Use of dermal regeneration template (Integra) for reconstruction of full-thickness complex oncologic scalp defects.

The reconstruction of full-thickness scalp defects remains a surgical challenge. Different types of reconstruction had varying success including the use of dermal regeneration template (DRT). We reviewed the surgical outcome of 30 patients who underwent application of DRT for resurfacing of full-thickness scalp defects when the pericranium was excised and the outer cortex of the calvarial bone was burred after the excision of scalp neoplasm. This was a retrospective review of 30 patients who had scalp reconstruction with DRT undertaken by the senior author between October 2004 and June 2007. The mean age of patients in our series was 63 years (37-91 years). There were 14 men and 16 women. The indications for re-excision and DRT reconstruction in 28 patients were close margins and aggressive tumor type, whereas 2 patients had a recurrence. The mean defect size was 95 cm2 (16-275 cm2). The second stage of the reconstruction occurred on postoperative day 42 (postoperative days 27-62). The mean follow-up period was 14 months. Two patients had minor complications. For both stages, the combined average operative time was 128 minutes. The use of DRT is a rung of the reconstructive ladder that deserves consideration. In our series of 30 patients who required secondary reconstruction of complex scalp defects, the use of DRT has been seen to provide safe and durable soft-tissue cover for full-thickness scalp defects. The reduced operative time and inpatient stay are desirable characteristics particularly in elderly patients with multiple comorbidities.

Reconstruction of segmental acquired auricular defects.

The 2-stage Nagata method for auricular reconstruction in patients with microtia is a widely accepted technique. We have modified this technique into a single-stage procedure for the reconstruction of acquired segmental auricular defects. A prospective analysis was made of the senior author's first 20 consecutive cases over a 4-year period (February 2004 to February 2008). The mean age of patients in our series was 34 years (range, 17-59 years). There were 15 males and 5 females; 13 were right-sided and 7 were left-sided segmental auricular defects. Five patients had had previous auricular reconstruction including local flaps and grafts. Costal cartilage harvest was ipsilateral to the defect in all cases. All 20 patients underwent a single-stage modification of the Nagata technique. Mean duration of surgery was 8.56 hours (range, 5.5-11.5 hours). Mean hospital stay was 7.6 days (range, 4-19 days). Mean time from initial surgery to a satisfactory completion of treatment was 21 months. Overall, a low complication rate and high patient satisfaction were observed in this series. We believe the single-stage modified Nagata technique offers consistent high-quality results in the treatment of acquired segmental auricular defects. All patients undergoing autologus ear reconstruction need to be assessed in a multidisciplinary setting and should be offered all other options for treatment.

Venous thrombosis in coupled versus sutured microvascular anastomoses.

BACKGROUND: The anastomotic coupling device (ACD) is currently used for microsurgical venous anastomoses as an alternative to sutures and can reduce anastomotic time. METHODS: We reviewed the microsurgical procedures performed at the University of Texas M. D. Anderson Cancer Center over a 40-month period. Procedures were performed for elective reconstruction of the breast, head or neck, or extremities after tumor excision. Thrombosis and ultimate flap salvage rates were compared between cases using ACDs and those using sutures for the venous anastomoses. RESULTS: Seven hundred twenty-three free flaps were included in the study. There were no intraoperative technical complications using the ACD. Overall, the venous thrombosis rates were not significantly different between the ACD (1.4%, 2/139 cases) and sutured (3.3%, 19/584 cases) groups. Salvage rates following venous thrombosis were not significantly different for venous anastomoses performed with an ACD (50%, 1 of 2 cases salvaged) compared with venous anastomoses performed with sutures (68.4%, 13 of 19 cases salvaged). CONCLUSION: The ACD is a useful alternative to sutured venous anastomoses that can reduce anastomotic time while achieving similar patency rates.

Sensory recovery in the sensate free transverse rectus abdominis myocutaneous flap.

BACKGROUND: Preservation and restoration of sensation to improve the quality of the reconstruction have not always been considered a priority in efforts to reconstruct the breast. Studies have documented spontaneous recovery of sensation in reconstructed breasts, but this recovery was variable and unpredictable. The authors conducted a pilot study to compare sensory recovery in innervated versus noninnervated microsurgical breast reconstruction patients. METHODS: The authors investigated a group of 14 patients who had undergone microsurgical breast reconstruction with a muscle-sparing free transverse rectus abdominis myocutaneous flap. Seven patients had reinnervation of their flaps, and seven did not. The two patient groups were similar in age (mean age, 46 years for the innervated group and 51 years for the noninnervated group) and length of follow-up (mean duration of follow-up, 39 months for the innervated group and 40 months for the noninnervated group). Sensitivity to fine touch was assessed using Semmes-Weinstein monofilaments. By testing over a defined grid and over the entire reconstructed breast, it was possible to develop color maps, or sensory topograms, of the areas sensing different levels of pressure for each patient. The patient's ability to differentiate between hot (60 degrees C) and cold (5 degrees C) was recorded. RESULTS: In a comparison of sensation in flap skin (skin paddle of rectus abdominis myocutaneous flap) with nonflap skin (native breast skin), sensitivity to fine touch was statistically better in (1) innervated flap skin compared with noninnervated flap skin (p = 0.003), (2) innervated nonflap skin compared with noninnervated flap skin (p = 0.006), (3) innervated nonflap skin compared with noninnervated nonflap skin (p = 0.037), and (4) innervated flap skin compared with noninnervated nonflap skin (p = 0.006). Temperature differentiation was significantly better in patients with innervated flaps than in patients with noninnervated flaps in all zones (p = 0.02). These differences persisted beyond a follow-up period of 3 years. CONCLUSIONS: The authors' findings confirm that reinnervation of microsurgically reconstructed breasts achieves sensory recovery that is superior to that in breasts reconstructed without reinnervation. If sensation is important and the anatomical factors are favorable, reinnervation may represent a worthwhile refinement in attempts to achieve normality for patients undergoing breast reconstruction.