Endoscopic harvest of the gracilis muscle flap.

Endoscopic technique is becoming increasing prevalent in plastic surgery and is being explored for use in tissue harvest for microneurovascular transplantation. To advance the art truly, endoscopic technique must provide similar success and complication rates, operative time, and ease of performance as the traditional "open" surgical harvest. We report the successful microvascular transplantation in 6 patients of gracilis muscles harvested with endoscopic guidance. Dissection of the primary pedicle was done through a small proximal incision, and subsequent dissection was accomplished with an endoscope through the primary incision and a small distal incision. This method provides excellent success of transfer and decreased morbidity compared with the open technique. Specifically, the resulting scar from the endoscopic technique is considerably smaller, with just a 5-cm proximal and a 1.5-cm distal scar. The technique is accomplished with standard endoscopic equipment and is learned rapidly. We believe the improved aesthetic outcome makes endoscopic gracilis harvest a preferred technique.

A cadaveric and clinical evaluation of endoscopically assisted zygomatic fracture repair.

An endoscopic method of malar arch repair without a bicoronal incision has been recently described. To determine the effectiveness of this new technique, a cadaver study was performed to evaluate the capacity of this technique to (1) restore the anatomic position of a fractured malar arch, (2) rigidly fixate the arch, and (3) avoid injury to the frontal branch of the facial nerve. The technique of endoscopically assisted fracture repair was then applied to a clinical series of consecutive patients presenting with displaced zygomatic fractures with comminution at the malar arch. All cadaveric specimens repaired with this endoscopic technique demonstrated anatomic reduction and rigid fixation of the arch without disruption of the frontal branch of the facial nerve. In all clinical cases, four-point rigid plate fixation (zygomaticofrontal, infraorbital, malar arch, and zygomaticomaxillary buttress) was achieved endoscopically with limited access incisions. All clinical cases demonstrated excellent skeletal restoration of the zygoma on postoperative computed tomography scans. On clinical examination, facial symmetry and normal facial nerve function were observed in all patients after operation.

Endoscopic-assisted repair of a malar fracture.

Although the zygomatic arch can be employed as a key landmark to the accurate alignment of a displaced malar fracture, it has been traditionally avoided because of the need for a bicoronal incision. Exposure of the zygomatic arch by means of the conventional bicoronal incision has several possible disadvantages, including an increased risk of blood loss, alopecia, loss of sensation posterior to the incision, and traction palsy of the facial nerve. Endoscopic-assisted exposure of a zygomatic arch can largely obviate the disadvantages of a bicoronal incision and yield this site accessible to reduction and fixation in the routine treatment of displaced malar fractures. A case of endoscopic-assisted open reduction and internal fixation of a moderately displaced malar fracture is presented. In particular, exposure and fracture fixation of the zygomatic arch were performed without the need for a bicoronal incision.

The arterial anatomy of larynx transplantation: microsurgical revascularization of the larynx.

Advances in immunosuppression and selective reinnervation may soon make laryngeal transplantation a potential therapy for patients undergoing total laryngectomy. Successful transplantation requires a clear delineation of those vessels necessary to completely revascularize the larynx. Our hypothesis is that the arterial inflow provided by a single superior thyroid artery is sufficient to revascularize the entire larynx. To test this hypothesis, 8 cadavers were studied via either barium latex injection (n = 4) to assess contralateral tissue perfusion or India ink (n = 4), to determine the degree of mucosal perfusion. Following injection via a single superior thyroid artery, all larynges demonstrated either complete, bilateral tissue perfusion evidenced by x-ray visualization of the barium latex injected specimen or bilateral mucosal staining with India ink. We conclude that bilateral perfusion of the entire larynx transplant, including laryngeal and epiglottic mucosa, would occur after revascularization of a single superior thyroid artery. These findings suggest that reliable revascularization of a larynx transplant is technically possible using modern microsurgical techniques.

Canine laryngeal transplantation: preliminary studies and a new heterotopic allotransplantation model.

While transplantation of the larynx may eventually be useful in post-laryngectomy reconstruction, three criteria must first be met before human transplants can be attempted: transplant viability must be high, immunosuppression must be safe and effective and functional recovery of the larynx must occur. To study these first two criteria, a total of 11 canine larynx transplants were performed: 3 autografts, 6 orthotopic allografts and 2 heterotopic allografts. The rationale and technical performance of these different transplant procedures are reviewed in detail. Orthotopic transplant recipients received cyclosporin A (CsA) while the heterotopic allograft recipients received RS-61443 and methylprednisolone in addition to CsA. Overall, 9 of 11 of the transplants remained viable. In contrast, all 3 autografted animals developed esophageal-cutaneous fistulas; 2 developed sepsis and were sacrificed on post-operative days (POD) 5 and 28, respectively. The third survived for 91 days and demonstrated a high degree of regeneration in the recurrent and superior laryngeal nerves of the transplant. Orthotopically transplanted dogs also had a high morbidity and perioperative mortality (5 of 6 animals). The single "long-term" survivor was treated with CsA alone, but developed complete transplant rejection on POD 33. The two heterotopic transplant recipients had no perioperative morbidity and the combination of CsA, RS-61443 and methylprednisolone given these latter animals was effective in the long-term prevention of rejection. One of these heterotopic recipients died of sepsis on POD 68 while the other remained alive and well on POD 168. Our present findings show that currently available microsurgical techniques allow experimental canine laryngeal transplantation to be done with significantly high transplant viability rates. (ABSTRACT TRUNCATED AT 250 WORDS)

The need for preoperative leg angiography in fibula free flaps.

Among arterial anatomic conditions which will adversely affect the harvest of the fibula are 1) significant arteriosclerotic disease within the tibial-peroneal vessels; 2) peroneal arteria magna (PAM), a condition in which only the peroneal artery supplies the foot; and 3) absence of the peroneal artery, either congenitally or as an acquired defect. In each of these anatomic conditions, removal of the peroneal vessels and the fibula free flap will jeopardize either the donor leg, the fibula flap, or both. All patients considered for fibula flaps were evaluated with preoperative leg angiograms. In 28 consecutive patients evaluated with angiography for planned free-fibula flap reconstructions, 23 actually underwent free-fibula harvest. Angiographic abnormalities that altered the operative plan were found in seven (25 percent) patients. Four of the seven patients had vascular examinations prior to surgery with abnormal findings. Three of the seven (11 percent) patients with abnormal arterial anatomy had normal vascular examinations prior to surgery. Thus, if a preoperative angiogram had not routinely been done, the abnormal anatomy would not have been discovered until surgery. This could have resulted in an unusable flap in one patient, and an ischemic or gangrenous foot in two other patients. With this angiographic guidance, there were no vascular complications from harvest of the fibula. The routine use of preoperative bilateral leg angiography is recommended, or an alternative method of vessel imaging, in all patients evaluated for microvascular free-tissue transfer of the fibula.

Changing trends in postmastectomy breast reconstruction: a 13-year experience.

Over the past two decades, significant advances have been made in the treatment of breast cancer and reconstruction following mastectomy. This analysis represents a 13-year review (1979-1991) of 455 postmastectomy reconstructions involving 381 patients (age range 25 to 76 years, mean 51 years). Follow-up was 6 months to 13 years (mean 5 years). Timing of the reconstruction, reconstructive techniques used, incidence of complications, and final results were determined. Reconstructions were divided into three chronologic study groups: group I, 1979-1983; group II, 1984-1987; and group III, 1988-1991. A significant increase in the use of autogenous reconstruction was identified: 13 percent in group I to 37 percent in group III (p < 0.0002). Complication rates were not significantly different among the three groups (p > 0.02). Significant decreases in the use of implants alone and the latissimus dorsi flap with implant were identified, while tissue expansion and TRAM flap use increased significantly (p < 0.002). Also, a significant increase in immediate reconstruction from 6 percent in group I to 28 percent in group III occurred (p < 0.0002). There was no significant difference in complication rates between immediate and delayed reconstruction in any study group. Operative time averaged 2 hours less for nonautogenous techniques; however, autogenous reconstruction required significantly fewer operative revisions. The identified trends toward immediate reconstruction and use of autogenous tissue have been accomplished without an increase in complications. Despite a decrease in overall implant use, the textured silicone saline-filled expander/implant remains the most frequently used device for breast reconstruction, providing a safe and predictable method to accomplish both immediate and delayed postmastectomy reconstruction.

A prospective study of early soft tissue coverage of grade IIIB tibial fractures.

Between 1987 and 1990, 45 consecutive patients with grade III tibial injuries were treated by an established protocol. There were 31 men and 14 women. The average age was 27 years (range, 17-68 years). The average follow-up was 16 months (range, 12-46 months). Early bony fixation consisted of an external fixator in 28 patients and a non-reamed intramedullary nail in 17 patients. No significant difference in complications was noted between the two types of fixation systems. Forty-three percent of the patients underwent early bone grafting. Free muscle flaps were employed in 78% of patients with a 97% success rate. Local muscle flaps were utilized in 22% of patients with an 84% success rate. Local infection occurred in three patients (6%). Osteomyelitis occurred in two patients (4%). Bony union was present in 98% of patients (44 of 45). Limb salvage was 98% (44 of 45). Early bone grafting (< or = 3 months) yielded earlier bony union (average, 40 weeks) than late bone grafting (average, 52 weeks). This study proves the efficacy of an established protocol of early muscle flap coverage in the management of grade IIIB tibial fractures in a consecutive series of patients. Early bone grafting appears to be beneficial to early bony union. The intramedullary rod fixation system offers an acceptable alternative to the external fixator system in severe acute open tibial fractures.

Sensory reinnervation of muscle free flaps for foot reconstruction.

A retrospective study was performed to measure sensibility in sensory-to-motor innervated microvascular muscle transplants to the foot. Seven transplants were on the weight-bearing surface of the foot. Five of seven flaps had light-touch sensation. Mean vibrometer readings of the innervated transplants were 15.7 (range: 5 to 40) vs. 5.3 (range 2 to 9) on the contralateral foot. Semmes-Weinstein scores of the innervated flaps were 3.84 (one), 4.74 (one), 5.46 (two), and 6.45 (three) vs. 3.22 (one), 3.84 (one), 4.08 (one), and 4.17 (four) on the contralateral foot. This study documents that sensory-to-motor innervated free muscle flaps may regain measurable sensibility.

A true aneurysm of a collateral branch of a proper digital artery.

An idiopathic true aneurysm of a collateral branch of the proper radial digital artery of the index finger was treated by ligation and resection. The proper digital artery remained in continuity without interruption, and the patient's symptoms were relieved.

Zero-time prehospital i.v.

Advances in prehospital stabilization and resuscitation of traumatized victims continue to have an impact on morbidity and mortality. Certain aspects of Advanced Trauma Life Support still remain controversial. Recent reports have questioned the usefulness of IV's started in the prehospital phase both because of delay in transport and because of the actual or theoretical lack of adequate volume infusion during transport. If IV lines can be started while an accident victim is en route to the hospital with no delay in transport, then much of the argument against prehospital IV's becomes irrelevant. From October 1985 through November 1986 we prospectively studied IV access attempts in 350 consecutive patients. Overall IV's started at the scene were 77% successful (n = 70) and en route 81% (n = 213) of attempts were successful. Of those with BP less than 100 mm Hg, there were 66% successful on-scene attempts and 72% successful en-route attempts. Protocols for IV administration in non-trapped patients should initiate IV access only en route to the hospital while the ambulance is moving. Even if delay at the scene is minimal, it is not possible to justify any delay, since IV's can be successfully instituted en route.