Management of secondary soft-tissue deficits following microsurgical head and neck reconstruction by means of another free flap

Secondary soft-tissue deficits may develop following a microsurgical reconstruction in the head and neck region because of inadequate planning or chronic effects of radiotherapy. Although most cases could be managed with alternative methods, free flaps might be necessary in difficult cases. Herein are described 11 cases of microsurgical head and neck reconstruction in which secondary soft-tissue deficits required transfer of another soft-tissue free flap. All patients had malignant tumors treated with surgical resection, and their defects were reconstructed with free flaps. Seven patients received either preoperative or postoperative adjunctive radiotherapy. These patients gradually developed signs and symptoms of soft-tissue deficiency in the reconstructed area, and a soft-tissue free flap transfer was required for treatment within an average of 21.5 months of their initial reconstruction. Five rectus abdominis, one rectus femoris, one latissimus dorsi, one tensor fasciae latae myocutaneous, one radial forearm, one medial arm, and one dorsalis pedis flap were used for this purpose. All flaps survived completely. The average follow-up time was 32 months. Significant improvement was achieved in all cases, and no further major surgical procedures were required. Secondary soft-tissue deficits that could not be predicted or prevented during the initial microsurgical reconstruction may be treated successfully by a subsequent free soft-tissue transfer in selected cases.     

Free transfer of expanded parascapular, latissimus dorsi, and expander "capsule" flap for coverage of large lower-extremity soft-tissue defect

The coverage of large soft-tissue defects usually requires a large flap transfer, especially in a combination and expanded form. However, some large soft-tissue defects still cannot be covered by such flaps. In this article, we present a case of a civil war injury in a patient from Afghanistan who had severe trauma to the right knee, lower thigh, and upper leg and a marked soft-tissue defect. This large soft-tissue defect was covered with a large combined free flap of the expanded parascapular and latissimus dorsi muscle, including a large retrograde hinge flap of the tissue expander capsule and a complementary skin graft. The defect was covered completely, and the final result was excellent.     

Selective alteration of palpebral fissure form by lateral canthopexy

A method is described for altering the shape and position of the palpebral fissure at the lateral canthus. Three steps are essential to alter shape and position. They are (1) identification of a lateral canthal soft-tissue mass consisting of periosteum, lateral canthal ligament, and orbicularis muscle, (2) extensive subperiosteal soft-tissue mobilization of the lateral canthal soft-tissue mass (LCSTM) from a point just superior to the zygomaticofrontal suture and inferiorly along the infraorbital rim to a point corresponding with a vertical line drawn from the pupil downward, and (3) cutting of all soft tissue, including orbicularis muscle from dermis to bone and from bone to conjunctiva, from the lateral canthal soft-tissue mass medially to a point equal to a vertical line drawn from the pupil downward. After tension-free shifting laterally and superiorly has been accomplished, the lateral canthal soft-tissue mass is fixed into bone with minimal overcorrection. If there is still soft-tissue skin resistance, then overcorrection is desirable. The most difficult judgments in the procedure are the amount of superior and lateral tension to be placed on the palpebral fissure. As an aid in these judgments, the lateral-most extent of the palpebral fissure should be approximately 3 mm above the medial canthus horizontally and 3 to 4 mm medial to the medial-most portion of the lateral orbital rim. If overcorrection occurs, it can be released relatively simply.     

Variation in soft-tissue thicknesses on the human face and their relation to craniometric dimensions

The average thickness of soft tissues on parts of the face is known, but its variation has not been related to cranial morphology. To investigate this relationship, measurements of facial soft-tissue depths and craniometric dimensions were taken on adult, white Australian cadavers (17 male and 23 female). Significant correlations between many soft-tissue depths and craniometric dimensions were found, suggesting a relationship between the amount of soft tissue present on the face and the size of the underlying bony skeleton. Soft-tissue depths were highly positively correlated with each other; craniometric dimensions were correlated but to a lesser extent. Males had thicker soft tissues and larger craniometric dimensions than females; considerable overlap of ranges was also noted. Multiple regression analysis was used to produce equations predicting the soft-tissue depth at specified areas of the face from craniometric dimensions. A subsample of nine cadavers was examined for the effects of tissue embalming. Embalming caused significant initial increases in facial soft-tissue depths. Cadavers embalmed for less than 6 months had soft-tissue depths significantly greater than for fully embalmed cadavers. The evidence that facial soft-tissue thicknesses vary with craniofacial dimensions has implications for forensic identification, facial aesthetic surgery, and approximation of the facial features of extinct individuals.     

Simultaneous reconstruction of cervical soft tissue and esophagus with a gastro-omental free flap

A microvascular transfer of gastric tube and omentum was used to simultaneously reconstruct cervical soft-tissue and esophageal defects in five patients. All patients had previous high-dose radiation and multiple flap reconstructions. The largest esophageal and soft-tissue defects were 10 cm and 160 cm2, respectively. All wounds healed primarily except for one orocutaneous fistula. There was one death from an intraoperative stroke. The gastro-omental flap is useful in cases where the reconstructive surgeon is faced with both esophageal and soft-tissue defects--particularly in heavily irradiated patients who have few reconstructive options.     

Non-invasive assessment of soft-tissue artifact and its effect on knee joint kinematics during functional activity

The soft-tissue interface between skin-mounted markers and the underlying bones poses a major limitation to accurate, non-invasive measurement of joint kinematics. The aim of this study was twofold: first, to quantify lower limb soft-tissue artifact in young healthy subjects during functional activity; and second, to determine the effect of soft-tissue artifact on the calculation of knee joint kinematics. Subject-specific bone models generated from magnetic resonance imaging (MRI) were used in conjunction with X-ray images obtained from single-plane fluoroscopy to determine three-dimensional knee joint kinematics for four separate tasks: open-chain knee flexion, hip axial rotation, level walking, and a step-up. Knee joint kinematics was derived using the anatomical frames from the MRI-based, 3D bone models together with the data from video motion capture and X-ray fluoroscopy. Soft-tissue artifact was defined as the degree of movement of each marker in the anteroposterior, proximodistal and mediolateral directions of the corresponding anatomical frame. A number of different skin-marker clusters (total of 180) were used to calculate knee joint rotations, and the results were compared against those obtained from fluoroscopy. Although a consistent pattern of soft-tissue artifact was found for each task across all subjects, the magnitudes of soft-tissue artifact were subject-, task- and location-dependent. Soft-tissue artifact for the thigh markers was substantially greater than that for the shank markers. Markers positioned in the vicinity of the knee joint showed considerable movement, with root mean square errors as high as 29.3 mm. The maximum root mean square errors for calculating knee joint rotations occurred for the open-chain knee flexion task and were 24.3°, 17.8° and 14.5° for flexion, internal–external rotation and abduction–adduction, respectively. The present results on soft-tissue artifact, based on fluoroscopic measurements in healthy adult subjects, may be helpful in developing location- and direction-specific weighting factors for use in global optimization algorithms aimed at minimizing the effects of soft-tissue artifact on calculations of knee joint rotations.     

Multipaddled Anterolateral Thigh Chimeric Flap for Reconstruction of Complex Defects in Head and Neck

The anterolateral thigh flap has been the workhouse flap for coverage of soft-tissue defects in head and neck for decades. However, the reconstruction of multiple and complex soft-tissue defects in head and neck with multipaddled anterolateral thigh chimeric flaps is still a challenge for reconstructive surgeries. Here, a clinical series of 12 cases is reported in which multipaddled anterolateral thigh chimeric flaps were used for complex soft-tissue defects with several separately anatomic locations in head and neck. Of the 12 cases, 7 patients presented with trismus were diagnosed as advanced buccal cancer with oral submucous fibrosis, 2 tongue cancer cases were found accompanied with multiple oral mucosa lesions or buccal cancer, and 3 were hypopharyngeal cancer with anterior neck skin invaded. All soft-tissue defects were reconstructed by multipaddled anterolateral thigh chimeric flaps, including 9 tripaddled anterolateral thigh flaps and 3 bipaddled flaps. The mean length of skin paddle was 19.2 (range: 14–23) cm and the mean width was 4.9 (range: 2.5–7) cm. All flaps survived and all donor sites were closed primarily. After a mean follow-up time of 9.1 months, there were no problems with the donor or recipient sites. This study supports that the multipaddled anterolateral thigh chimeric flap is a reliable and good alternative for complex and multiple soft-tissue defects of the head and neck.     

Muscle activity in the leg is tuned in response to impact force characteristics

Based on results from quasi-static experiments, it has been suggested that the lower extremity muscle activity is adjusted in reaction to impact forces with the goal of minimizing soft-tissue vibrations. It is not known whether a similar muscle tuning occurs during dynamic activities. Thus, the purpose of this study was to determine the effect of changes in the input signal on (a) vibrations of lower extremity soft-tissue packages and (b) EMG activity of related muscles during heel-toe running. Subjects performed heel-toe running in five different shoe conditions. Ground reaction forces were measured with a KISTLER force platform, soft-tissue vibrations were measured with tri-axial accelerometers and muscle activity was measured using surface EMG from the quadriceps, hamstrings, tibialis anterior and triceps surae groups from 10 subjects. By changing both the speed of running and the shoe midsole material the impact force characteristics were changed. There was no effect of changes in the input signal on the soft-tissue peak acceleration following impact. A significant correlation (R2=0.819) between the EMG pre-activation intensity and the impact loading rate changes was found for the quadriceps. In addition, the input frequency was shown to approach the vibration frequency of the quadriceps. This evidence supports the proposed paradigm that muscle activity is tuned to impact force characteristics to control the soft-tissue vibrations.     

Proteomic signatures corresponding to histological classification and grading of soft-tissue sarcomas

We performed a global protein expression study on soft-tissue sarcoma in order to develop novel diagnostic biomarkers and allow molecular classification. 2-D difference gel electrophoresis was used to generate the global protein expression profiles of 80 soft-tissue sarcoma samples with seven different histological backgrounds. We found that 67 protein spots distinguished the subtypes of soft-tissue sarcoma. Hierarchical clustering with these 67 protein spots resulted in the grouping of all 80 sarcoma samples corresponding to the histological classification. We found that the expression pattern of tropomyosin isoforms was different in conventional and pleomorphic leiomyosarcomas. We also identified five proteins, including alpha-1-antitrypsin, alpha-actinin 1, HSP27, and elongation factor 2, that could differentiate between malignant fibrous histiocytomas and leiomyosarcomas in grade III into low-risk and high-risk groups, which differed significantly with respect to survival. These results establish proteomics as a powerful tool to develop novel biomarkers for diagnosis and molecular classification of soft-tissue sarcomas. Identification of proteins associated with survival in grade III sarcoma will allow delineation of a high-risk group that may benefit from adjuvant therapy and the exclusion of low-risk patients in whom additional therapies are unlikely to exhibit clinical benefit.     

Muscle activity reduces soft-tissue resonance at heel-strike during walking

Muscle activity has previously been suggested to minimize soft-tissue resonance which occurs at heel-strike during walking and running. If this concept were true then the greatest vibration damping would occur when the input force was closest to the resonant frequency of the soft-tissues at heel-strike. However, this idea has not been tested. The purpose of this study was to test whether muscle activity in the lower extremity is used to damp soft-tissue resonance which occurs at heel-strike during walking. Hard and soft shoe conditions were tested in a randomized block design. Ground reaction forces, soft-tissue accelerations and myoelectric activity were measured during walking for 40 subjects. Soft-tissue mass was estimated from anthropologic measurements, allowing inertial forces in the soft-tissues to be calculated. The force transfer from the ground to the tissues was compared with changes in the muscle activity. The soft condition resulted in relative frequencies (input/tissue) to be closer to resonance for the main soft-tissue groups. However, no increase in force transmission was observed. Therefore, the vibration damping in the tissues must have increased. This increase concurred with increases in the muscle activity for the biceps femoris and lateral gastrocnemius. The evidence supports the proposal that muscle activity damps soft-tissue resonance at heel-strike. Muscles generate forces which act across the joints and, therefore, shoe design may be used to modify muscle activity and thus joint loading during walking and running.     

Precision rhinoplasty. Part II: Prediction

This retrospective study was undertaken to investigate the soft-tissue response rate to the skeletal and soft-tissue alterations following a rhinoplasty. Ninety-eight patients, 80 females and 18 males, with a mean follow-up of 13 months, were included in this study. The tracings of the outline of preoperative cephaloxerograms and life-size photographs were superimposed on the postoperative ones, and the differences were measured and confirmed with measurements of intraoperative resected segments. The soft-tissue response to skeletal alterations was measured in seven different zones. Zone 1 (nasion) and zone 7 (nasal spine area) had the lowest mean response rate of approximately 25 percent. Zone 2 (proximal bridge) and zone 3 (midbridge) had a 60 percent response rate. Zone 4 (supratip area) had a 43 percent response, zone 5 had a 41 percent response, and zone 6 had a 40 percent response rate. There were statistically significant differences among the response rates of thick, medium, and thin noses. Age was an important factor in zones 1, 4, 5, 6, and 7. The patient's sex did not influence the soft-tissue response rate to skeletal alterations. The soft-tissue response in relation to the alar base narrowing was about 52 percent. This study reveals a predictable soft-tissue response to skeletal alterations on all zones except zone 7 (nasal spine area).     

Management of soft-tissue problems in leg trauma in conjunction with application of the Ilizarov fixator assembly

Forty-five patients presenting with high-energy open grade III tibial diaphyseal fractures were treated with the Ilizarov technique. Of these patients, 28 required plastic surgical intervention for achieving wound closure. Most of the injuries were complicated by initial neglect and inadequate primary soft-tissue coverage resulting in osteitis, sequestration, and segmental diaphyseal tibial defects, often in combination with skin-envelope deficits of various types in and around the fracture perimeter. The unique soft-tissue problems encountered while using the Ilizarov fixator have not been focused on in previous reports on the management of segmental bone defects. Four basic local flap procedures: the transposition flap, rotation flap, adipofascial turnover flap, and Z-plasty are useful and versatile for managing most types and grades of soft-tissue defects associated with a segmental bone loss with the Ilizarov technique.     

Sonography of nasal tip anatomy and surgical tip refinement

The amorphous or wide nasal tip is the most commonly encountered nasal tip deformity, but little has been done to measure the effect of standard rhinoplasty techniques on nasal tip width. In the clinical routine, nasal tip width and soft-tissue cover thickness are estimated by inspection and palpation rather than by measurement. In this study, a B-mode sonograph with a 12-MHz transducer was used in a noncontact mode to measure tip width 0.5 cm occipital to the tip defining point, distance between the alar cartilage domes, and thickness of the soft-tissue cover overlying the lower lateral cartilages. These parameters were measured 3 to 8 weeks before and 56 days to 19 months after a transdomal suture tip plasty in 18 patients. The distance between the alar cartilage domes seemed to be an important factor for tip width because interdomal distance, not soft-tissue cover thickness, correlated with tip width before surgery (correlation: 0.53). Conversely, the degree of tip refinement correlated with preoperative soft-tissue cover thickness (correlation: 0.75), but not with interdomal distance. Ultrasonic imaging of nasal soft tissues may help to assess the effect of different tip refining procedures and other soft-tissue changes after rhinoplasty.     

Chin disfigurement following removal of alloplastic chin implants

Insertion and subsequent removal of alloplastic chin implants is not an innocuous procedure, as commonly believed. Ten women, aged 23 to 62 years of age (mean 45 years) are reported in whom severe soft-tissue deformities were observed 6 months to 6 years (mean 32 months) after removal of their implants. Resulting deformities consisted of chin ptosis and bizarre soft-tissue pogonial bunching and dimpling in repose or on animation in 9 of the 10 patients (90 percent). Asymmetrical motion of the lower lip was noted by 5 of the 10 patients. Two patients complained of pain and tenderness over the soft-tissue pogonion. The "bizarre" soft-tissue chin deformities, once established, are virtually uncorrectable. Presently, we recommend serious consideration be given to performing an immediate osseous genioplasty in patients requiring removal of alloplastic chin implants to prevent the evolution of such abnormalities.     

Lateral facial soft-tissue prediction model: analysis using Fourier shape descriptors and traditional cephalometric methods

This study was designed to investigate the relationship between traditional skeletal cephalometric measurement and Fourier analysis of the lateral soft-tissue profile. A random sample of 121 untreated subjects of European descent, with wide ranges of malocclusions and underlying facial patterns, was selected in the Orthodontic Unit at the University of Melbourne. Lateral cephalograms were available for all subjects. Both traditional lateral cephalometric analysis and Fourier soft-tissue profile analysis were carried out. Multivariate statistical analysis among 11 hard-tissue cephalometric measurements and the first 50 Fourier harmonics was then performed. This analysis formed the basis for a subsequently proposed soft-tissue prediction model. From this model, 50 predicted x- and y-harmonics were generated for each subject in the total sample. Calculation of Pearson's correlation coefficients between the actual and predicted harmonics revealed strong relationships for many of the lower-order harmonics. To further test the model, the prediction-coefficients derived from all 121 subjects were then used to make predictions for the first 50 x- and y-harmonics for a subgroup of 10 independent test subjects. Once again, Pearson's correlations between the actual and predicted harmonics of the test model in the lower-order harmonics revealed strong associations. Superimposition of the actual and predicted soft-tissue outlines, however, revealed that much actual detail in the region between the nose and the chin was still lost using the predicted Fourier harmonics. This suggests that soft-tissue prediction based on this Fourier test model, while already useful in Forensic facial reconstruction, may not yet be appropriate for useful diagnosis and planning in clinical disciplines.     

The role of free-tissue transfers in lower-extremity reconstruction

Eighty-five free flaps were performed in 76 patients for defects in the lower extremity. A new classification of lower-extremity defects was devised to help define the role of free-tissue transfers: group 1, soft-tissue defects; group 2, soft-tissue and bone loss less than 8 cm; group 3, massive soft-tissue and bone loss greater than 8 cm; and group 4, bone defect only. Each group was further divided into clean (A) and infected (B) wounds. Our overall results include resolution of the presenting problem in 82 percent; there were 17 flap losses (20 percent), persistent osteomyelitis in 8, and 10 amputations. This review has prompted us to limit our indications for limb salvage, particularly in group 3B, in patients with compound injuries that include loss of plantar sensation, and in patients with large segments of infected bone.     

The surgical management of orbital neurofibromatosis

Orbitofacial neurofibromatosis may cause severe soft-tissue deformity along with pulsating exophthalmos. The orbit is enlarged, and the greater wing of the sphenoid is absent. The eye in some cases may be functionally useless, immobile, displaced, and blind. In these, orbital exenteration with soft-tissue excision and orbital reconstruction is recommended. External cover is provided by the thin eyelid skin, and a prosthesis ultimately allows a very satisfactory end result. Four such cases with a minimum of 2 years of follow-up are presented.     

The superficial musculoaponeurotic system of the nose

Thirty noses were examined macroscopically and histologically to determine the fibromuscular and aponeurotic layers. There are five soft-tissue components beneath the dermis: a superficial fatty panniculus, a fibromuscular layer, a deep fatty layer, a longitudinal fibrous sheet, and an interdomal ligament. The nose is covered by a nasal SMAS, which forms part of the SMAS of the face. The continuous fibromuscular layer interconnects the musculature through aponeuroses, thus distributing their forces. The alar muscles change the transnasal pressure of the nasal valve, affecting respiration. To preserve the integrity of the nasal soft-tissue layers, one may elevate the soft-tissue envelope beneath the nasal musculature.     

The role of tissue expansion in the treatment of atypical facial clefting

Tissue expansion can be a valuable tool in the reconstruction of soft-tissue defects in craniofacial clefts. To our knowledge, there have been no reports in the literature of the use of tissue expanders to help solve this problem. We report the case of a child with an atypical Tessier no. 3 craniofacial cleft who had a forehead tissue expander placed, inflated, and thus used to provide sufficient local facial skin for repair of the soft-tissue defect.     

Relationship between running loads and soft-tissue injury in elite team sport athletes

Although the potential link between running loads and soft-tissue injury is appealing, the evidence supporting or refuting this relationship in high-performance team sport athletes is nonexistent, with all published studies using subjective measures (e.g., ratings of perceived exertion) to quantify training loads. The purpose of this study was to investigate the risk of low-intensity (e.g., walking, jogging, total distances) and high-intensity (e.g., high acceleration and velocity efforts, repeated high-intensity exercise bouts) movement activities on lower body soft-tissue injury in elite team sport athletes. Thirty-four elite rugby league players participated in this study. Global positioning system data and the incidence of lower body soft-tissue injuries were monitored in 117 skill training sessions during the preseason and in-season periods. The frailty model (an extension of the Cox proportional regression model for recurrent events) was applied to calculate the relative risk of injury after controlling for all other training data. The risk of injury was 2.7 (95% confidence interval 1.2-6.5) times higher when very high-velocity running (i.e., sprinting) exceeded 9 m per session. Greater distances covered in mild, moderate, and maximum accelerations and low- and very low-intensity movement velocities were associated with a reduced risk of injury. These results demonstrate that greater amounts of very high-velocity running (i.e., sprinting) are associated with an increased risk of lower body soft-tissue injury, whereas distances covered at low and moderate speeds offer a protective effect against soft-tissue injury. From an injury prevention perspective, these findings provide empirical support for restricting the amount of sprinting performed in preparation for elite team sport competition. However, coaches should also consider the consequences of reducing training loads on the development of physical qualities and playing performance.