Sequentially linked free flaps in head and neck reconstruction.

Free tissue transfer has become a useful technique for reconstructing complex three-dimensional defects following the extirpation of head and neck malignancies. This technique, however, may be limited by inadequate vascularity in the recipient site when a patient has been subjected to operative procedures or radiation therapy. The use of serial flaps, with the first flap connected sequentially to the second, reduces the need for dual recipient vessels in a surgical field when two flaps are required for reconstruction. Although this procedure is more technically demanding than more traditional approaches, it can provide a satisfactory, reliable one-stage composite reconstruction under these difficult circumstances. Results have been functionally and aesthetically superior to those achieved with pedicled one-flap reconstructive methods.

One-stage total penile reconstruction with a free sensate osteocutaneous fibula flap.

This is the first series of total penile reconstructions with the free sensate osteocutaneous fibula flap. The main advantages of this flap lie in its intrinsic rigidity, its superior donor-site location, and its long vascular pedicle. The fibula flap provides better bone volume than does the radial forearm flap, which commonly results in a floppy phallus in the absence of bone. Penile prostheses in other flaps have enjoyed limited success. Forearm donor-site complications can be avoided. The donor site in the lower extremity can be readily covered with a sock. The vascular pedicle of the fibula flap is of sufficient length to allow end-to-side anastomosis of the flap to the femoral artery. Interpositional vein grafts are unnecessary, and dissection of the inferior epigastric artery system to serve as a donor artery may be avoided. The appearance of the neophallus is excellent. We present only the first four continuous cases of the six we have performed because sufficient follow-up data are available only for these four. The advantages and disadvantages of fibula and forearm donor sites, the long-term fate of the bony component, the importance of sensation, and the vascularized urethral reconstruction are discussed. High patient satisfaction and the advantages of the technique convince us that the fibula osteocutaneous flap is superior for total penile reconstruction.

Estrus detection by using vaginal cytologic examination in miniature swine.

Vaginal smears were obtained from four Yucatan miniature swine daily for 69 days and stained with hematologic stain. Epithelial cells were categorized as superficial, large intermediate, small intermediate, or parabasal. Leukocytes were also quantitated. External signs of estrus were recorded, including swelling, discharge, restlessness, or vocalization. Mean age of three of the swine was 147 days at the beginning of the study. The fourth pig was 317 days old. The three younger swine had their first observed estrus at the age of 178 days (range, 167 to 196 days). Mean cycle length was 17 to 21 days. The moving mean leukocyte count (i.e., each value was averaged with the values for the previous day and the following day) always exceeded the epithelial cell count (regardless of type), except during the 3 to 4 days when the pigs exhibited external signs of estrus. Further, epithelial cells were at their peak during estrus, decreasing markedly during diestrus, and increasing again during proestrus. The combined superficial plus large intermediate cell counts were significantly higher during estrus than during diestrus or proestrus. We conclude that daily vaginal smears can be used to determine the stage of estrus in Yucatan pigs.

Scrotal construction by expansion of labia majora in biological female transsexuals.

Construction of male genitalia in biological female transsexual patients is problematic. We report 3 transsexuals with scrotal construction by tissue expansion of the labia majora. In each patient, tissue expanders were inserted into the labia majora several months before free flap phalloplasty. In 2 patients, the tissue expanders were removed, and testicular implants were placed into the labial pockets. In the other patient, the tissue expanders were left in place. Because of the close embryological relationship between the labia majora and the scrotum, the neoscrotum appears natural in color match, hair pattern, and skin texture. The anatomical position of the labia majora produces a scrotum properly located in relation to surrounding anatomical structures. Excellent aesthetic results can be achieved with this procedure. Based on our experience, we advocate this procedure for scrotal construction in biological female transsexual patients.

Simultaneous maxillary and mandibular reconstruction with one free osteocutaneous flap.

The concept of immediate reconstruction of massive facial injury with rigid internal fixation and free-tissue transfer continues to evolve. This case is unique in that it is the first report of the following: (1) simultaneous combined maxillary and mandibular reconstruction with one vascularized bone graft and (2) immediate total maxillary reconstruction with vascularized fibular bone. The nasopharynx was closed with a tubed radial forearm flap. Reconstruction was staged over several days, with dissection/banking of flaps, grafts, recipient sites, and debridement as a preliminary stage.

Experimental rectus abdominis myocutaneous and rectus abdominis myoperitoneal flaps as urinary bladder wall substitutes in miniature swine.

An experiment was performed in Yucatan miniature swine to determine the feasibility and characteristics of musculocutaneous or musculoperitoneal flaps as urinary bladder wall substitutes. In five swine, a single-pedicle skin island flap (rectus abdominis myocutaneous, RAM/C) was sutured into the bladder. In five other swine the flap was a peritoneum island (rectus abdominis myoperitoneal, RAM/P). Three swine were sham-operated controls. The patches were in place for 20 weeks, remaining viable and elastic. Inflammation, maceration, and infection were absent. Skin patch histology was unchanged. The peritoneal patches became resurfaced with uroepithelium. The sham bladder volume (ml/kg body weight) did not differ significantly from RAM/P bladder volume (p = 0.54). RAM/C bladders were slightly smaller than shams (p = 0.11) and significantly smaller than RAM/P bladders (p = 0.03). Substitution of the bladder wall with RAM patch flaps is feasible. This is an important preliminary step toward our goal of nonenteral urinary bladder wall substitution.

Absent neovascularization in a lower extremity free flap: a case report.

A patient with a free-tissue transfer to the lower leg underwent amputation three months post-operatively. The amputated limb and the free flap were evaluated angiographically immediately following amputation. Vascular injection of the extremity, with clamping of the pedicle, demonstrated that the area of the flap was devoid of radiopaque vessels, and communications from the surrounding tissue were absent. This clinical evidence, added to published clinical reports, suggests that the lower extremity, unlike the head and neck, does not develop collateral circulation to a free-tissue transfer. Late postoperative sacrifice of the vascular pedicle to a lower extremity free-tissue transfer should be approached cautiously, with the realization that collateral circulation is not assured.

Reconstruction of midface bone defects with vitallium micromesh.

Complex midface defects following trauma and tumor resection present a challenging problem for maxillofacial surgeons. Regardless of the cause of these defects, restoration of accurate contour is essential to achieve both proper function and cosmetically acceptable appearance. Traditionally, bone grafts have been the preferred method of reconstruction. We present the first report of the use of Vitallium micromesh in reconstruction of midface bone and cartilaginous defects in 3 patients. In 1 patient, bone loss resulted from trauma; in the other 2, loss was due to tumor resection. In all 3 patients, Vitallium micromesh was used successfully as a replacement for the bony skeleton without morbidity or complications. Use of this material is contingent on its rigid fixation. We do not recommend use of this technique in the absence of rigid fixation.

Major thermal burn as a result of intraoperative heating blanket use.

A 72-year-old woman sustained a 30% full-thickness total body surface area burn as a result of a malfunction in a heating blanket during coronary artery bypass surgery. Early burn wound excision and wound closure with skin grafts were performed. The patient experienced wide swings in systolic blood pressure. She was treated with antibiotics and received maximal mechanical support. However, cardiac collapse occurred, and the patient died on the tenth day after burn injury. Previous case reports have discussed only minor burns that resulted from heating blanket use. The magnitude of this injury and the death that resulted from it highlight the importance of preoperative and intraoperative equipment checks and careful intraoperative core temperature monitoring.

Immediate breast reconstruction at the time of mastectomy for breast cancer.

Immediate breast reconstruction avoids or lessens the psychosocial trauma associated with a disfiguring mastectomy. The complications seen in this small patient sample are not in excess of those seen in patients undergoing delayed reconstruction. Fifteen immediate breast reconstructions were performed at the time of mastectomy for cancer. Flap or implant reconstruction alone was determined on an individual basis. No delays in the initiation of adjuvant chemotherapy or hormone therapy were caused by the reconstructions. There were no instances of total flap loss or wound infection. One implant was lost due to exposure. Other complications were similar to those associated with modified radical mastectomy alone. These preliminary results suggest that immediate breast reconstruction at the time of mastectomy may be offered with safety to newly diagnosed breast cancer patients.

The Ilizarov method (callus distraction) in the treatment of open fractures of the tibia.

The treatment of bone defects, in particular open fractures of the tibia, represents a significant health care concern for physicians and surgeons in the Commonwealth. Traditional methods of treatment, including those that utilize internal and/or external fixation devices, often have drawbacks. The Ilizarov method (callus distraction), which combines acute shortening with subsequent lengthening using an external ring fixator, offers a new approach to treating bone defects. The authors describe the Ilizarov method, discuss Ilizarov's research and his development of the callus distraction technique, and review the growing body of English-language literature assessing the use of the Ilizarov method.

Reconstruction of the lower lip and chin with the composite radial forearm-palmaris longus free flap.

Four cases of total lip and chin reconstruction are presented. In three, the composite radial forearm-palmaris longus free flap was used for reconstruction. In the fourth case, the palmaris longus was separated from the flap but still used as a lower lip sling. In all cases, the entire lower lip and the soft tissue of the chin were reconstructed in one stage. All patients healed primarily, and the three who underwent radiotherapy tolerated it without complications. Lip seal and speech were good, and there was no problem with drooling. Postoperative results emphasize the importance of respecting the aesthetic unit of the lower lip and chin.

Immediate closure of traumatic upper arm and forearm injuries with the latissimus dorsi island myocutaneous pedicle flap.

This paper reports the authors' experience with latissimus dorsi island pedicle flaps in the acute treatment of massive arm injuries. Seven patients with upper arm injuries and four patients with forearm injuries were treated with latissimus dorsi pedicle flaps. All cases involved massive soft-tissue loss and open fractures. Primary healing of wounds occurred without complications in 10 of 11 patients; the eleventh developed a wound infection. There were no instances of flap loss or vascular complications. This report compares and discusses surgical management options and details the importance of robust, immediate soft-tissue coverage for optimal functional recovery. Contrary to traditional thought, delay in definitive wound closure may be unnecessary when aggressive debridement is followed by acute flap closure.

Traumatic infected pseudoaneurysm of the hand.

A rare case of ruptured infected pseudoaneurysm of the hand resulting from penetrating trauma is reported. The patient was seen initially with an acute infection of the hand associated with pulsatile bleeding. Diagnostic evaluation should include arteriography as a guide for the operative plan.

Immediate reconstruction of bone and skin defects of the humerus with free fibular graft and muscle flap.

The following Case Report describes the immediate reconstruction of bone and skin defects of the humerus with a free fibular graft and muscle flap. A 33-year-old white female sustained a gunshot wound to the left upper extremity with a 3.08 caliber high-powered rifle. The entry wound was on the lateral aspect of her mid-arm. The exit wound on the anteromedial aspect of the upper extremity measured approximately 10 x 15 cm. A segmental loss of the middle of the humerus and a defect of the radial nerve were noted. Within 48 hours after injury, reconstructive surgery was begun. A free vascularized fibula graft, peroneal artery, and concomitant vein were harvested from the left lower extremity, prepared, and inserted "peg in hole" fashion between the humerus fragments. The proximal segment was inserted between two fracture fragments, and the two fragments, including the proximal fibula, were transfixed with a single screw. The graft was revascularized with end-to-side anastomosis of the peroneal vessels to the brachial artery and its concomitant vein. The entire reconstruction was then covered with rotation of the latissimus dorsi muscle flap and a split-thickness skin graft. All wounds and the donor site healed primarily. Post-operative orthopaedic management consisted of maintenance of the external fixator for three months. Postoperative x-rays at 5 months showed healing at both ends of the fibular graft. A history of free fibula transfers and a discussion of the importance of aggressive, early, bony reconstruction using the free vascularized fibula graft are presented.

Successful replantation of a totally amputated ear.

A case of a totally amputated ear that was successfully replanted using microvascular anastomosis is reported. This is the sixth such case reported in the literature. This case varies from those of previous reports in that systemic heparinization was not administered and interpositional vein grafts were not used.

Use of the rectus abdominis muscle and fascia flap in reconstruction of epispadias/exstrophy.

Inferiorly based rectus abdominis muscle flaps and fascial flaps have been used to construct a firm abdominal wall without hernias and to provide coverage of the bladder, bladder neck, and proximal urethra in the secondary reconstruction of patients with epispadias/exstrophy complex. They have also been used to produce an elevation of the mons area, which is lacking in the typical exstrophy patient. Rectus fascial flaps have been the mainstay of abdominal closure when wide diastasis of the rectal muscles is present and when the lower abdomen lacks fascial support. We are pleased with the results of utilizing either the rectus muscle or rectus fascia in this complex condition. We have been using fascial flaps for over 10 years in our epispadias/exstrophy closures and abdominal wall strengthening procedures. We have been using bone grafts and the rectus muscle for the construction of a mons for the past 5 years. Although the rectus muscle procedure to cover the bladder and the bladder neck has been in use for only 2 years, we have seen patients with incontinence restored to a continent state; these patients have not been plagued with fistula problems when a neourethra has to be constructed to elongate the phallus. Previous attempts at urethral repair in this area have been successful in the main, but an occasional fistula at the junction between the penile skin and the abdominopubic skin has resulted. Since using the rectus muscle to cover the bladder and bladder neck area, we have not had this problem. Patients with epispadias/exstrophy remain such difficult problems that every advance in technique should be used to improve results.(ABSTRACT TRUNCATED AT 250 WORDS)