Reconstruction of the lower lip after radical resection for cancer: the "Pharaoh technique".

For patients affected by far advanced lower lip cancer, with great local tumor destruction but few or no metastases, we advocate radical resection. Here we describe a method for these repairs, using two deltopectoral flaps. It produces a good functional result and satisfactory appearance. No recurrences have been observed in our 5 cases during a two-year follow-up.     

Experimental use of a gastric flap on an omental pedicle to close defects in the trachea, pharynx, or cervical esophagus.

The use of local or regional skin flaps for repairs after head and neck cancer surgery often increases the deformity of the patient. We present a new procedure using a gastric flap on an omental pedicle. It has been successful in dog experiments where we transferred it to the head and neck region, to serve as a substitute for the standard skin flaps.     

Uses of the trapezius and sternomastoid myocutaneous flaps in head and neck reconstruction.

Both of these myocutaneous flaps can supplant forehead and deltopectoral flaps, in certain indications. They are additional arterialized flaps for the armamentarium of the reconstructive surgeon, and can be useful in many repairs in the head and neck region.     

Periumbilical rectus abdominis perforator preservation significantly reduces superficial wound complications in "separation of parts" hernia repairs

Midline ventral hernia repair with bilateral sliding myofascial rectus abdominis flaps, or the "separation of parts" technique, has low hernia recurrence rates. However, this technique, as originally described, creates massively undermined skin and subcutaneous tissue flaps. These undermined skin flaps can suffer marginal skin loss, fat necrosis, and delayed wound healing. The authors propose that preserving the periumbilical rectus abdominis perforators to the abdominal skin flaps will decrease the prevalence of postoperative superficial wound complications. A retrospective review of 66 consecutive, large, midline hernia repairs using a separation of parts technique was undertaken to identify any correlation between the preservation of periumbilical rectus abdominis perforators to the skin flaps and the prevalence of postoperative wound complications. In 25 cases, the standard separation of parts technique was performed with wide undermining of the skin and subcutaneous tissues. In 41 cases, the modified separation of parts technique was performed with maintenance of the periumbilical rectus abdominis perforators to the abdominal skin flaps.Comparison of these two groups revealed no difference in age; sex; body mass index; initial hernia size on physical examination; prevalence of smoking, diabetes, or steroid use; or prevalence of a simultaneous intraabdominal procedure. A statistically significant difference was noted in postoperative wound complications between the two groups (p < 0.05). Of patients who underwent the standard separation of parts technique, five of 25 patients (20 percent) had wound complications as compared with one of 41 patients (2 percent) who underwent the modified separation of parts technique with perforator preservation. The postoperative hernia recurrence (7 percent and 8 percent, respectively) and hematoma (4 percent and 2 percent, respectively) rates were similar in both groups. A trend of increased wound complications was noted when separation of parts was combined with an intraabdominal procedure (18 percent versus 3 percent, p = 0.08). Interestingly, within this group, the modified separation of parts technique with preservation of the periumbilical rectus abdominis perforators demonstrated a trend of fewer wound complications as compared with the standard separation of parts technique (7 percent versus 31 percent, p = 0.15). The authors conclude that preservation of the periumbilical rectus abdominis perforators significantly reduces the prevalence of major postoperative superficial wound complications in separation of parts hernia repairs. Simultaneous intraabdominal procedures with separation of parts hernia repairs seem to increase the prevalence of wound complications. This increased prevalence of wound complications seems to be minimized when the modified separation of parts technique is performed.     

Use of thirty latissimus dorsi flaps

Experiences with 30 latissimus dorsi flaps are described. Used either as a muscle flap, as a myocutaneous flap, or as an "island" of skin nourished by a subcutaneous pedicle of muscle and vessels, the flap has an excellent blood supply and is suitable for many repairs of defects of the chest wall.     

Free rectus abdominis muscle flap reconstruction of the middle and posterior cranial base

A multidisciplinary approach by the neurosurgeon, ENT surgeon, and plastic surgeon has been used in seven patients with extensive tumors involving the middle and posterior skull base. Wide resection of these tumors was accomplished, and the resultant defect of the cranial base was reconstructed using free rectus abdominis muscle flaps. The free muscle flap has been used to reconstruct defects in the posterior and lateral walls of the nasopharynx, obliterate the exposed paranasal sinuses, and cover tenuous dural repairs or dural grafts overlying the temporal lobe and posterior fossa to prevent cerebrospinal fluid leakage and ascending meningitis.     

Bilateral cleft lip and nasal repair

SUMMARY: The bilateral cleft lip and nasal repair has remained a challenging endeavor. Techniques have evolved to address concerns over unsatisfactory features and stigmata of the surgery. The authors present an approach to this complex clinical problem that modifies traditional repairs described by Millard and Manchester. The senior author (H.S.B.) has developed this technique with over 25 years of surgical experience dealing with the bilateral cleft lip. This staged lip and nasal repair provides excellent nasal projection, lip function, and aesthetic outcomes. Lip repair is performed at 3 months of age. Columellar lengthening is performed at approximately 18 months of age. A key component of this repair focuses on reconstruction of the central tubercle. A triangular prolabial dry vermilion flap is augmented by lateral lip vermilion flaps that include the profundus muscle of the orbicularis oris. This minimizes lateral lip segment sacrifice and provides improved central vermilion fullness, which is often deficient in traditional repairs. The authors present the surgical technique and examples of their clinical results.     

Use of the AO plate for immediate mandibular reconstruction in cancer patients

Free vascularized bone grafts have revolutionized mandibular reconstruction, yet their use in all mandibulectomy patients is not always necessary. A recently developed alternative to bony reconstruction has been the use of the AO reconstruction plate. We compared the use of the AO reconstruction plate with immediate free bone graft mandibular reconstruction in 31 patients. Reconstruction plates were used in 20 and immediate free bone grafts were used in 11 patients. The overall success rate for use of the plate was 15 of 20 (75 percent). There were 6 anterior reconstructions, of which only 2 (33 percent) were successful. This is opposed to 13 of 14 (93 percent) lateral reconstructions that were successful in lateral plate placements. There were 11 immediate composite free flaps: 4 iliac crest, 4 scapula, 2 fibula, and 1 composite radial forearm flaps. Six repairs were for anterior defects, and there were 5 full-thickness defects, 3 of which were in the anterior position. All 11 flaps were successful. In conclusion, we believe the reconstruction plates are a useful adjunct for mandibular replacement in the head and neck cancer patient but should be reserved for lateral defects. For anterior reconstructions, even in patients with locally advanced disease, free-tissue transfer of composite osteocutaneous flaps is the reconstructive method of choice.     

Endocrine regulation of trace element homeostasis in the rat

Conclusion The mechanisms responsible for the modifications of the concentrations of elements in tissues induced by hormonal influences are complex, because each hormone has pleiotropic actions that are sometimes opposite. Among these modifications, it is often difficult to distinguish between the adaptive defensive changes and the changes responsible for disorders or for exacerbating them, for example, Fe accumulation in tissues after HPX, TPTX, and castration. Moreover, in clinical conditions, hormonal disturbances are often enhanced by other defects, such as an excessive or a deficient intake of elements.     

Postoperative irradiation after reconstructive surgery: comparative study of radiosensitivity between free-skin grafts and skin flaps

Radiation effects after reconstructive surgery (free-skin grafts and skin flaps) were studied in the rat, and the optimum time for irradiation was determined. The radiosensitivity of both free-skin grafts and skin flaps showed the same trend depending on time of irradiation after operation. The grafts or flaps irradiated in the hypervascular stage showed severe reactions to irradiation, whereas those irradiated in the hypovascular stage showed milder reactions in gross and microangiographic observation. Vascular damage should be given primary consideration when deciding the proper time for irradiation after reconstructive surgery. In general, free-skin grafts showed more severe reactions than skin flaps, especially in the grafts irradiated in the early stage after operation. The experimental results of this study cannot be readily transferred to a clinical setting, but they suggest that postoperative irradiation could be begun 3 to 4 weeks after operation with respect to graft or flap survival, and the results of the clinical cases almost coincide with these experimental results.     

Versatile fasciocutaneous flaps based on the medial septocutaneous vessels of the arm

Dissections in cadavers injected with latex confirm that direct septocutaneous branches from the brachial artery are the main source of irrigation for the fascial plexus of the inner arm. They are arranged in a vertical row from the level of the pectoralis major insertion down to a few centimeters above the medial epicondyle. Multiple fasciocutaneous flaps can be outlined utilizing these vessels, with either pedicled or island designs, proximally or distally based. Twelve clinical cases are reported. Axillary and elbow-crease contractures can be released with island flaps, and thumb and hand defects can be covered in a cross-arm fashion. Other clinical applications are suggested as well. The special quality of the skin transposed in this way, the simplicity of the surgical technique, and the circulatory reliability are the main advantages of these versatile flaps.     

Functional tissue engineering: the role of biomechanics

"Tissue engineering" uses implanted cells, scaffolds, DNA, protein, and/or protein fragments to replace or repair injured or diseased tissues and organs. Despite its early success, tissue engineers have faced challenges in repairing or replacing tissues that serve a predominantly biomechanical function. An evolving discipline called "functional tissue engineering" (FTE) seeks to address these challenges. In this paper, the authors present principles of functional tissue engineering that should be addressed when engineering repairs and replacements for load-bearing structures. First, in vivo stress/strain histories need to be measured for a variety of activities. These in vivo data provide mechanical thresholds that tissue repairs/replacements will likely encounter after surgery. Second, the mechanical properties of the native tissues must be established for subfailure and failure conditions. These "baseline data" provide parameters within the expected thresholds for different in vivo activities and beyond these levels if safety factors are to be incorporated. Third, a subset of these mechanical properties must be selected and prioritized. This subset is important, given that the mechanical properties of the designs are not expected to completely duplicate the properties of the native tissues. Fourth, standards must be set when evaluating the repairs/replacements after surgery so as to determine, "how good is good enough?" Some aspects of the repair outcome may be inferior, but other mechanical characteristics of the repairs and replacements might be suitable. New and improved methods must also be developed for assessing the function of engineered tissues. Fifth, the effects of physical factors on cellular activity must be determined in engineered tissues. Knowing these signals may shorten the iterations required to replace a tissue successfully and direct cellular activity and phenotype toward a desired end goal. Finally, to effect a better repair outcome, cell-matrix implants may benefit from being mechanically stimulated using in vitro "bioreactors" prior to implantation. Increasing evidence suggests that mechanical stress, as well as other physical factors, may significantly increase the biosynthetic activity of cells in bioartificial matrices. Incorporating each of these principles of functional tissue engineering should result in safer and more efficacious repairs and replacements for the surgeon and patient.     

The effects of gravity on delayed and transplanted delayed tubed flaps.

Altering the position (elevated or dependent) had no immediate effect on the blood supply of delayed or transplanted delayed tubed flaps. However, after 72 hours the mean survival length in the dependent tubes was less than that in the elevated tubes. (This difference was only significant in the delayed untransplanted flaps, and not so in the delayed transplanted flaps). All of the dependent tubes had a significant increase in water content (compared to the elevated tubes). This increase was greater in the transplanted delayed tubed flaps. The tissue pCO2 levels were significantly increased after 24 hours in the dependent transplanted tubes, reflecting poor circulation and ischemia in them. The rate of clearance of subcutaneously injected technetium-99m was significantly increased in the dependent transplanted tubes after 72 hours, while in the elevated tubes the clearance rate was similar to that in normal skin. The morphological appearance of the vessels in these flaps complemented the results of the functional study.     

The tumbling concha-cartilage flap for correction of lop ear

This article presents a new surgical method that uses tumbling concha-cartilage flaps to correct lop ears. Through a posterior or anterior auricular skin incision, a rectangular or T-shaped cartilage flap is elevated from the concha and tumbled backward. After passing under the postauricular skin, the flap's tip is fixed to the lidded helix or scapha. The recoiling force of the flap's conchal side enables the lidded portion to be in a normal, erect, anatomic position. The method also increases the vertical height of the ear and creates a normally shaped scapha. Sixteen lop ears were corrected using this procedure, with most of them maintaining natural auricular features. Therefore, this method was considered effective for the correction of moderate lop ear deformity.     

Preferential use of end-to-side arterial anastomoses in free flap transfers.

In our early clinical experience with free flaps, we used end-to-end arterial anastomoses and in 9 our of 24 we had complete failures--7 of which were due to early arterial thrombosis. Contrarily, in 41 consecutive free flaps with end-to-side anastomoses we have not had a single failure. At the same time that we began using the end-to-side anastomoses, we also began using the latissimus dorsi free flap as our flap of first choice, and we agree that this was probably an additional reason for our improved success rate. The use of end-to-side anastomoses has the following advantages: (1) a high success rate; (2) preservation of all existing vessels in an injured extremity; (3) greater freedom of operative planning; and (4) technical simplicity in terms of access to the vessels. For us, these advantages have made end-to-side anastomosis the technique of choice in the transfer of free flaps.     

Free-style free flaps

Free-tissue transfer has become the accepted standard for reconstruction of complex defects. With the growth of this field, anatomic studies and clinical work have added many flaps to the armamentarium of the microvascular surgeon. Further advancements and experience with techniques of perforator flap surgery have allowed for the harvest of flaps in a free-style manner, where a flap is harvested based only on the preoperative knowledge of Doppler signals present in a specific region. Between June of 2002 and September of 2003, 13 free-style free flaps were harvested from the region of the thigh. All patients presented with an oral or pharyngeal cancer and underwent resection and immediate reconstruction of these flaps. All flaps were cutaneous and were harvested in a suprafascial plane. The average size of the flaps was 108 cm2 (range, 36 to 187 cm2), and the average length of the vascular pedicle was 10 cm (range, 9 to 12 cm). All flaps were successful in achieving wound coverage and functional outcomes without any vascular compromise necessitating re-exploration. Free-style free flaps have become a clinical reality. The concepts and techniques used to harvest a free-style free flap will aid in dealing with anatomic variations that are encountered during conventional flap harvest. Future trends in flap selection will focus mainly on choosing tissue with appropriate texture, thickness, and pliability to match requirements at the recipient site while minimizing donor-site morbidity.     

Efficacy of conventional monitoring techniques in free tissue transfer: an 11-year experience in 750 consecutive cases

Conventional free flap monitoring techniques (clinical observation, hand-held Doppler ultrasonography, surface temperature probes, and pinprick testing) are proven methods for monitoring free flaps with an external component. Buried free flaps lack an external component; thus, conventional monitoring is limited to hand-held Doppler ultrasonography. Free flap success is enhanced by the rapid identification and salvage of failing flaps. The purpose of this study was to compare the salvage rate and final outcomes of buried versus nonburied flaps monitored by conventional techniques. This study is a retrospective review of 750 free flaps performed between 1986 and 1997 for reconstruction of oncologic surgical defects. There were 673 nonburied flaps and 77 buried flaps. All flaps were monitored by using conventional techniques. Both buried and nonburied flaps were used for head and neck and extremity reconstruction. Only nonburied flaps were used for trunk and breast reconstruction. Buried flap donor sites included jejunum (n = 50), fibula (n = 16), forearm (n = 8), rectus abdominis (n = 2), and temporalis fascia (n = 1). Overall flap loss for 750 free flaps was 2.3 percent. Of the 77 buried flaps, 5 flaps were lost, yielding a loss rate of 6.5 percent. The loss rate for nonburied flaps (1.8 percent) was significantly lower than for buried flaps (p = 0.02, Fisher's exact test). Fifty-seven (8.5 percent) of the nonburied flaps were reexplored for either change in monitoring status or a wound complication. Reexploration occurred between 2 and 400 hours postoperatively (mean, 95 hours). All 44 of the salvaged flaps were nonburied; these were usually reexplored early (<48 hours) for a change in the monitoring status. Flap compromise in buried flaps usually presented late (>7 days) as a wound complication (infection, fistula). None of five buried flaps were salvageable at the time of reexploration. The overall salvage rate of nonburied flaps (77 percent) was significantly higher than that of buried flaps (0 percent, p<0.001, chi-square test). Conventional monitoring of nonburied free flaps has been highly effective in this series. These techniques have contributed to rapid identification of failing flaps and subsequent salvage in most cases. As such, conventional monitoring has led to an overall free flap success rate commensurate with current standards. In contrast, conventional monitoring of buried free flaps has not been reliable. Failing buried flaps were identified late and found to be unsalvageable at reexploration. Thus, the overall free flap success rate was significantly lower for buried free flaps. To enhance earlier identification of flap compromise in buried free flaps, alternative monitoring techniques such as implantable Doppler probes or exteriorization of flap segments are recommended.     

Effect of base, pentose, and phosphodiester backbone structures on binding and repair of pyrimidine dimers by Escherichia coli DNA photolyase.

Photolyases reverse the effects of UV light on cells by converting cyclobutane dipyrimidine photoproducts (pyrimidine dimers, Pyr mean value of Pyr) into pyrimidine monomers in a light-dependent reaction. Previous work has suggested that, based on substrate preference, there are two classes of photolyase: DNA photolyase as exemplified by the Escherichia coli enzyme, and RNA photolyases found in plants such as Nicotiana tabacum and Phaseolus vulgaris. In experiments aimed at identifying substrate determinants, including the pentose ring, for binding and catalysis by E. coli DNA photolyase we tested several Pyr mean value of Pyr. We found that the enzyme has relative affinities for photodimers of T mean value of T greater than or equal to U mean value of T greater than U mean value of U much greater than C mean value of C and that the E-FADH2 form of the enzyme repairs these dimers at 366 nm with absolute quantum yields of 0.9 (T mean value of T), 0.8 (U mean value of T), 0.6 (U mean value of U), and 0.05 (C mean value of C). The enzyme also repairs an isolated thymine dimer and the synthetic substrate, 1,1'-trimethylene-bis (thymine) cyclobutane dimer. Unexpectedly, we found that this enzyme, previously thought to be specific for DNA, repairs uracil cyclobutane dimers in poly(rU). The affinity of photolyase for a uracil dimer in RNA is about 10(4)-fold lower than that for a U mean value of U in DNA; however, once bound, the enzyme repairs the photodimer with the same quantum yield whether the dimer is in ribonucleoside or deoxyribonucleoside form.     

Have we found an ideal soft-tissue flap? An experience with 672 anterolateral thigh flaps

The free anterolateral thigh flap is becoming one of the most preferred options for soft-tissue reconstruction. Between June of 1996 and August of 2000, 672 anterolateral thigh flaps were used in 660 patients at Chang Gung Memorial Hospital. Four hundred eighty-four anterolateral thigh flaps were used for head and neck region recontruction in 475 patients, 58 flaps were used for upper extremity reconstruction in 58 patients, 121 flaps were used for lower extremity reconstruction in 119 patients, and nine flaps were used for trunk reconstruction in nine patients. Of the 672 flaps used in total, a majority (439) were musculocutaneous perforator flaps. Sixty-five were septocutaneous vessel flaps. Of these 504 flaps, 350 were fasciocutaneous and 154 were cutaneous flaps. Of the remaining 168 flaps, 95 were musculocutaneous flaps, 63 were chimeric flaps, and the remaining ten were composite musculocutaneous perforator flaps with the tensor fasciae latae. Total flap failure occurred in 12 patients (1.79 percent of the flaps) and partial failure occurred in 17 patients (2.53 percent of the flaps). Of the 12 flaps that failed completely, five were reconstructed with second anterolateral thigh flaps, four with pedicled flaps, one with a free radial forearm flap, one with skin grafting, and one with primary closure. Of the 17 flaps that failed partially, three were reconstructed with anterolateral thigh flaps, one with a free radial forearm flap, five with pedicled flaps, and eight with primary suture, skin grafting, and conservative methods.In this large series, a consistent anatomy of the main pedicle of the anterolateral thigh flap was observed. In cutaneous and fasciocutaneous flaps, the skin vessels (musculocutaneous perforators or septocutaneous vessels) were found and followed until they reached the main pedicle, regardless of the anatomic position. There were only six cases in this series in which no skin vessels were identified during the harvesting of cutaneous or fasciocutaneous anterolateral thigh flaps. In 87.1 percent of the cutaneous or fasciocutaneous flaps, the skin vessels were found to be musculocutaneous perforators; in 12.9 percent, they were found as septocutaneous vessels. The anterolateral thigh flap is a reliable flap that supplies a large area of skin. This flap can be harvested irrespective of whether the skin vessels are septocutaneous or musculocutaneous. It is a versatile soft-tissue flap in which thickness and volume can be adjusted for the extent of the defect, and it can replace most soft-tissue free flaps in most clinical situations.