1 versus 1.0 percent), flap revision rates (32 percent of patients versus 30 percent), and length of postoperative hospitalization (18.7 versus 18.8 days) were not significantly different in the two groups. Among the elderly, significant increases in flap loss rates were noted with the use of end-to-side arterial anastomosis, placement of the anastomosis within a zone of injury, and the use of the gracilis muscle donor site. Our data suggest that the primary cause of free-flap failure is construction of the anastomosis within a zone of injury. Free-tissue transfer is a valuable option in the repair of tissue defects in the elderly and should not be denied as a treatment because of patient age.

Transparent polyurethane (Omiderm) dressing for free flaps.

A transparent polyurethane dressing (Omiderm) for free flaps is presented. Considering the importance of reliable flap monitoring postoperatively, this synthetic membrane allows for constant ability to observe the flap, assess the capillary filling, and detect the blood flow with an ultrasound Doppler device.

Reconstruction of complex maxillectomy defects with the scapular-free flap.

The defect resulting from partial or complete maxillectomy can often be reconstructed with a skin graft and a prosthesis. In situations where this simple maneuver is unsatisfactory, a more complex reconstructive modality, providing the restoration of composite tissue, is required. The scapular microvascular-free flap was used in this series of 11 patients, as a cutaneous flap in 3 and as an osteocutaneous flap in 8, to meet the specific reconstructive needs of each patient. Excellent to satisfactory restoration of facial contour and palatal function was achieved in 10 patients. There was 1 flap failure. There were no donor site complications. Selected case histories are presented to demonstrate a spectrum of reconstructive problems. There are clear limitations to its applicability, such as the odd scapular bone contour, the thickness of the cutaneous paddle, the position change required for flap harvesting, and the risk of flap failure. The scapular flap has proven to be useful in restoring bony and soft tissue contour of the face, rigid support for the velum, oronasal separation, support for the orbit, and obliteration of the maxillary sinus. We found the scapular-free flap to be a useful tool for reconstructing complex and variable maxillectomy defects.

Expanding the horizons in treatment of severe peripheral vascular disease using microsurgical techniques.

The use of microvascular tissue transfer as an adjunct to arterial reconstruction has begun to have a positive impact on limb salvage in patients with advanced arteriosclerosis and nonhealing ischemic wounds. However, many patients with severe peripheral vascular insufficiency not amenable to conventional arterial reconstructive procedures eventually require limb amputation. We have treated 12 patients with advanced peripheral vascular disease and nonhealing ischemic wounds by three different methods. These included distal bypass alone, distal bypass done in conjunction with free-tissue transfer, and free-tissue transfer alone. All bypass grafts were done to vessels at or below the ankle using a reversed saphenous vein. In each case, the distal anastomosis was performed, using the operating microscope and standard microvascular technique. Mean follow-up for these patients is 18 months. Distal bypass alone resulted in limb salvage in three of five patients. In the combined bypass and free-flap group, three of five patients had salvage of their threatened extremity at a 1-year follow-up. Two patients with ischemic ulcers, rest pain, and unsuitable distal vessels for bypass were treated with free-tissue transfer alone. This resulted in healed wounds, limb salvage, and complete resolution of the rest pain symptoms in both patients. When advanced ischemia is complicated by large areas of tissue loss, combined bypass and microvascular free-issue transfer, performed in stages or simultaneously, is safe and can often result in limb salvage. In the rare instance of a completely obliterated distal runoff bed, free-tissue transfer alone may provide not only a healed wound, but also a means of "indirect" revascularization of the extremity and limb salvage.

Fasciocutaneous island flap based on the medial plantar artery: clinical applications for leg, ankle, and forefoot.

Soft-tissue deficits over the plantar forefoot, plantar heel, tendo calcaneus, and lower leg are often impossible to cover with a simple skin graft. The previously developed medial plantar fasciocutaneous island flap has been adapted to cover soft-tissue defects over these areas. This fasciocutaneous flap based on the medial plantar neurovascular bundle is capable of providing sensate and structurally similar local tissue. Application of this fasciocutaneous island flap is demonstrated in 12 clinical cases. Successful soft-tissue cover was achieved on the plantar calcaneus (four patients), tendo calcaneus (four patients), lower leg (two patients), and plantar forefoot (two patients). Follow-up ranged from 6 months to 5 years. All flaps were viable at follow-up. Protective sensation was present in 11 of 12 flaps evaluated at 6 months. In addition, all 11 patients were able to ambulate in normal footwear. The medial plantar island flap seems to be more durable than a skin graft, and the donor site on the non-weight-bearing instep is well tolerated. This study demonstrates that the medial plantar fasciocutaneous island flap should be considered as another valuable tool in reconstructive efforts directed at the plantar forefoot, plantar heel, posterior ankle, and lower leg.

Extensive and complex defects of the scalp, middle third of the face, and palate: the role of microsurgical reconstruction.

Twenty-one patients with gigantic defects of the scalp and middle third of the face and palate following excision of neglected or recurrent tumors, burns, and infections have undergone microsurgical reconstruction. Wide resection of the middle third of the face, orbit, and palate requires "complex" three-dimensional volume reconstruction, whereas extensive defects of the scalp and skull (exceeding 80 cm2) require coverage of the larger surface area soft-tissue defect and the exposed brain and dura. The latissimus dorsi free-muscle flap and split-thickness skin graft have become our methods of choice for extensive scalp and skull defects. The latissimus dorsi musculocutaneous free flap is preferable for reconstruction of complex palatal and external skin and orbital defects of the middle third of the face. Microsurgical free-tissue transfer reliably frees the oncologic surgeon from the constraints imposed by conventional reconstructive techniques and may therefore allow improved curative or at least palliative resection of these extensive tumors.

Lymphoma presenting as a salivary gland mass.

A retrospective review of 36 cases of lymphoma presenting as a salivary gland mass was conducted over a 34-year period. A significant increase in the occurrence of lymphoma was noted in proportion to other salivary gland tumors (P less than 0.01, chi 2 analysis: 1954-1972, 11 of 714 (1.5%); 1973-1979, 9 of 201 (4.5%); 1980-1987, 16 of 265 (6.0%). The mean age was 61 years, sex distribution was equal, and 75% occurred in the parotid. Only 42% presented with signs or symptoms other than a painless mass. Glandular excision was done in early stages of the disease while biopsy was done at later stages. Frozen section analysis was accurate in all but one case and was useful in determining if biopsy were adequate. All patients were definitively treated with chemotherapy and/or radiotherapy. Several instructive points are apparent. Any patient presenting with an isolated salivary gland mass can have a lymphoma. There has, in fact, been a significantly increasing proportion of salivary gland lymphoma among the various salivary gland tumors in our patient population. In contrast to other salivary gland tumors, surgery is reserved for diagnosis and not for treatment. A lymph node biopsy may be sufficient to establish a diagnosis, in which case, glandular excision is unnecessary. Most of the patients presented with an asymptomatic isolated salivary gland mass. The presence of adjacent adenopathy, a rubbery feel to the mass, and the intraoperative appearance were the most suggestive signs of lymphoma. Frozen section analysis is helpful in determining the appropriate extent of surgery and is recommended.

Microsurgery for macrodefects: microvascular free-tissue transfer for massive defects of the head and neck.

Despite defect location and the fear of creating complex massive defects, coverage of large areas of soft tissue loss, with or without exposed calvaria, dura, and brain, can be reconstructed reliably with microvascular free tissue transfer. This technique permits separation of the oronasopharynyx from the intracranial contents, coverage of dural grafts, restoration of composite tissue loss, and achievement of superior aesthetic results in a single stage. When choosing vascular anastomotic sites, free-flap transfer permits a greater latitude in flap orientation, tailoring, and inset than is possible when using fixed pedicled rotation flaps. When confronted with a deeply invasive or gigantic malignancy, a multidisciplinary team approach is optimal. The risk associated with sophisticated ablative and reconstructive operative procedures is justified when dealing with potentially curable lesions. The success of these extensive procedures is related not only to the functional result and the aesthetic appearance, but most importantly to the resultant quality of life they allow.

The plantar digital web space island flap for reconstruction of the distal sole.

A neurovascular flap of interdigital web space skin based on the plantar circulation is described. The flap is useful for reconstructing distal plantar defects that do not have an adequate surface for skin grafting. It leaves a donor defect in a non-weight-bearing area and does not disrupt the structural integrity of the foot. The surgical anatomy and operative approach are detailed. The key to the approach is to preserve the fat pad around the neurovascular bundle during the dissection. Six patients have successfully undergone this procedure and have been followed for at least 2 years postoperatively. The plantar island flap is a reliable flap for repairing plantar defects overlying the metatarsal heads.

Scapular free flap for repair of massive lower facial composite defects.

The scapular osteocutaneous free flap provides excellent tissue for reconstruction of massive lower facial defects. Five cases of full-thickness cheek and lip defects associated with mandibular loss were successfully repaired with sandwiched osteocutaneous scapular flaps plus a parascapular or latissimus dorsi flap. In two instances the osteocutaneous scapular flap was harvested along with a parascapular skin paddle. The other three patients had latissimus dorsi myocutaneous units taken with the scapular osteocutaneous flap from the same subscapular pedicle.

Split jejunal free-tissue transfer in oropharyngoesophageal reconstruction.

From January 1, 1981 to July 1, 1981, ten patients underwent immediate reconstruction utilizing split jejunal free-tissue transfers following resection of large oropharyngeal neoplasms. All 10 flaps were successfully transferred. Three patients were irradiated preoperatively and six patients were irradiated 2 to 3 weeks postoperatively. Nine patients were available for follow-up until their death from 10 to 39 months postoperatively (average 26 months). All but two patients died of their original tumor. Six of the nine patients had a good early functional result; taking semisoft or soft diets allowed them to maintain or gain weight. Three patients had poor early results with limited oral feedings due to repeated aspiration in two and severe gastroesophageal reflux in another. Postoperative graft biopsies were obtained in five patients, showing normal mucosa or mild chronic inflammation histologically even following irradiation. Postoperative barium studies showed varying degrees of graft peristalsis. Complication rates were acceptable, and donor-site morbidity was minimal. Neither preoperative nor postoperative radiation affected the viability of the grafts. Therefore, this technique should continue to find application as a reliable method of providing like tissue for reconstructing a variety of large oropharyngeal defects.

The osteocutaneous scapular flap for mandibular and maxillary reconstruction.

Microfil injections in 8 cadavers and clinical experience with 26 patients have demonstrated a reliable blood supply to the lateral border of the scapula based on branches of the circumflex scapular artery. This tissue has been used successfully for reconstruction of a variety of defects resulting from maxillectomy and mandibular defects from cancer and benign tumor excisions. Advantages of this tissue over previous reconstructive methods include the ability to design multiple cutaneous panels on a separate vascular pedicle from the bone flap allowing improvement in three-dimensional spatial relationships for complex mandibular and maxillary reconstructions. The lateral border of the scapula provides up to 14 cm of thick, straight corticocancellous bone that can be osteotomized where desired. The thin blade of the scapula provides optimum tissues for palate and orbital floor reconstruction. There have been no flap failures and minimal donor-site complications.