Treatment of difficult TRAM flap hernias using intraperitoneal synthetic mesh application.

The authors report the successful repair of large lower abdominal hernia defects after transverse rectus abdominis muscle (TRAM) flap breast reconstruction in 11 patients using a technique of intraperitoneal application of synthetic polypropylene (Prolene) mesh anchored to the peritoneal surface of the abdominal wall tissues. Five of these patients had previously failed hernia repairs after a unipedicle TRAM flap breast reconstruction employing the onlay mesh technique, with two of the patients having undergone three previous hernia repairs. The other six patients had developed large hernias after bipedicle TRAM flap reconstruction without previous mesh supplementation of the abdominal wall repair. After their successful hernia repairs, all of the patients healed without difficulty and demonstrated no sign of recurrence in an 8 to 36-month follow-up. Each patient returned to her activity level before breast reconstruction.

The separation of anatomic components technique for the reconstruction of massive midline abdominal wall defects: anatomy, surgical technique, applications, and limitations revisited.

Reconstruction of massive abdominal wall defects has long been a vexing clinical problem. A landmark development for the autogenous tissue reconstruction of these difficult wounds was the introduction of "components of anatomic separation" technique by Ramirez et al. This method uses bilateral, innervated, bipedicle, rectus abdominis-transversus abdominis-internal oblique muscle flap complexes transposed medially to reconstruct the central abdominal wall. Enamored with this concept, this institution sought to define the limitations and complications and to quantify functional outcome with the use of this technique. During a 4-year period (July of 1991 to 1995), 22 patients underwent reconstruction of massive midline abdominal wounds. The defects varied in size from 6 to 14 cm in width and from 10 to 24 cm in height. Causes included removal of infected synthetic mesh material (n = 7), recurrent hernia (n = 4), removal of split-thickness skin graft and dense abdominal wall cicatrix (n = 4), parastomal hernia (n = 2), primary incisional hernia (n = 2), trauma/enteric sepsis (n = 2), and tumor resection (abdominal wall desmoid tumor involving the right rectus abdominis muscle) (n = 1). Twenty patients were treated with mobilization of both rectus abdominis muscles, and in two patients one muscle complex was used. The plane of "separation" was the interface between the external and internal oblique muscles. A quantitative dynamic assessment of the abdominal wall was performed in two patients by using a Cybex TEF machine, with analysis of truncal flexion strength being undertaken preoperatively and at 6 months after surgery. Patients achieved wound healing in all cases with one operation. Minor complications included superficial infection in two patients and a wound seroma in one. One patient developed a recurrent incisional hernia 8 months postoperatively. There was one postoperative death caused by multisystem organ failure. One patient required the addition of synthetic mesh to achieve abdominal closure. This case involved a thin patient whose defect exceeded 16 cm in width. There has been no clinically apparent muscle weakness in the abdomen over that present preoperatively. Analysis of preoperative and postoperative truncal force generation revealed a 40 percent increase in strength in the two patients tested on a Cybex machine. Reoperation was possible through the reconstructed abdominal wall in two patients without untoward sequela. This operation is an effective method for autogenous reconstruction of massive midline abdominal wall defects. It can be used either as a primary mode of defect closure or to treat the complications of trauma, surgery, or various diseases.

Marriage abdominoplasty expands the mini-abdominoplasty concept.

The marriage of aggressive superwet liposculpture of the abdomen and adjacent anatomic regions with a modification of well-established open surgical techniques to address skin excess and perform muscle plication was used to treat 29 patients presenting for aesthetic abdominal contouring over the past 3 1/2 years. The charts of 57 patients who had aesthetic contouring procedures on the abdomen performed from December of 1994 to July of 1998 were retrospectively reviewed. Fifteen patients underwent suction lipectomy alone, 13 patients were treated with conventional abdominoplasty, and 29 underwent "marriage abdominoplasty." The 29 patients who underwent marriage abdominoplasty presented with deformities marked by excess lower abdominal skin and adipose tissue, with or without muscle laxity (Psillakis types II, III, and IV). Seventeen procedures were performed under local anesthesia with deep conscious sedation on an outpatient surgical basis. In 12 patients, the operation accompanied a hysterectomy, urologic procedure, or additional aesthetic surgical procedure(s) and was done under general anesthesia. Suction aspirates ranged between 540 and 2600 cc (mean, 1160 cc) and were accompanied by lower abdominal skin excision in every case, which was performed predominantly through short and medium-length incisions (mean, 15 cm). Rectus abdominis muscle plication was performed where necessary, using vertical plication of the infraumbilical rectus muscles in 27 patients (93 percent) and full-length plication in two patients (7 percent). All patients demonstrated significantly improved contours and have seemed to manifest less pain when compared with patients treated by full traditional abdominoplasty. Postoperative complications have included upper abdominal skin waviness (2), annoying paresthesias and discomfort persisting for 6 months (1), seroma (1), and marginal skin necrosis with an open wound (1). The latter problem occurred in the only patient who was treated with a revision procedure. Thus, the complication rate was 17 percent (5 of 29 patients). The marriage of aggressive superwet liposculpture of the entire abdomen with standard open surgical techniques used to treat skin excesses and allow abdominal muscle plication where necessary offers the advantage of reduced surgery when compared with full abdominoplasty, while consistently achieving significant contour improvement. This concept is applicable to the majority of patients presenting for the treatment of abdominal deformities and has markedly expanded the application of the mini-abdominoplasty concept.

Endometrioma of the abdominal wall following combined abdominoplasty and hysterectomy: case report and review of the literature.

An unusual case is reported of abdominal wall endometrioma presenting in a lower abdominal scar following a combined hysterectomy and abdominoplasty performed 5 years earlier. Current diagnostic methods and recommended surgical management are outlined.

Breast reconstruction with a pedicled TRAM flap.

Breast reconstruction with the pedicled transverse rectus abdominis myocutaneous (TRAM) flap remains a useful option for most patients seeking autogenous tissue reconstruction. This article emphasizes aesthetic analysis of the opposite breast and tissue requirements as important determinants of the preoperative reconstructive plan and guides for specific procedure selection (unipedicle versus bipedicle). This article succinctly reviews the techniques and tips for flap elevation and inset, designed to produce consistent aesthetic outcomes with pedicled TRAM flap breast reconstruction.

Thermal injuries following TRAM flap breast reconstruction.

Following transverse rectus abdominis musculocutaneous (TRAM) flap breast reconstruction there are predictable sensory changes in both the abdominal skin and the skin of the reconstructed breast. Cutaneous anesthesia and dysesthesias are troublesome and annoying for many patients. More importantly, these sensory changes can lead to burn injury in the uninformed patient. Over the past 9 years 5 of our patients have sustained third-degree burn injuries to the skin following breast reconstruction with the TRAM flap. Four of these occurred while sunbathing while wearing a black bathing suit and one was the result of a direct thermal injury. Two patients sustained injuries to the breast, 2 patients experienced injuries to the abdomen, and 1 patient experienced injuries to both sites. All of these untoward events occurred within the initial 4 months following surgery. Four patients healed with topical wound treatment but 1 patient required a full-thickness skin graft to optimize cosmesis of the reconstructed breast. Patient examples illustrating burn injuries and treatment outcomes are shown. Mechanisms involved are sensory and thermoregulatory loss locally at the anterior abdominal wall and at the reconstructed breast. The reinnervation potential according to experimental and clinical studies is reviewed. There are sensory and thermoregulatory changes in the skin at the donor and recipient site during TRAM flap breast reconstruction. Patients should be carefully informed about these and warned to avoid prolonged contact with hot objects and sun exposure, especially when wearing a dark-colored swimsuit.

Microsurgical reconstruction of the head and neck: interdisciplinary collaboration between head and neck surgeons and plastic surgeons in 305 cases.

Three hundred five microsurgical free flaps have been performed for defects of the head and neck by a team of two head and neck surgeons and two plastic surgeons over a 9-year period, with a success rate of 91.2%. The most common flaps used were the jejunum (89), radial forearm (57), rectus abdominis (48), latissimus dorsi (40), scapular (32), fibula (15), and iliac crest (11). Thirty-three flaps required reexploration for anastomotic thrombosis or hematoma (10.8%), of which 18 flaps were salvaged (54.5%). Thirteen flap failures occurred in 113 patients who had received preoperative irradiation (11.5%), but this was not statistically significant. Seven flaps failed in 20 patients who required an interposition vein graft (35%) and this was statistically significant. Ninety patients (31.5%) developed a major complication other than anastomotic thrombosis or death. Despite postoperative intensive care nursing and monitoring, 18 patients died postoperatively in the hospital (6.3%). The average hospital stay was 21.1 days with a range from 5 to 95 days. During this 9-year time period, various free flaps have evolved as the preferred choice for free flap reconstruction of a specific defect of the head and neck. The latissimus dorsal muscle flap surfaced with a nonmeshed split-thickness skin graft is the optimal free flap for reconstruction of the scalp and skull, whereas a multiple-paddle latissimus dorsi musculocutaneous flap is the best flap for reconstruction of complex defects of the middle third of the face and maxilla. The radial forearm flap and free jejunal transfer have become the preferred choices for intraoral reconstruction and pharyngo-esophageal reconstruction, respectively. There still remains no universally accepted flap for mandibular reconstruction, but the fibular osteocutaneous flap and a reconstruction plate protected by a radial forearm flap have largely superseded the iliac crest and scapular osteocutaneous flaps. Radical resection of tumors of the head and neck with immediate reconstruction by microsurgical free tissue transfer followed by adjuvant radiation therapy provides the best possible chance for cure and functional and social rehabilitation of the patient.

Ischaemia-induced expression of bFGF in normal skeletal muscle: a potential paracrine mechanism for mediating angiogenesis in ischaemic skeletal muscle.

To test the hypothesis that induction of endogenous bFGF can lead to angiogenesis in ischaemic skeletal muscle, we studied the expression of bFGF after transposition of a well-vascularized muscle flap onto an ischaemic hindlimb in the rabbit. The results indicated a marked induction of bFGF mRNA throughout the myoblasts of the well-perfused muscle flap but not the myoblasts of the ischaemic muscle. bFGF protein was detected in the muscle flap, particularly in the myoblasts located closest to a newly formed, adjacent interface, and in the interface itself. In contrast, bFGF expression was not induced after transposition of a well-perfused muscle flap onto healthy muscle tissue. These data provide evidence that the juxtaposition of ischaemic skeletal muscle with healthy mesenchymal tissue triggers an increased expression of bFGF in the myoblasts of the well-perfused muscle. This paracrine induction of bFGF, in turn, leads to increased angiogenesis and regeneration of the ischaemic skeletal muscle.

Subungual keratoacanthoma masquerading as a chronic paronychia.

Subungual keratoacanthoma is a rare, benign tumor of the digits. Patients present with progressive fusiform swelling, erythema, and tenderness, usually affecting a single digit on the radial side of the hand. A cup-shaped lytic lesion of the distal phalanx is a uniform finding on radiography. Delay in diagnosis and misdiagnosis are common because of the rarity of the lesion and difficulties with histological differentiation from subungual squamous cell carcinoma. Accurate diagnosis requires a high index of suspicion, a careful history, and histological evaluation. The natural progression of the disease appears to be continued growth with ongoing destruction of the distal phalanx. Proper treatment involves surgical removal of the mass by curettage and close follow-up for at least 2 years to monitor for local recurrence.

Oromandibular reconstruction using a keel-shaped modification of the radial forearm osteocutaneous flap.

The keel-shaped modification for harvest of the radial forearm osteocutaneous flap has been used to reconstruct 19 oromandibular defects in 18 patients. Fourteen men and 4 women ranging in age from 22 to 72 years have undergone composite mandibular reconstruction, with follow-up ranging from 3 to 36 months. Sixteen patients (17 reconstructions) had resection of advanced malignancies, and 2 patients sustained shotgun wounds. Twelve symphyseal and 7 lateral or posterior defects were reconstructed with donor radius bone ranging in length from 5 to 13.5 cm. Double osteotomies were performed in 7 patients. Two skin paddles were used in 4 patients to provide simultaneous intraoral lining and external skin coverage. The radial forearm osteocutaneous flap is still an excellent choice for oromandibular reconstruction. Anterior and lateral composite mandibular defects were satisfactorily reconstructed both aesthetically and functionally using the keel-shaped modification of the radial forearm flap. Donor-site problems were uncommon and minor, and long-term forearm function was minimally affected. Radius fracture occurred in only 1 patient.

Use of fluorescein to predict survival of a free jejunal transfer after disruption of the arterial pedicle on postoperative day 12.

The arterial pedicle to a free jejunal transfer was inadvertently disrupted on the 12th postoperative day. Intravenous fluorescein indicated viability of the entire jejunal transfer except for a 2 cm diameter area on the antimesenteric border midway between the upper and lower enteric anastomoses. The entire jejunum survived except for the small area which failed to fluoresce; this area was converted to a controlled pharyngocutaneous fistula. Neovascularisation from surrounding, unirradiated tissue can allow survival of a free vascularised jejunal transfer after disruption of arterial inflow as early as 12 days postoperatively.

Soft-tissue reconstruction of craniofacial defects.

This article describes work in the reconstruction of combined midfacial and palatal defects with the use of a latissimus dorsi musculocutaneous free flap with separate skin paddles designed to reconstruct multiple tissue surfaces.

Analysis of lower extremity blood flow in the patient with peripheral vascular insufficiency: a guide for plastic surgeons.

Accurate assessment of lower extremity blood flow is critical in selecting appropriate therapy for patients with peripheral vascular disease and nonhealing wounds. Although physical examination provides an idea about the extent and significance of the disease, further evaluation, including both noninvasive and invasive studies, is routinely obtained. Appropriate studies will provide valuable information about the location and severity of disease, the need for revascularization before definitive wound coverage, and the likelihood of wound healing. A brief overview of vascular laboratory tests, highlighting the values and limitations of each, is presented here.

Breast masses in the augmentation mammaplasty patient: the role of ultrasound.

The detection and evaluation of breast parenchymal abnormalities in the presence of a radiodense implant are often difficult with standard techniques of physical examination and mammography. Breast lesions can be obscured on one or both views by the radiodense implant or concealed within the dense tissue at the prosthesis-breast tissue interface. We investigated the role of ultrasound as an adjunct to mammographic special views, including posterior displacement (Eklund et al.), in previously augmented patients who presented with a clinically palpable mass. The records of 125 consecutive breast augmentation patients seen by us over a 4-year period were retrospectively reviewed. Twenty-six patients presented with a palpable breast abnormality. All 26 patients underwent diagnostic mammograms and sonograms. Findings included 8 parenchymal lesions (4 cysts, 2 fibroadenomas, 1 seroma, 1 breast carcinoma), 8 implant-related irregularities (4 ruptures, 3 bulges, and 1 valve), and normal fibroglandular tissue in 10 patients. Mammography yielded a convincing diagnosis in 7 of 26 patients, whereas ultrasound characterized the abnormality in every case. Ultrasound is a useful adjunct to mammography in evaluating palpable breast abnormalities in the breast augmentation patient. It offers improved visualization of the breast tissue-prosthesis interface, and it is helpful in distinguishing breast parenchymal lesions from palpable irregularities of the implant.

Partial mastectomy and breast reduction as a valuable treatment option for patients with macromastia and carcinoma of the breast.

The essential goals of every reconstructive procedure of the breast are to create a breast mound and establish symmetry. Breast conservation operation is now a widely accepted treatment for carcinoma of the breast. Four patients who presented with macromastia or mammary hypertrophy and a simultaneous carcinoma of the breast were treated by combined partial mastectomy and bilateral breast reduction. Incisions on the breast were made using standard Wise pattern (keyhole) markings. In each instance, the tumor was removed with a generous margin of normal surrounding mammary tissue. Two procedures used the inferior pedicle technique and two were done by resection and transplantation of the nipple. The average mammary tissue resection was 825 grams. All incisions healed primarily and necessary adjuvant chemoradiation was not delayed. Each patient is alive and well without evidence of disease with a follow-up period ranging from seven to 43 months. Postoperatively, the appearance of the breast is esthetically improved and all symptoms related to macromastia have resolved. Advantages of combining these two techniques include improved symmetry, easier postoperative self-examination of the breast and decreased radiation effect noted with larger breasts. Postoperative mammograms have been useful for patient follow-up evaluation. Combined segmental mastectomy and breast reduction represents a valuable treatment option for the patient who presents with macromastia and carcinoma of the breast. The carcinoma ablative procedure is not compromised and the improved symmetry of the breast has resulted in an excellent cosmetic outcome in these patients.

The cervicopectoral rotation flap--a valuable technique for facial reconstruction.

Four cases of lower cheek reconstruction using the cervicopectoral rotation-advancement flap are reported. This fasciocutaneous flap can be raised quickly, provides excellent colour and texture match for the tissues of the face, and donor site morbidity is minimal. It is an especially useful method for lower cheek reconstruction following wide excision of melanomas of the cheek and for advanced parotid tumours where skin replacement is required following resection.

Silicone implant rupture: detection with US.

The authors evaluated the ability of ultrasound (US) in detection of silicone implant ruptures and compared US detection with that of mammography and physical examination in 22 women with 29 sites of implant leakage. On sonograms, leaks were evident from a highly echogenic pattern of scattered and reverberating echoes with loss of detail posterior to the echogenic area. The area appears as a "snowstorm" and has a well-defined anterior margin but a poorly defined posterior margin. Twenty-five sites in 19 women were surgically confirmed. Mammograms obtained with various views and sonograms were available for comparison in 20 of 25 surgically confirmed leaks. Of all 29 leaks, 14 were detected at physical examination as palpable masses. Six of these 20 leaks were not detected with mammography. With US, only one leak was not detected. US allowed more accurate prediction of the extent of free silicone in the breast and enabled detection of silicone within axillary nodes. Recognition of the characteristic highly echogenic sonographic appearance of microglobules of free silicone in the soft tissues can improve detection of implant rupture.

Vascularized free-tissue transfer in head and neck surgery.

Microsurgical vascularized free-tissue transfer has had a dramatic impact on the field of head and neck reconstruction. This technique has extended the extirpative limits of resection by facilitating complex reconstruction of head and neck defects in one stage with very high success and minimal patient morbidity. Although its impact on improving cure rates and survival statistics has yet to be determined, it has proven very valuable in the palliation of patients with advanced malignancies. The horizons for future applications are infinite. Neurotization of free-flap transfer may potentially improve the functional outcome for patients. In the future, free flaps may be prefabricated to allow for improved mandibular reconstruction or tracheal reconstruction. These tissue composites may potentially be a vehicle through which adjuvant therapy can be better delivered to the tumor bed. Microsurgical free-tissue transfer will have an expanding role in the treatment of patients with head and neck tumors, and continued refinements in these techniques will open new vistas for the reconstructive surgeons in the future.

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.

Microvascular free tissue transfer for reconstruction of head and neck cancer defects.

Over the last 10 years, microvascular free tissue transfer techniques have broadened the range of the head and neck surgeon, allowing for successful reconstruction of extensive curative extirpations in one operation with minimal morbidity. Success rates of more than 90% are now being achieved consistently. This article provides an overview of these revolutionary techniques for oral cavity, mandibular, and hypopharyngeal reconstructions. Patients are selected for microvascular free tissue transfer because of the large size of their defect, its location (eg, anterior mandibular loss), or complexity (circumferential defects of the hypopharynx). Others may be good candidates for this surgery because of previous radiotherapy or failed reconstructive surgery. Donor sites range from the radial forearm to the jejunum.