Free composite myo-osseous flap with serratus anterior and rib: indications in head and neck reconstruction.

BACKGROUND: Although the microvascular transfer of the serratus/rib myo-osseous composite flap has been previously described, the indications for its use in head and neck reconstruction have not been fully explored. Slender and easily contoured, rib bone offers reconstructive advantages over other bone sources under certain circumstances. The serratus/rib myo-osseous flap can provide vascularized muscle, bone, and cartilage; in combination with the latissimus dorsi muscle, the serratus/rib flap provides additional soft-tissue bulk on a single thoracodorsal vascular pedicle unrestricted by orientation requirements of the bone. Many orientations of bone and soft tissue are possible. METHODS: We describe, through three illustrative cases, the indications for this flap, which might include bony, cartilaginous, and soft-tissue requirements in the retromolar trigone region, large calvarial defects, and large composite full-thickness cheek and mandibular defects. CONCLUSIONS: The serratus/rib composite myo-osseous flap reliably provides vascularized bone of relatively delicate composition which offers advantages in certain reconstructive circumstances. In addition, when combined with latissimus dorsi muscle on a single vascular pedicle, it supplies additional soft-tissue bulk which can be positioned without being constrained by the bone placement. Finally, this is a useful "backup" supply of vascularized bone when other sources cannot be used due to, for example, inability to use fibula in the face of severe peripheral vascular disease and inability to use iliac crest if this has been previously used as a donor site for nonvascularized free grafts (as in secondary reconstructions).

Musculoaponeurotic plication in abdominoplasty: how durable are its effects?

Abdominal myofascial plication has become an integral part of aesthetic abdominoplasty in an effort to narrow the waistline. Out of concern for the durability of this procedure, we performed a study using standard radiographs and clinical photographs to determine if there was long-term separation of the plication. Nine patients were entered into the study. In one patient immediate total separation of the plication occurred, and in another no separation occurred at all. The remaining patients' plication separated over only a 1-3-cm distance in the central part of the abdomen (original maximum width of plication was 12-16 cm). Aesthetic appearance was not compromised by this minor degree of separation. We conclude that the effects of musculoaponeurotic plication are durable.

Clinical relevance of positive breast periprosthetic cultures without overt infection.

The true incidence of positive breast periprosthetic cultures in the absence of overt infection is not clearly established. We retrospectively reviewed data from 389 implants that were removed for reasons other than clinical infection. Many of these patients presented with a variety of musculoskeletal ailments. Others had symptomatic capsular contracture as the presenting complaint. In a few a known implant rupture was the reason for explantation. We identified a positive culture rate of 23.5 percent from capsule tissue. Most of these organisms were coagulase-negative staphylococci and anaerobic diphtheroids, but fungi and other organisms (generally felt to be more pathogenic than the less virulent coagulase-negative staphylococci) also were cultured. In an attempt to identify the clinical relevance of these positive cultures, we statistically evaluated the culture results for associations with capsular contracture, implant rupture, type of implant, and location of implant. Of these, the only statistically significant correlation was between positive culture result and symptomatic capsular contracture (Baker class IV).

Vasoactive effects of smoking as mediated through nicotinic stimulation of sympathetic nerve fibers.

Patients who smoke have higher complication rates than nonsmokers following many surgical procedures. It is not known if the adverse effects of smoking are caused by a nicotine effect or by some other potentially harmful agents that exist in tobacco smoke. It is also not known if these vasoactive effects are mediated through sympathetic nerve fibers (via nicotinic receptors in ganglia) or through elevated circulating levels of vasoactive hormones. We designed a 5-day protocol to measure relative blood flow both before and after a digital sympathetic block in the digits of subjects who were regular smokers following both smoking and wearing of a transdermal nicotine patch. Suitable pulse/wave tracings were recorded on 23 subjects. We also measured serum levels of nicotine, cotinine, vasopressin, norepinephrine, epinephrine, dopamine, and carboxyhemoglobin on each test day. Data for these serum levels were available in 30 test subjects. Digital sympathetic block had a significant beneficial effect in reversing the decreased digital blood flow that occurred after smoking (and also with use of the nicotine patch), despite the elevated circulating levels of vasopressin and norepinephrine seen with smoking. The vasoactive effects of smoking are probably due to the nicotinic effects on sympathetic fibers at the ganglionic levels.

The hemodynamic and hematologic effects of cigarette smoking versus a nicotine patch.

Patients who smoke have higher complication rates than nonsmokers in the postoperative period. The authors designed an experimental protocol for habitual smokers (n = 30) to determine the specific hemodynamic and hematologic adverse effects possibly caused by nicotine and whether the method of nicotine delivery and systemic nicotine levels achieved might influence these adverse effects. During the 5-day study, subjects were asked to refrain from smoking, and testing sessions were conducted as follows: on day 1, the subjects smoked two cigarettes immediately before testing; on day 3 (control day), testing was done after not smoking for 48 hours and then the subjects were instructed to wear a transdermal nicotine patch (PROSTEP 22 mg/day) for 24 hours and replace it with another so that, on day 5, testing took place after the subjects had worn the patch for approximately 34 hours. At each testing session, digital artery pulse amplitude and a number of clinical and serum blood level parameters were measured. Relative digital blood flow after smoking (69.2 +/- 5.8%) and with the patch (80.4 +/- 7.6%) was lower than on the control day (100.0 +/- 0.0%). The nicotine patch, unlike smoking, had no effect on vasopressin or fibrinogen concentrations, hematocrit, or white cell or platelet counts; both smoking and the patch resulted in elevated norepinephrine levels.

In situ skin grafting of free muscle flaps prior to microvascular transfer to provide intraoral lining for full-thickness defects.

BACKGROUND: Previously, the importance of providing skin for intraoral lining for full-thickness mucocutaneous defects has been emphasized. More recently, simple skin grafting of the intraoral portion of muscle flaps has been described. METHODS: Six patients were evaluated who had full-thickness mucocutaneous defects reconstructed by means of free muscle flaps with skin grafting of the intraoral muscle surface. An illustrative case is provided. A technique of preplacing the skin graft on the muscle prior to microvascular transfer is described. Mucosal biopsies were performed at the reconstruction site. RESULTS: All patients had complete take of the skin grafts. No fistulas occurred. Functional and esthetic results were satisfactory. CONCLUSIONS: The ideal candidate for this form of reconstruction is one in whom there is a large, full-thickness mucocutaneous defect. Preplacement of the skin graft reduces ischemia time, allows suturing of the skin graft to the muscle surface outside the narrow confines of the oral cavity, and enables placement of multiple quilting sutures that secure the graft against shear forces and so obviate the need for a stent dressing.

A review of 198 patients (389 implants) who had breast implants removed.

Because of the large number of women now returning to their plastic surgeons with concerns about their breast implants many years after surgery, we are afforded an ideal opportunity to evaluate these patients over the long-term. This study reviewed 198 patients (389 implants) who underwent explantation by two surgeons over a 2-year period, correlating prosthesis type, location, and length of time since implantation with two adverse endpoints, implant rupture and symptomatic capsular contracture. Significant findings included a relatively high rate of implant rupture in patients whose implants had been in place over 20 years, an increased incidence of both symptomatic capsular contracture and implant rupture in single lumen gel implants and a positive correlation between severity of capsular contracture and implant rupture.

Keratoacanthoma: when to observe and when to operate and the importance of accurate diagnosis.

Although keratoacanthoma regresses spontaneously, treating physicians seldom allow these lesions to progress through their natural course. We describe two cases of skin lesions, the first being a keratoacanthoma, which enlarged rapidly and then involuted with minimal scarring. The second lesion was initially misdiagnosed and failed to respond to medical management. An accurate diagnosis of squamous cell carcinoma was not made until the lesion had become deeply invasive. These two lesions have helped clarify our thoughts about the observation of keratoacanthomas, the need for frequent patient follow-up when a lesion is not surgically ablated, and the importance of providing the pathologist with an adequate biopsy specimen for diagnostic purposes.

Capsular compliance: a measure of a "hard" prosthesis.

Capsular contracture prevents a natural "feel" to an augmented breast and is frequently a source of patient and physician dissatisfaction postoperatively. The degree of hardness of a breast is difficult to quantitate. We have developed a rodent model that measures the pressure rise in a capsule in response to increasing intraluminal volume, generating a pressure-volume curve. The curve's break point determines the volume contained within the capsule and the slope of the steep part of the curve to the right of the break point determines capsule resistance to stretch and deformation. In a group of 14 rats, resistance to distension increased progressively over a 14-week period whereas capsule surface area, break point volume, and resting intraluminal pressure remained relatively constant. This model allows the assessment of changes in capsule contracture over time without having to kill the animal.

A method for optimizing skin graft healing and outcome of wounds of the penile shaft and scrotum.

Split-thickness skin grafting provides the best functional and aesthetic result in the treatment of wounds of the penis and scrotum. Achieving graft adherence and take in this anatomically mobile region is challenging. A simple method of effectively stabilizing skin grafts in the treatment of penile and perineal wounds is described, and patients in whom complete graft take was achieved are discussed.