Real-Time Assessment of Free Flap Capillary Circulation Using Videocapillaroscopy.

BACKGROUND: Free tissue transfer is a common method of reconstruction for various surgical defects. Many clinical assessment methods, including flap color monitoring and capillary refill time measurements, are commonly used to assess the microcirculation of the flap, yet there is no objective tool available that can clear real-time visualization of the flap microcirculation. The purpose of this study was to use a novel videocapillaroscope to evaluate the circulation changes on free flap skin surfaces while purposely clamping pedicle vessels. METHODS: Ten patients who underwent free flap transfer for head and neck cancer from November of 2019 to June of 2020 were included in the study. Videocapillaroscopic observation was performed after flap elevation, and changes in the flap skin capillary circulation with artery-controlled and vein-controlled clamping were recorded. RESULTS: Average total surgery time was 517.91 minutes (SD, 73.3 minutes), average flap elevation time was 102.9 minutes (SD, 18.3 minutes). When the pedicle artery or vein was purposely clamped, the movement of red blood cells in blood vessels stopped; when clamps were removed after 60 seconds, the restoration of red blood cell movements was rapidly observed. When the pedicle artery was clamped, the number of visualizable blood vessels decreased and flap color became relatively white. When the pedicle vein was clamped, the number of visualizable blood vessels increased, and flap color tone had a tendency toward red. CONCLUSION: Novel videocapillaroscopy can be utilized for objective real-time flap monitoring by directly visualizing flap skin capillary microcirculation. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

Dynamic Changes on Video-capillaroscopy and Potential Microsurgical Application: Temperature and Skin Surface Readings.

Video-capillaroscopy is being explored as a potential tool for microsurgical flap monitoring. A detailed examination of the effect of temperature on capillary changes using video-capillaroscopy is yet to be investigated. We analyzed the video-capillaroscopy findings on different skin areas often used for flap harvest at normal body temperatures and at lower temperatures. Skin capillaries at the lateral thigh, anterior forearm, mid-axillary line, abdomen, and fingertips were observed using video-capillaroscopy in 20 healthy Japanese individuals. Further, ImageJ software was used to measure the blood vessel area and blood flow velocity, and comparisons were drawn between normal body temperature and lower body temperature states. All measures of blood vessel area and average blood flow velocity for the different anatomical regions were significantly different before and after cooling (P < 0.001). The mean reduction rate of the vessel area was significantly different among anatomic regions (P < 0.001). Post-hoc analysis revealed a significant difference in the vessel area reduction rate between anatomic areas (P < 0.05); except when comparing the thigh versus finger, the forearm versus abdomen, and the mid-axillary line versus abdomen. The mean blood flow velocity was significantly different among anatomic regions (P < 0.001). Post-hoc analysis revealed a significant difference between the thigh and forearm (P = 0.009), the forearm and fingertip (P = 0.001), and the abdomen and fingertip (P = 0.004). Decreasing the skin temperature resulted in a significant vasoconstriction and reduction in capillary flow velocity. It is imperative to keep the monitored area warm during video-capillaroscopy assessment to avoid false diagnosis of vascular occlusion.

Abdominoplasty: My Preferred Techniques.

BACKGROUND: Abdominoplasty has been evolving since the 1960s with many technical innovations throughout the years. It has become one of the most frequent and common procedures done in aesthetic plastic surgery, with the ultimate goal of not only to remove the excess tissue in the abdominal area but also to achieve an aesthetic trunk silhouette. OBJECTIVE: The prime objective of this article was to describe our preferred approach for a full cosmetic abdominoplasty. METHODS: We summarized all the key technical aspects from our shared surgical approach for abdominoplasty. The article describes collective experiences from authors performing the surgery in South America, North America, and Asia. RESULTS: The key technical aspects identified were conservative muscle plication, customized excess tissue resection, and ultrasound-assisted liposuction to improve definition in the abdominal lines and body curves, combined with lipofilling. The aesthetic results are presented. CONCLUSIONS: Abdominoplasty should be customized to every patient's anatomy and desired cosmetic outcome, taking into consideration all the anatomical areas surrounding the abdominal wall.

Integrating Fat Graft with Blepharoplasty to Rejuvenate the Asian Periorbita.

BACKGROUND: Contemporary periorbital rejuvenation is undergoing a paradigm shift to an approach that prioritizes volume preservation and/or augmentation. However, the technical difficulties of using traditional fat grafting techniques in this area and the distinct ethnic features make periorbital rejuvenation in Asians especially challenging. Here, the authors present their approach to enhance the periorbita and outcomes. METHODS: A retrospective chart review was performed for 33 consecutive patients who underwent microautologous fat transplantation (MAFT) to the periorbita using the MAFT gun device combined with excisional blepharoplasty. Additionally, preoperative and postoperative photographs were analyzed by external evaluators to grade the aesthetic outcomes and fat resorption rates. RESULTS: Three months after surgery, patients looked on average 5.4 ± 3.4 years younger, and the aesthetic result was graded 7.4 ± 2 in a one-to-ten scale. The fat resorption rate was 19.6% ± 3.5% at 3 months and 32.2% ± 3.9% after 12 months (range: 12-24 months; P = 0.007). The overall morbidity rate was 12% (4 patients), including 1 visible lump (3%), an overcorrection case (3%) in the lower eyelid, and 2 palpable lumps in the upper eyelid (6%) which were not visible. One case of lower eyelid hollowness required secondary fat grafting. CONCLUSIONS: Traditional blepharoplasty procedures can be combined with fat grafting techniques to address volume loss and tissue descend while keeping ethnic identity. A fat injection device like the MAFT gun is safe and effective and provides long-term predictable outcomes for fat grafting around the periorbital thin skin.

When the Gastrointestinal Conduit for Total Esophageal Reconstruction Is Not an Option: Review of the Role of Skin Flaps and Report of Salvage With a Single-Stage Tubed Anterolateral Thigh Flap.

This review adds to the limited body of literature describing the use of skin flaps for reconstruction of the esophagus and includes a report of a successful 1-stage, intrathoracic reconstruction of the cervical and thoracic esophagus after failed gastrointestinal conduit. Already widely used for reconstruction of the pharynx and cervical esophagus, the versatile anterolateral thigh flap can be considered an option for more extensive defects of the cervical and thoracic esophagus in this challenging patient population when gastric, jejunal, or colon conduits are not available. The authors believe the anterolateral thigh flap should be considered in 1-stage anatomic reconstruction of the cervical and thoracic esophagus in the absence of feasible gastrointestinal conduits.

Two-stage face transplantation: a new concept in vascularized composite allotransplantation.

BACKGROUND: Animal models and clinical cases of facial allotransplantation have been performed as a single stage procedure. A staged surgery might offer some advantages in selected cases. In this study, a two-stage face transplantation approach was performed on rat and the feasibility and safety were evaluated. METHODS: Brown Norway rats were used as donors and Lewis rats as recipients in the allotransplantation groups. A total of 33 hemiface-scalp transplantations were performed. Syngeneic orthotopic transplantations were performed either in one-stage (one single stage surgery; N = 3), local two-stage [heterothopic transplantation to the neck during the first stage and graft rotation as a pedicled flap to cover the facial defect on postoperative day (POD) 2; N = 3], or distant two-stage approaches (heterothopic transplantation to the groin during the first stage and free graft transfer to the face on postoperative day 2; N = 3). In the allotransplantation groups using the same approaches, 12 received no treatment (N = 4 each subgroup) and 12 received the same tapering dose of cyclosporine (10 to 2 mg/Kg/day; N = 4 each subgroup). Graft survival and the rejection grades were assessed clinically and pathologically. RESULTS: All syngeneic transplants survived for the follow-up period of 180 days. The mean rejection-free survival and total survival of the allograft in the no treatment group was 6 ± 0.3 and 14.3 ± 4.5 days in the one-stage group, 6 ± 0.4 and 18.5 ± 1 days in the local two-stage group and 6 ± 0.2 and 14.3 ± 5.7 (P > 0.05). All allografts in the treatment groups did not develop rejection during the 42 days follow-up period. CONCLUSIONS: It is feasible, reliable, reproducible, and safe to perform a two-stage face transplantation in rats. This novel approach has the potential to be applied in research and eventually in selected clinical cases of facial allotransplantation.

A new rat model for orthotopic abdominal wall allotransplantation.

BACKGROUND: Abdominal wall, one of the most commonly transplanted composite tissues, is less researched and lacking animal models. Its clinical necessities were emphasized in multiple case series to reconstruct large abdominal defects. Previous animal models have only studied components of the abdominal wall transplant. We describe findings from a new model that more likely reflect clinical transplantation. METHODS: Full-thickness hemiabdominal wall flap was procured from Brown Norway (BN) rats and transplanted to an orthotopic defect on Lewis rats. Three groups were studied: group 1: Lewis to Lewis syngeneic; group 2: BN to Lewis control; and group 3: BN to Lewis with postoperative cyclosporine. Vascular imaging and cross vessel section were performed along with full-thickness abdominal wall. Immune cell profiling with flow cytometry at different time points was studied in all groups. RESULTS: Syngeneic group had no rejection. Control group consistently showed rejection around postoperative day 6. With cyclosporine treatment, however, transplant and recipient tissue integration was observed. Flow cytometry revealed that innate immunity is responsible for the initial inflammatory events following abdominal wall engraftment. Adaptive immunity cells, specifically interferon-γ-producing T helper (Th) 1 and interleukin-17-producing Th17 cells, dramatically and positively correlate with rejection progression of abdominal wall transplants. CONCLUSIONS: Technical, histological, and immunological aspects of a new rat model are described. These results give clues to what occurs in human abdominal wall transplantation. In addition, Th1, a proinflammatory cell, was found to be a potential biomarker for allograft rejection.

A novel rat full-thickness hemi-abdominal wall/hindlimb osteomyocutaneous combined flap: influence of allograft mass and vascularized bone marrow content on vascularized composite allograft survival.

Vascularized bone marrow transplantation (VBMT) appears to promote tolerance for vascularized composite allotransplantation (VCA). However, it is unclear whether VBMT is critical for tolerance induction and, if so, whether there is a finite amount of VCA that VBMT can support. We investigated this with a novel VCA combined flap model incorporating full-thickness hemiabdominal wall and hindlimb osteomyocutaneous (HAW/HLOMC) flaps. Effects of allograft mass (AM) and VBMT on VCA outcome were studied by comparing HAW/HLOMC VCAs with fully MHC-mismatched BN donors and Lewis recipients. Control groups did not receive treatments following transplantation. Treatment groups received a short course of cyclosporine A (CsA), antilymphocyte serum, and three doses of adipocyte-derived stem cells (POD 1, 8, and 15). The results showed that all flaps in control allogeneic groups rejected soon after VCAs. Treatment significantly prolonged allograft survival. Three of eight recipients in HLOMC treatment group had allografts survive long-term and developed donor-specific tolerance. Significantly higher peripheral chimerism was observed in HLOMC than other groups. It is concluded that the relative amount of AM to VBMT is a critical factor influencing long-term allograft survival. Accordingly, VBMT content compared with VCA mass may be an important consideration for VCA in humans.

Internal distraction osteogenesis to correct symptomatic cephalocranial disproportion.

BACKGROUND: Cephalocranial disproportion describes a state of volume mismatch between brain size and intracranial space. Nonsyndromic single-suture craniosynostosis patients can present with symptoms from elevated intracranial pressure because of inadequate or delayed treatment. The purpose of this study was to present five sagittal synostosis children with symptomatic cephalocranial disproportion treated with cranial vault distraction osteogenesis. METHODS: Asymmetric transverse internal distraction osteogenesis was performed to preferentially expand the posterior cranium. A wider base plate, pivot screw, anterior hinge plate, and flexible drive rod were applied to minimize device failure while accomplishing lateral rotation of parietal bones. A distraction protocol was developed and produced consistent results. RESULTS: Two girls and three boys underwent distraction for sagittal synostosis between 2002 and 2006. Average age at surgery was 5.8 years. All had resolution or amelioration of preoperative symptoms. Average operating room time for distractor placement was 2.5 hours (152 minutes) and average hospital stay was 2.8 days. The average distracted distance was 14.4 mm. Average operating room time for distractor removal was 1.1 hours (69 minutes) and average hospital stay was 1.6 days. No perioperative complications occurred. Average follow-up period was 4.2 years, with no recurrence of symptoms. CONCLUSIONS: Symptomatic cephalocranial disproportion can present in older children with craniosynostosis. Asymmetric transverse distraction of the posterior cranial vault is a safe and effective treatment modality for this population.

Assessment of changes in cochlear function with pneumolabyrinth after middle ear trauma.

OBJECTIVE: To describe a case of pneumolabyrinth secondary to tympanic membrane/ossicular trauma and the subsequent recovery of sensorineural hearing loss managed with conservative measures. PATIENTS: A 15-year-old boy presented to an outside hospital with signs and symptoms of acute hearing loss, vertigo, and tinnitus after penetrating injury to his right tympanic membrane. In addition, computed tomography demonstrated air density within the vestibule. INTERVENTIONS: The patient was managed conservatively with bed rest, avoidance of straining, corticosteroids, and antibiotics. MAIN OUTCOME MEASURES: Computed tomography, audiologic testing. RESULTS: Patient recovered near-normal hearing subjectively. There was closure of the air-bone gap (