Elective free-tissue transfer in pediatric patients.

Twenty-two elective free-tissue transfers for reconstruction of various defects were performed in 20 pediatric patients over a 7-year period. Patient ages ranged from 5 to 17 years (mean: 12.5 years). There were six open wounds, six unstable scars, five tumor resection defects, three facial gunshot wounds, one facial paralysis, and one penis agenesis. Ten free flaps were transferred to the head and neck region, seven to the lower extremity, four to the upper extremity, and one to the genital area. Ten fasciocutaneous flaps, seven muscle or myocutaneous flaps, and five vascularized bone grafts were transferred. All flaps survived, except for one in an electrical burn patient. The success rate was 95 percent. No vessel spasm was observed. Children tolerated long operation periods better than adults. The recovery time after surgery was considerably shorter than in adults. The mean operative time was 6 hr, and the average hospital stay was 12 days. The mean follow-up period was 27 months. Results of this study indicate that microvascular free-tissue transfer is a safe and reliable method for the reconstruction of various defects in children.

Secondary venous ischemic injury associated with neutrophil infiltration and lipid peroxidation: amelioration of injury by cyclosporin A in a rat inguinal island flap.

Secondary venous ischemia caused by anastomotic failure is one of the major causes of failure after free tissue transfers and replantations. The effects of cyclosporin A (CsA) on secondary ischemic injury associated with neutrophil infiltration and lipid peroxidation were evaluated in a rat inferior epigastric island skin flap model. Primary ischemia was produced by arteriovenous occlusion for 2 hours. Twenty-four hours later, secondary venous ischemia was produced by 5 hours of venous occlusion. Nonischemic (n = 5), primary ischemic (n = 5), and secondary ischemic control groups (n = 10), and four treatment groups (n = 10) were created. Treatment groups received either 15 or 30 mg per kilogram per day oral CsA for 3 days before flap elevation, or 15 or 30 mg per kilogram intravenous CsA at 4 hours of secondary venous ischemia. Flap survival area, malondialdehyde (MDA) content, and myeloperoxidase (MPO) activity were assayed for each group. The mean flap survival area of the high-dose posttreatment group was significantly higher than the secondary ischemic control group (29% +/- 39% vs. 3% +/- 8%; p < 0.05, Student's t-test). The MDA and MPO levels of each treatment group were significantly lower than the secondary ischemic control group at hours 1 and 24 (p < 0.0001, Student's t-test). The lowest MDA and MPO levels were achieved in the high-dose posttreatment group. Results suggest that CsA may improve flap survival after secondary venous ischemia by attenuating neutrophil infiltration and by reducing lipid peroxidation.

Soft-tissue reconstruction of sole and heel defects with free tissue transfers.

Reconstruction of the weight-bearing surface of the foot is a challenging problem for the reconstructive surgeon. Because local tissues are not usually available for reconstruction, distant tissue transfers are often necessary. The authors report 20 patients with sole and heel defects that were reconstructed with free flaps. Two patients had bilateral reconstruction. Three patients were younger than 10 years. Etiological causes were burn scar (N = 7), trauma (N = 7), chronic wound (N = 3), and tumor resection (N = 5). All defects were located at a weight-bearing area. Gracilis muscle (N = 11), neurosensorial radial forearm (N = 7), latissimus dorsi muscle (N = 2), rectus abdominis muscle (N = 1), and posterolateral thigh flaps (N = 1) were used for reconstruction. Muscle flaps were preferred for the deep and irregular defects or chronic, open infected wounds. All flaps survived except for one total and two partial complications of necrosis. Recurrence of ulceration was observed in 1 patient with spinal cord trauma. The mean follow-up period was 33.7 months (range, 1-84 months). Patients were evaluated by direct gait observation, footprints, pedograms, and the Semmes-Weinstein monofilament test. All patients returned to normal daily activity with individual gait patterns. Functional outcomes of both muscle and fasciocutaneous flaps were satisfactory. Presence of deep sensation, preservation of musculoskeletal integrity, and patient compliance are the main factors for durability of reconstruction.

Malignant tumors requiring maxillectomy.

Seventy cases with malignant tumors requiring maxillary resection in the past 10 years were reviewed, retrospectively. The primary site of tumor was adjacent skin in 53%, maxillary sinus or maxilla in 20%, palate and alveolar arch in 13%, lip and buccal mucosa in 13%, and mandible in 1% of the cases. The most common histopathological diagnoses was squamous cell carcinoma (54%), followed by basal cell carcinoma (20%). Most of the patients had advanced tumors, either neglected or recurred. Orbital exenteration was performed in 28 cases, mandibulectomy in six cases, combined craniofacial resection in seven cases, and radical neck dissection in 18 cases. Major skin loss was present in majority of the patients. Postsurgical defects were reconstructed with pedicled flaps in 37 cases and free flaps in 12 cases. Lining of the maxillary sinus defects was provided with split-thickness skin grafts. Patients with palatal defects were encouraged to use prosthetic obturators. Postoperative radiotherapy was performed in 32 patients and combined radiotherapy and chemotherapy in 12 patients. Communication could be established with only 52 patients. Sixty-three percent of them have survived without recurrence and distant metastasis. Resection of the tumor with free surgical margins and appropriate evaluation of the surgical defect for the most suitable reconstruction are the mainstays of treatment of the midfacial tumors.

Serratus anterior free fascial flap for dorsal hand coverage.

Reconstruction of the dorsal surface of hand defects requires thin, pliable, well-vascularized tissue with a gliding surface for the extensor tendon course. Fasciocutaneous or fascial flaps are the two surgical options. Fascial flaps present the advantages of thinness and low donor site morbidity. The authors present 4 cases of serratus anterior free fascial flap (SAFFF) used to cover the dorsum of the hand. The SAFFF with skin graft has many advantages for a fascial flap: long, constant vascular pedicle; very thin, well-vascularized tissue; low donor site morbidity; and the possibility of simultaneous donor and recipient site dissection. Furthermore, it can be associated with other flaps of the subscapular system for complex reconstructions. Of the 4 observations described, 2 used associated flaps, 1 used the SAFFF with a latissimus dorsi flap, and 1 used a scapular bone flap with the SAFFF. One flap was lost due to an electrical lesion to the forearm vessels.

Extracorporeal septoplasty combined with open rhinoplasty.

Extracorporeal septoplasty is a radical solution for the severely deviated nose. The major problems associated with this procedure are fixation of the septal cartilage graft and dorsal irregularities. Extracorporeal septoplasty was performed in combination with open rhinoplasty in 17 patients with severe nasal deformities. In this technique septum was totally removed through the columellar incision of open rhinoplasty, corrected outside, and replaced as a free "L" shaped cartilage graft. The cartilage graft was fixated to the upper lateral cartilages to restore the natural relations of the anatomical structures. Additional rhinoplastic manipulations were also performed. The follow-up period was up to 18 months. The overall result was successful in all patients. Nasal deviation did not recur and secondary revisions were not needed for any patient during follow-up.

Coverage of knee-tumor-resection prostheses with free flaps.

Free latissimus dorsi free flaps were used for the treatment of three patients with malignant tumors localized at the distal end of the femur. In all cases, a knee prosthesis was used after tumor resection. In two patients, the prosthesis was covered with a free latissimus dorsi flap immediately after insertion. In one patient, the exposed prosthesis that was inserted 9 months previously was also covered with a free latissimus dorsi flap. Histopathologic diagnosis of the tumors was osteosarcoma in two cases and fusiform cell sarcoma in one case. Free-tissue transfers were successful in spite of preoperative chemotherapy and/or radiotherapy. Chemotherapy was started 3 weeks postoperatively in all cases. Patients ambulated 6 weeks after surgery and knee functions were satisfactory during a 1 year follow-up.

Wineglass pattern for vertical mammaplasty.

The ideal reduction mammaplasty technique should create a pleasing breast shape with minimal scarring. The long and conspicuous scar associated with the classic inverted "T" pattern mammaplasty techniques are not acceptable for many patients. Periareolar mammaplasty techniques cause less scarring, but they have major disadvantages such as scar widening, areolar distortion, and insufficient breast projection. We used a new pattern for vertical mammaplasty to overcome the insufficient breast projection caused by the round block technique and applied it to 51 patients during the last 3 years. This method results in a single vertical scar and a periareolar scar, allows sufficient volume reduction, and provides good breast shape and projection; the results are durable. This procedure is safe, causes few complications, and is easy to learn and perform.

Evaluation of lipid peroxidation and total antioxidant status in plasma of rats following thermal injury.

Thermal injury initiates systemic inflammatory reactions producing burn toxins, an inflammatory response, oxygen radicals and finally peroxidation. The relationship between the amount of products of oxidative metabolism and natural scavengers of free radicals determines the outcome of local and distant tissue damage, and further organ failure in burn injury. To determine the relationship between the level of total natural scavengers of the body, the place of superoxide dismutase in this capacity, and its relation with lipid peroxidation, malondialdehyde, superoxide dismutase levels and total antioxidant status were measured in plasma. Animals were subjected to 30 per cent full thickness body surface area burn, and their blood was collected at 24 h postburn. Plasma malondialdehyde levels were significantly elevated above the level of controls (P < 0.02). Burn injury caused a remarkable decrease in superoxide dismutase (45 per cent decrease, P < 0.0001) and total antioxidant status (14 per cent decrease, P < 0.01) when compared to control.

The fate of alloplastic materials placed under a burn scar: an experimental study.

The behavior, under burn scars, of three different alloplastic materials, silicone, Medpor and Proplast, was compared in an animal model. A standard burn wound was created in rats, and 3 months later silicone, medpor and proplast alloplasts were placed under the burn scar. The rats were followed for another 3 months and ulceration and/or alloplast exposure rates were evaluated. At the end of this period specimens were examined histologically for the thickness of the fibrous capsule around the implant, thickness of the overlying tissue, tissue ingrowth and vascularization of the implants. Ulceration and exposure occurred in 2 of the 12 Medpor, 2 of the 12 Proplast and none of the 12 silicone implants. Fibrous capsule was significantly thicker around the silicone implants. Tissue ingrowth and vascularization were most prominent in Medpor implants while thickness of the overlying tissue was maximum in Proplast implants. These findings suggest that complications with silicone implants may be less than with other porous implants when used under burn scarred tissue.

A well-differentiated giant liposarcoma originating from the buccal fat pad.

Although liposarcoma is one of the most common soft-tissue sarcomas, facial localization is extremely rare. The buccal fat pad is an important anatomic structure located in the face that recently gained interest as a result of increasing research on facial anatomy. In this paper, we report a case of giant liposarcoma originating from the buccal fat pad. The precise localization of the tumor was determined preoperatively with computed tomography examination. The liposarcoma that invaded the body and the extensions of the buccal fat pad was resected completely. The pathological examination revealed a sclerosing, well-differentiated liposarcoma, which is known to be very rare in the head and neck region. Chemotherapy and radiotherapy were not necessary because of the favourable histological type of the tumor and the advanced age and poor general condition of the patient. Local recurrence and distant metastasis were not observed during the 1-year follow-up.

Free rectus abdominis muscle flap for the treatment of complications after neurosurgical procedures.

Neurosurgical procedures may lead to mortal complications. Exposure of the dura mater, brain, or other intracranial structures; persistent cerebrospinal fluid fistulas; and connection between the extradural space and the nasopharynx and paranasal sinuses are complications that can be best treated with microvascular free tissue transfers. We report two patients with complications that occurred after neurosurgical operations. Both patients were treated by a team, including a plastic surgeon, ear, nose, and throat surgeon, and a neurosurgeon. Free rectus abdominis muscle flap was the choice of treatment for reconstruction.

Reverse first dorsal metatarsal artery adipofascial flap.

An adipofascial flap distally based on the first dorsal metatarsal artery is described. This flap was used successfully in three cases with skin defects of the distal foot. The advantages of this flap are minimal donor site morbidity and its applicability for larger defects. The surgical technique is described, and indications, advantages, and disadvantages of the method are discussed and compared with the distally based first dorsal metatarsal artery fasciocutaneous flap. The reverse first dorsal metatarsal artery adipofascial flap offers a new solution for reconstruction of distal foot defects.

Reversed roof graft for the severely deviated nose.

A new technique for the correction of the severely deviated nose is described. After submucosal resection of the septum, the nasal hump is resected, reversed, and reinserted. This technique was applied to 27 patients over a four-year period with successful results. The advantages and disadvantages of the method are discussed.

The use of FK506 and skin allografting for the treatment of severe burns in an animal model.

A 30% burn injury was found highly immunosuppressive in mice by means of two in vivo measurements of cell-mediated immunity, and this immunosuppression could be prevented by early excision and grafting. FK506, a new immunosuppressive agent, was given at different doses for 12 days after early excision and grafting following burn and all doses prolonged the acceptance time of allografts from 14 to 20 days. Allograft rejection was not seen when animals were on the drug. Higher doses prolonged the rejection more, even after the cessation of the drug, and they caused some degree of immunodepression. Immunosuppressive treatment with FK506 when used following burn injury affected cell-mediated immunity minimally to moderately when compared to burned control groups.

An alternative treatment of massive burns: skin allografts and cyclosporin immunosuppression without severe additional depression of cell-mediated immunity in an animal model.

This study investigated the effects of early excision of eschar and grafting with cyclosporin immunosuppression on immunological changes following burn injury. The immunological status of the rat was studied using two in vivo measures following a (30 per cent TBSA) full skin thickness burn injury. Cyclosporin was found to be a powerful immunosuppressive agent in skin transplantation, and its risks, efficacy and possible side-effects after thermal injury have been investigated. This study demonstrated that a large burn was profoundly immunosuppressive, and early excision and grafting was able to restore cell-mediated immunity significantly as reflected by two in vivo assays. The short course of the immunosuppressive treatment to delay skin allograft rejection did not cause a severe additional effect on cell-mediated immunity after thermal injury. Allograft survival appeared to be related to immunosuppression caused mainly by cyclosporin treatment and also by the immunosuppressive effect of the burn.