Microvascular soft-tissue transplantation for reconstruction of acute open tibial fractures: timing of coverage and long-term functional results.

Seventy-two patients with Gustilo grade IIIB open tibial fractures were treated with free-tissue transfers. If successful free-tissue transfer for soft-tissue reconstruction is performed within 15 days of injury, the risk of major complications is 3.6 percent. Long-term retrospective follow-up (mean 42 months) revealed successful limb salvage in 93 percent, good aesthetic results in 80 percent, and patient satisfaction in 96 percent. However, 66 percent of patients exhibited significantly decreased range of motion of the ankle, 44 percent experienced swelling and edema requiring elastic support and activity modification, and 50 percent occasionally required an assistance device for ambulation. The long-term employment rate was 28 percent, and no patient returned to work after 2 years of unemployment. In contrast, 68 percent of amputees after lower extremity trauma over the same period returned to work within 2 years. Patients need to realize the disruptive nature of this injury on their family, job, and future.

The effect of bovine basic fibroblast growth factor on skin flap survival in rats.

Basic fibroblast growth factor (bFGF) was prepared from bovine pituitary glands and evaluated for its effect on the viability of pedicle skin flaps in rats. Pedicle flaps measuring 3 x 7.5 cm and based cephalad were created on the backs of animals. The treatment group received bFGF in saline solution intradermally by Dermo-jet injection 30 minutes before flap elevation. Skin flaps treated with a single application of 80 U of bFGF demonstrated a significant increase in viability from 40.8% to 69.7% of the flap area (p less than 0.001); the flaps treated with 16 U of bFGF exhibited little improvement. Intradermal administration of bFGF to pedicle skin flaps produced an increase in viability that approximates the increase obtained by a surgical delay procedure; treatment of flaps with exogenous bFGF may offer advantages over surgical delay procedures.

The subcutaneous forehead lift with an anterior hairline incision.

This review of patients after forehead rhytidectomy represents the longest published postoperative follow-up to date. Fifty patients who had undergone subcutaneous forehead rhytidectomy through an anterior hairline incision were assessed by chart review, detailed questionnaire, and physical examination. The mean follow-up was 7.5 years with a range of 1 to 17 years. Benefits of the technique described include maintenance of forehead size, a mechanically efficient lift, a direct attack on wrinkles, and a low incidence of hair loss. Patient assessment indicates that the benefits of the procedure are long lasting. The disadvantages include the added precision required in executing the incision, closure, and time-consuming dissection.

Free nipple graft reduction mammoplasty.

Free nipple graft reduction mammoplasty is the procedure of choice in patients with massive breast hypertrophy, or those high-risk patients less able to undergo a more extensive procedure. A major criticism of the technique is that it creates a flat, boxy breast that lacks projection. A technical modification of free nipple graft reduction mammoplasty is presented. In this modification, a central, bulky, superiorly based dermal-parenchymal flap extending from the "key-hole" site to the superior aspect of the areola is designed. After tailoring, this central flap is folded superiorly and secured beneath the medial and lateral flaps to create the bulk of the breast mound. This central flap can be accurately tailored to achieve the desired breast size and projection. The medial and lateral breast flaps do not create the breast mound, and are only contoured over the top of this central flap to complement the final breast form.

The use of hyperbaric oxygen for preservation of free flaps.

The effects of hyperbaric oxygen (HBO) during tissue preservation on flap survival have been investigated in free flaps in rats. Groin skin flaps were harvested, stored in either room air or HBO (100% oxygen at 2.9 atm absolute) at 23 degrees C for 18 hours, and transplanted to the contralateral groin. Free flaps exhibit a high incidence of complete necrosis in the room air control. The survival of free flaps stored under HBO increased from 10% to 60% (p less than 0.05) after 18 hours of preservation. Skin flaps exhibited an increase in tissue hypoxanthine by 3.6-fold normal after 18 hours of storage in room air. HBO preservation prevented the accumulation of hypoxanthine and inhibited xanthine oxidase. Inhibition of the xanthine oxidase system may be one of the mechanisms of improved success of skin flap transplantation.

Effects of hyperbaric oxygen preservation on rat limb replantation: a preliminary report.

The effect of hyperbaric oxygen, administered during storage, on the survival of replanted limbs was evaluated in rats. The right hindlimbs of male Sprague-Dawley rats were severed and were replanted by microvascular anastomoses after storage in either room air or hyperbaric oxygen (100% oxygen at 2.9 atm absolute) at 23 degrees C for 5 hours. The administration of hyperbaric oxygen during storage improved limb survival from 50% in the room-air, control rats to 100% (p less than 0.05). The gastrocnemius muscle of limbs treated with hyperbaric oxygen demonstrated a higher level of energy reserves (creatine phosphate, adenosine triphosphate, glycogen, and glucose) than the same muscle in room-air, control rats. The mechanisms of the beneficial effect of hyperbaric oxygen on limb survival appears to be related to preservation of high-energy phosphates and glycogen.

Increased survival of island skin flaps by systemic heparin in rats.

The effects of systemic heparin on the survival of island skin flaps have been evaluated. Island flaps measuring 3 x 6 cm were created in the abdomen/groin of rats based on an inferior epigastric neurovascular pedicle. The venous drainage from the flap was occluded for various lengths of time ranging from 5 to 10 hours in the control rats and from 8 to 15 hours in the heparin-treated group of rats. The rats in the treated group received 1 ml of heparin solution (300-400 U/kg) through the contralateral saphenous vein immediately prior to the onset venous occlusion and an equivalent dose every 4 hours during venous occlusion. The group of control rats received 1 ml of saline solution. Flap survival was evaluated daily for 7 days. The flaps of control rats demonstrated a gradual decline of the survival rate after 6 hours of venous occlusion and no survival after 10 hours of venous occlusion. The flaps of heparin-treated rats exhibited complete survival until 12 hours of venous occlusion and no survival after 13 hours of venous occlusion. Thus, systemic heparin prolonged tissue tolerance to venous occlusion from 10 to 13 hours. The flaps of control rats demonstrated a significant accumulation of inosine plus hypoxanthine to 260% of normal after 8 hours of venous occlusion. The flaps of heparin-treated rats exhibited little alteration of inosine plus hypoxanthine, and contained a greater concentration of glucose and lactate than the flaps of control rats after 8 hours of venous occlusion. The results demonstrate that systemic heparin can increase tissue tolerance to venous occlusion and improve significantly the flap survival following subsequent reperfusion.

The effect of a free-radical scavenger, N-2-mercaptopropionylglycine, on the survival of skin flaps.

Oxygen free radicals may have an important role in tissue injury, which occurs on reperfusion of previously ischemic skin flaps. Therefore, therapy directed against the toxic effects of reactive oxygen species may protect skin flaps from ischemia/reperfusion injury. Various scavengers of oxygen free radicals have previously been reported to be effective in ameliorating ischemia/reperfusion injury. In the present study, N-2-mercaptopropionylglycine (MPG), a free-radical scavenger, was evaluated for its effectiveness in limiting the extent of necrosis resulting from ischemia/reperfusion injury in rat skin. Island skin flaps were elevated in the abdomen and groin based on an inferior epigastric neurovascular pedicle. The venous drainage from the flap was occluded for 7 hours, and reperfusion was established. The majority of flaps in the control group exhibited complete necrosis on Day 7 postoperatively. Treatment with systemic MPG (20 mg/kg of body weight) significantly improved flap survival from 22 to 71% (p less than 0.01) when administered at the time of reperfusion. However, MPG administered 1 hour after reperfusion did not influence the survival of the flaps. The results suggest that MPG may exert its beneficial effects on flap survival by scavenging oxygen free radicals formed at the time of reperfusion following prolonged ischemia.

The effects of hyperbaric oxygen on free flaps in rats.

The effects of hyperbaric oxygen on survival were investigated in free flaps and island flaps. Skin flaps transplanted following 18, 21, and 24 hours of preservation at 24 degrees C demonstrated survival rates of 20%, 10%, and 0%, respectively. Treatment with hyperbaric 100% oxygen improved the survival rates to 66%, 67%, and 40%. A preservation time of 21 to 24 hours at room temperature appears to be the threshold of irreversible ischemic damage. In acute island flaps, flap survival was improved significantly from 35% to 53% and 64% of the random flap area by preoperative or postoperative treatment, respectively. Prolonged preoperative and postoperative treatment improved survival to 66%.

Effect of electrical stimulation on survival of skin flaps in pigs.

The purpose of this study was to investigate the effect of electrical stimulation on ischemia-induced tissue injury in skin flaps. Bipedicle skin flaps measuring 4 X 20 cm were created bilaterally on the flanks of 12 Yorkshire pigs. The ischemic central portions of the flaps were treated with 35 mA of electrical current at a frequency of 128 Hz for 30 minutes twice daily during the initial nine days following skin-flap elevation. The treatment schedule consisted of negative-electrode stimulation during the first three days, positive-electrode stimulation during the second three days, and negative-electrode stimulation during the seventh to ninth days. Five control pigs underwent either no treatment (n = 3) or sham treatment (n = 2). The mean area of the skin flaps exhibiting necrosis was 28.0% in the control animals and 13.2% in the stimulated animals. These areas were significantly different (p less than .001). The results indicate that pulsed electrical stimulation can improve the survival of skin flaps.

Improved skin flap survival with nicotinic acid and nicotinamide in rats.

The effects of some components of the coenzyme nicotinamide adenine dinucleotide (NAD) on tissue viability were investigated in acute island skin flaps which were constructed to exceed the blood supply provided by a unilateral pedicle of inferior epigastric vessels. Control flaps undergo significant necrosis. Treatment with nicotinamide or nicotinic acid, precursors of NAD, prior to flap elevation significantly improved the area of viability in the random portion of the flap from 44 +/- 9% (mean +/- SD) to 67 +/- 12 and 65 +/- 5%, respectively. Similarly, NAD improved viability to 68 +/- 10% (P less than 0.001). Treatment with other components, adenosine diphosphoribose or quinolinic acid, had no effect on flap survival. The results suggest that nicotinic acid and nicotinamide deserve therapeutic consideration with regard to the treatment of ischemia/reperfusion injury in skin.

Superior gluteal artery steal syndrome.

A sacral ulcer is described where ischaemia due to a vascular "steal" syndrome in the gluteal angiotome was the cause of persistent failure of flap reconstruction. Thrombotic obliteration of the abdominal aorta had resulted in the development of collaterals which, paradoxically, deprived the flaps based on standard angiotomes of their major source of blood supply, as they became the major source of perfusion for the legs. Healing of the ulcer was successfully achieved only after aorto-iliac reconstruction. Two other cases of ischaemic sacral ulceration, associated with aortic occlusion, are described.

Xanthine:acceptor oxidoreductase activities in ischemic rat skin flaps.

Xanthine:acceptor oxidoreductase activities were assayed in free skin flaps following prolonged preservation. In normal rat skin, xanthine dehydrogenase transfers electrons to NAD+ and accounts for 73% of total oxidoreductase activity, and xanthine oxidase transfers electrons to molecular oxygen and accounts for the remaining 27%. Xanthine oxidase activity increased significantly in skin flaps during ischemia: approximately 30 and 100% increases after 6 and 24 hr of ischemia, respectively. Allopurinol inhibited xanthine oxidoreductase activity: free skin flaps obtained from allopurinol-treated animals exhibited a low level of xanthine oxidoreductase activity throughout the period of preservation. Systemic allopurinol significantly improved the survival rate from 32 to 75% of free flaps transferred after 24 hr of preservation at room temperature. These observations suggest that the xanthine oxidase system is a major source of oxygen free radicals following ischemia/reperfusion in skin. The increase in xanthine oxidase is attributable to the conversion of xanthine dehydrogenase to oxidase, a conversion which involves sulfhydryl oxidation in skin flaps.

The role of metal ions in ischemia/reperfusion injury in skin flaps.

The role of hydroxyl radical generation by the metal-catalyzed Haber-Weiss reaction in producing injury to postischemic skin flaps in rats was evaluated. The venous drainage from groin island flaps was occluded for 7 hr and then reperfused. The flaps were infused with either deferoxamine, CaNa2EDTA, histidine, salicylate, or vehicle (saline) at the time of reperfusion. In another experimental group, the role of hydrogen peroxide was evaluated by the infusion of catalase at the time of reperfusion. Treatment with a single dose of deferoxamine (40 mg/kg), CaNa2EDTA (50 mg/kg), or histidine (50 mg/kg), significantly increased the flap survival rate from 24 to 63, 75, and 63%, respectively. A large dose of salicylate (80 mg/kg) improved the flap survival rate (to 63%): a smaller dose (40 mg/kg) offered no improvement. A large dose of catalase ameliorated the survival rate (to 88%). The results suggest that the presence of metal ions is required for the expression of free radical-induced tissue damage. Hydrogen peroxide appears to be essential for the production of this injury.

Pseudomalignancies.

The plastic surgeon encounters a variety of lesions that are benign histologically, but malignant in terms of their manifestations and clinical course. Many of these desperate pathologic situations present exceedingly difficult problems in terms of their diagnosis and management. Clinical entities that tend to be grouped within this type of pathologic phenomenon include giant pigmented nevi, arteriovenolymphatic malformations, neurofibromatosis, and localized overgrowth. The authors examine such lesions on the basis of their presentations, pathogeneses, and pathophysiology.

Frontal cranioplasty: risk factors and choice of cranial vault reconstructive material.

A study of patients with large cranial defects involving the frontal bone, frontal sinus, nose, and orbit does not support the contention that there is a clear superiority of reconstructive material despite a history of previous bone infection. No patient with an isolated cranial reconstruction experienced an infection despite location in the area of the frontal sinus or the use of acrylic material. All patients experiencing infection underwent simultaneous reconstruction of the frontal cranium and nose and three- or four-wall reconstruction of the orbit, where the frontal sinus had previously been eliminated and where a previous bone infection had been present. Risk factors associated with cranioplasty were timing (p = 0.001) and cranial vault reconstruction in communication with previously infected ethmoid sinuses and the nose (p = 0.03). A history of previous bone infection suggests increased risk (p = 0.15). The choice of reconstructive material was not significant, although acrylic cranioplasties did not experience the complications expected from a review of the literature.

Improved survival in free skin flap transfers in rats.

We have demonstrated previously that oxygen-derived free radicals are important mediators of tissue injury in experimental island skin flaps that have been subjected to prolonged ischemia (vascular occlusion) followed by reperfusion. In this study the role of oxygen free radicals in ischemia/reperfusion injury has been investigated in free flap transfers. Groin skin flaps were harvested, stored at room temperature for 21 to 24 hours, and transplanted to the contralateral groin. These free flap transfers normally exhibit a high incidence of complete necrosis. Treatment before the onset of reperfusion with a single dose of superoxide dismutase (SOD), a scavenger of superoxide radicals, increased the survival rate of these skin flaps from 38% in the control group to 76% (p less than 0.025). Tissue levels of SOD were measured before ischemia, after ischemia but before reperfusion, and 30 minutes after reperfusion: untreated flap tissues, which were destined to undergo necrosis, exhibited a significant decrease in SOD activity after reperfusion, whereas SOD-treated flap tissues, destined to survive, demonstrated increased enzyme activity. High levels of tissue SOD activity thus appeared to be associated with improved flap survival. The results have significant clinical implications with regard to organ preservation and transplantation.

Midface fractures: advantages of immediate extended open reduction and bone grafting.

Experience with 240 midface (Le Fort and zygoma) fractures in multiple trauma patients has emphasized that superior aesthetic results are obtained by immediate extended open reduction with primary bone grafting. Internal fixation of 110 zygomatic and 130 Le Fort fractures was performed in the lower midface (zygomaticomaxillary and nasomaxillary buttresses). Open reduction of the condyle was employed in five concomitant Le Fort and subcondylar fractures with a loss of ramus height to prevent superior and posterior displacement of the middle and lower face. Bone grafts were utilized in 74 patients. They were most frequently employed in the orbit and less frequently in the lower midface. Bone graft survival paralleled that observed under elective conditions, and a slightly higher infection rate was observed. Extended open reduction and immediate bone grafting adds a new dimension to the aesthetic results obtained from facial fracture treatment. Structural bony integrity and pre-injury facial architecture may be restored in the absence of soft-tissue contracture. Restoration of the pre-injury facial architecture (the essence of facial fracture treatment) is more accurately accomplished when these techniques are utilized.