Vascularised free fibular flap in bone resection and reconstruction.

This paper compares allograft alone and in combination with vascularised free fibular flaps (FFF) to reconstruct long bone defects after tumour excision. We present 33 cases, 21 of these patients had reconstruction with an allograft alone as the initial procedure. Nine patients underwent reconstruction with FFF plus allograft plus iliac crest bone graft (ICG), two patients underwent reconstruction with a FFF and ICG and one patient underwent reconstruction with an allograft, a pedicled fibular flap and a FFF. The allograft was obtained from the Queensland Bone Bank and had been irradiated to 25 000Gy. In our experience (N=21) the complication rates with allograft alone were: delayed union 3, nonunion 7, fractured allograft 6, infection requiring resection of the allograft 3, other infections 2. The revision rate was 48% (10 cases of which five required a free fibular flap) and an average of 1.8 revision procedures were required. In the lower limb cases, the mean time to full weightbearing was 20 months and 40% were full weightbearing at 18 months. We felt that the high complication rate compared with other series may have been related to the irradiation of the graft. FFFs were used in 18 cases, 12 cases were primary reconstructions and six were revision reconstructions. The mean fibular length was 19.4 cm (range 10-29 cm). There were no flap losses and the FFF united at both ends of 11 of 12 primary reconstruction cases. One case had nonunion at one end, giving a union rate of 96% (23 of 24 junctions). When a FFF was used in combination with an allograft as a primary reconstruction, the allograft nonunion rate was 50% (five of 10 cases). The mean time to full weightbearing in the lower limb cases was 7.5 months and 100% were full weightbearing at 18 months. The FFF hastens time to full weightbearing but does not appear to affect the complication rates of allograft. The number of revision procedures required is reduced in the presence of a FFF and is the latter is a useful technique for the salvage of refractory cases.

Inducible nitric oxide synthase (iNOS) activity promotes ischaemic skin flap survival.

We have examined the role of nitric oxide (NO) in a model of functional angiogenesis in which survival of a skin flap depends entirely on angiogenesis to provide an arterial blood supply to maintain tissue viability. The different effects of nitric oxide synthase (NOS) inhibitors on rat skin flap survival appeared to be explained on the basis of their NOS isoform selectivity. Skin flap survival was decreased by iNOS-selective (inducible NOS) inhibitors, S-methyl-isothiourea, aminoguanidine and aminoethylthiorea; unaffected by the non-selective inhibitor nitro-imino-L-ornithine; and enhanced by the cNOS (constitutive NOS, that is endothelial NOS (eNOS) and neuronal NOS (nNOS)) inhibitor, nitro-L-arginine methyl ester. Skin flap survival was reduced in mice with targeted disruption of the iNOS gene (iNOS knockout mice), and the administration of nitro-L-arginine methyl ester significantly increased flap survival in iNOS knockout mice (P<0.05). iNOS immunoreactivity was identified in mast cells in the angiogenic region. Immunoreactive vascular endothelial growth factor (VEGF) and basic fibroblast growth factor were also localized to mast cells. The combination of interferon-gamma and tumour necrosis factor-alpha induced NO production and increased VEGF levels in mast cells cultured from bone marrow of wild-type, but not iNOS KO mice. The increased tissue survival associated with the capacity for iNOS expression may be related to iNOS-dependent enhancement of VEGF levels and an ensuing angiogenic response. Our results provide both pharmacological and genetic evidence that iNOS activity promotes survival of ischaemic tissue.

A model of bridging angiogenesis in the rat.

A model of angiogenesis has been developed in the rat. The epigastric vascular pedicle was exposed in the groin, a 7 mm segment of epigastric artery was excised leaving the vein intact and, after a variable period of time for angiogenesis to occur between the ends of the artery, a skin flap was elevated on the epigastric vascular pedicle so that it depended completely for its blood supply on bridging angiogenesis across the created gap. Skin flap survival and vessel counts were measured as indices of the angiogenic response. In this model we observed a spontaneous increase in vessel counts between the ends of the artery, and a corresponding increase in skin flap tissue survival until day 10 after which time vessel counts plateaued whilst tissue survival continued to increase until day 14. In the angiogenic pedicle, a time-dependent development of granulation tissue containing numerous macrophages and mast cells, and capillary sprouting were documented. When flap elevation was performed 7 days after arterial excision skin flap survival was 42%. Thus, in this model, 7 days is a suitable interval for the future evaluation of the effects of either pro- or anti-angiogenic agents.

Free tensor fasciae latae flap reconstruction of defects of the chest and abdominal wall: selection of recipient vessels.

Reconstruction of a full thickness defect of the abdominal or chest wall requires a combination of a rigid or semi-rigid layer and skin cover. The tensor fasciae latae (TFL) flap is unique in that it provides both of these in substantial quantities, but the most difficult aspect of using this flap in the anterior chest and abdomen is finding suitable recipient vessels. We describe a series of nine cases in which full thickness defects of the chest and abdominal wall were repaired using free vascularised TFL flaps. The recipient vessels included the gastroepiploic vessels (n = 2), the deep inferior epigastric artery (n = 3), the internal mammary artery (n = 2), and the superior thyroid and acromiothoracic arteries (n = 1 each). The gastroepiploic and internal mammary vessels are preferred because of their reliability and because the flap pedicle enters the centre of the deep surface of the flap so that if these vessels are used, circumferential tight closure of the fascial layer can be achieved, with consequent decreased risk of vessel kinking and future herniation.

A modified surgical technique for temporalis transfer.

A modification of the temporalis muscle transfer for facial animation in facial palsy is described. Seven cases are presented which demonstrate the advantages of the procedure, especially the avoidance of temporal hollowing and the greater power due to less dissection of the muscle belly, a more direct line of pull and the absence of a pulley. In addition, food pooling in the buccal sulcus is reduced, and the procedure is less extensive and thus better tolerated.

Island inner canthal and glabellar flaps for nasal tip reconstruction.

A series of inner canthal and glabellar island flaps for nasal tip reconstruction based on the angular artery and vein is presented. These flaps have the advantages of providing well vascularised tissue of the appropriate colour, texture and thickness for external skin and vestibular lining, with a wide arc of rotation and satisfactory donor site defect, in a single stage procedure.

Free jejunal interposition reconstruction after pharyngolaryngectomy: 201 consecutive cases.

BACKGROUND: Reconstruction of tubular defects following pharyngolaryngectomy has required complicated surgery with high perioperative morbidity and mortality. Free jejunal interposition provides an excellent reconstruction with potential for lower immediate complications and better long-term results than other procedures. METHODS: A total of 201 consecutive free jejunal interpositions were performed following pharyngolaryngectomy between 1977 and 1993. Operative details, complications, and outcome were prospectively documented. RESULTS: Perioperative mortality was low (4.5%) and microvascular success rate high (97%), although a small number of late failures were recorded. Average time until swallowing postoperatively was 11 days, and 92% of patients could maintain full nutrition. Voice rehabilitation was mentioned, and increasingly good results are being obtained. Complication rates for the neck (17%) and the abdomen (2.5%) were also low. There were no problems with excess mucus production or reflux. Radiation effect on the jejunal conduit was not detrimental to long-term patency of the vascular anastomoses or to function as a conduit. CONCLUSIONS: Comparison with other published techniques permits the contention that a free jejunal interposition is the reconstruction of choice after pharyngolaryngectomy.

Afferent arteriovenous anastomosis for thumb replantation: a case report.

Described is a case where an afferent arteriovenous anastomosis was successfully employed in the replantation of a large piece of composite tissue amputated from a patient's thumb. The operative procedure is described and aspects of arterialized venous vascular networks are discussed.