The effectiveness of the superiorly based pharyngeal flap in relation to the type of palatal defect and timing of the operation

A 10-year review of 39 patients who underwent a superiorly based pharyngeal flap for severe velopharyngeal insufficiency was performed. The effectiveness of the operation, as scored by standardized preoperative and postoperative evaluations, was related to age at operation, type of defect, and duration of velopharyngeal inadequacy. There was no statistical difference between those who were under the age of 6 years (100 percent were improved) at the time of the operation versus those 6 years and older (74 percent improved). Likewise, there was no difference between those patients who received an early flap (92 percent were improved) versus those who received a flap 2 or more years after initial palatorrhaphy (90 percent were improved). The type of palatal defect also was not a significant factor, and none of the patients exhibited a postoperative decrease in function (p less than or equal to 0.001). The operation offered reliable salvage of velopharyngeal competency regardless of the above-mentioned factors.     

Effect of smoking on complications in patients undergoing free TRAM flap breast reconstruction

Free pedicled transverse rectus abdominis myocutaneous (TRAM) flap breast reconstruction is often advocated as the procedure of choice for autogenous tissue breast reconstruction in high-risk patients, such as smokers. However, whether use of the free TRAM flap is a desirable option for breast reconstruction in smokers is still unclear. All patients undergoing breast reconstruction with free TRAM flaps at our institution between February of 1989 and May of 1998 were reviewed. Patients were classified as smokers, former smokers (patients who had stopped smoking at least 4 weeks before surgery), and nonsmokers. Flap and donor-site complications in the three groups were compared. Information on demographic characteristics, body mass index, and comorbid medical conditions was used to perform multivariate statistical analysis. A total of 936 breast reconstructions with free TRAM flaps were performed in 718 patients (80.9 percent immediate; 23.3 percent bilateral). There were 478 nonsmokers, 150 former smokers, and 90 smokers. Flap complications occurred in 222 (23.7 percent) of 936 flaps. Smokers had a higher incidence of mastectomy flap necrosis than nonsmokers (18.9 percent versus 9.0 percent; p = 0.005). Smokers who underwent immediate reconstruction had a significantly higher incidence of mastectomy skin flap necrosis than did smokers who underwent delayed reconstruction (21.7 percent versus 0 percent; p = 0.039). Donor-site complications occurred in 106 (14.8 percent) of 718 patients. Donor-site complications were more common in smokers than in former smokers (25.6 percent versus 10.0 percent; p = 0.001) or nonsmokers (25.6 percent versus 14.2 percent; p = 0.007). Compared with nonsmokers, smokers had significantly higher rates of abdominal flap necrosis (4.4 percent versus 0.8 percent; p = 0.025) and hernia (6.7 percent versus 2.1 percent; p = 0.016). No significant difference in complication rates was noted between former smokers and nonsmokers. Among smokers, patients with a smoking history of greater than 10 pack-years had a significantly higher overall complication rate compared with patients with a smoking history of 10 or fewer pack-years (55.8 percent versus 23.8 percent; p = 0.049). In summary, free TRAM flap breast reconstruction in smokers was not associated with a significant increase in the rates of vessel thrombosis, flap loss, or fat necrosis compared with rates in nonsmokers. However, smokers were at significantly higher risk for mastectomy skin flap necrosis, abdominal flap necrosis, and hernia compared with nonsmokers. Patients with a smoking history of greater than 10 pack-years were at especially high risk for perioperative complications, suggesting that this should be considered a relative contraindication for free TRAM flap breast reconstruction. Smoking-related complications were significantly reduced when the reconstruction was delayed or when the patient stopped smoking at least 4 weeks before surgery.     

Effects of aesthetic abdominoplasty on abdominal wall perfusion: a quantitative evaluation

Abdominoplasty procedures involve a high risk of early complications, including hematomas, seromas, necrosis, and wound-healing problems. Their rationale is evident from the vascular anatomy of the abdominal wall, as traditional abdominoplasty includes a division of the main perforating vessels. No studies exist to quantitatively assess the consequences of abdominoplasty on the perfusion of the random pattern abdominal flap. To address this issue and quantify the influence of classic abdominoplasty on the perfusion of the abdominal skin, the authors performed a prospective clinical trial including 15 low-risk patients undergoing abdominoplasty for aesthetic purposes. Perfusion of the abdominal flap was measured intraoperatively using the technique of dynamic laser-fluorescence-videoangiography. In the region between the umbilicus and the transverse scar (zone 1), the increment of fluorescence (the slope of the intensity curve during inflow of the indocyanine green) was recorded and compared with the intensity curve of normal tissue that was not involved in surgery (thoracic wall). The results of the intraoperative indocyanine green perfusography showed a significant impairment of the vascular supply of zone 1 in all patients. The mean perfusion index in this region was 17.2 percent (range, 5 to 32 percent) of the perfusion of the surrounding skin that was not involved in surgery. The complication rate was 33 percent (five patients) and included two cases of hematoma and three cases of scar dehiscence with skin and/or fat necrosis. These data indicate that conventional abdominoplasty including extended undermining and division of the superficial and the deep arterial systems causes profound devascularization of the abdominal flap. This might explain the high incidence of complications following this procedure.     

Does velopharyngeal closure pattern affect the success of pharyngeal flap pharyngoplasty?

Historically at The Hospital for Sick Children in Toronto, pharyngeal flap pharyngoplasty has been the treatment of choice for treatment of velopharyngeal insufficiency, regardless of velopharyngeal closure pattern. The authors hypothesize that pharyngeal flap pharyngoplasty is more effective in treating velopharyngeal insufficiency in patients with circular or sagittal velopharyngeal closure and less effective in treating the coronal closure pattern. Ninety-three patients who underwent superiorly based pharyngeal flap surgery for velopharyngeal insufficiency were evaluated in a retrospective chart review. Closure pattern was determined preoperatively by nasopharyngoscopy or multiview videofluoroscopy. Nasalance was assessed preoperatively and at 6 weeks and 1 year postoperatively. Nasalance during nonnasal speech was decreased on average, for all closure patterns, postoperatively. However, a significantly higher percentage of patients were corrected to normal nasalance scores in thenoncoronal group than in the coronal group (57 percent versus 35 percent, respectively) at 1 year postoperatively (p < 0.05). Surgical overcorrection, as determined by postoperative hyponasality, occurred at a rate of 13 percent in the coronal group versus 7 percent in the noncoronal group (not statistically significant). The results demonstrate that hypernasality in patients with a coronal velopharyngeal closure pattern can be improved by pharyngeal flap pharyngoplasty. This procedure, however, is more frequently effective in correcting noncoronal closure pattern velopharyngeal insufficiency than coronal pattern velopharyngeal insufficiency. The authors are now more selective in their approach to the management of velopharyngeal insufficiency and are more inclined to treat coronal pattern velopharyngeal insufficiency with sphincter pharyngoplasty.     

Factor XI deficiency: implications for management of patients undergoing aesthetic surgery.

We report our experience in patients with an abnormal partial thromboplastin time elevation due to factor XI deficiency (Rosenthal syndrome) who presented for aesthetic surgery consideration. Preoperative evaluation included a thorough history, physical examination, coagulation profile, and hematological consultation. Nine of 10 patients underwent 12 elective aesthetic procedures without undue intraoperative or postoperative bleeding. Based on these findings, we stratified patients as low risk or high risk. Low-risk patients were those with greater than 15 percent factor XI levels, or those with 5 to 14 percent factor XI levels but a history of multiple major surgical procedures without bleeding complications. High-risk patients were those with factor XI levels less than 15 percent, history of bleeding either spontaneously or with surgery, and a family history of bleeding diathesis from factor XI deficiency. Low-risk patients had fresh frozen plasma available for the procedure, whereas high-risk patients received fresh frozen plasma 2 hours before surgery. We conclude that (1) in these patients with abnormally high partial thromboplastin time values and no prior known bleeding disorder, we have identified factor XI deficiency as the prevalent coagulopathy; (2) partial thromboplastin time does not necessarily correlate with factor XI levels; (3) patients can be classified as high or low risk for elective surgery based on factor XI levels and prior surgical or family history; (4) recommendations for perioperative management can be made based on this risk profile; and (5) aesthetic surgery can be performed successfully and safely on patients with factor XI deficiency on a case-by-case basis when appropriate guidelines are enforced.     

Thoracodorsal vessels as recipient vessels for the free TRAM flap in delayed breast reconstruction.

The internal mammary vessels have been recommended as the first choice recipient vessels for delayed breast reconstruction with the free TRAM flap. This approach has avoided surgery in the previously operated axilla, has required a shorter pedicle length, and has allowed for more medial placement of the TRAM tissue. Frequency of nonusable axillary vessels has been reported at 11 percent, with a 6 percent incidence of flap loss in the delayed reconstructive setting. We reviewed our experience with the thoracodorsal vessels as recipient vessels in delayed free TRAM breast reconstruction to assess more accurately the adequacy of these potential recipient vessels. All patients undergoing delayed TRAM reconstruction were reviewed. Forty-seven of 300 consecutive TRAM procedures were for planned delayed free reconstruction. In seven of the patients (15 percent), the thoracodorsal vessels were found to be inadequate for free reconstruction. A supercharged pedicled TRAM was used for reconstruction in each of these seven patients. Average operating room time was 7 hours. Mean follow-up time was 38 months. Nineteen percent of all patients developed at least one complication. Twelve percent of free TRAM patients developed a complication, whereas 57 percent of supercharged patients developed a postoperative complication. The difference in complication rates was statistically significant. The thoracodorsal vessels have provided an adequate recipient vessel in 85 percent of delayed free TRAM reconstructions, comparable to previous reports. Pedicling and supercharging the flap, in those situations in which the thoracodorsal vessels were inadequate, were associated with an increased incidence of postoperative complications. This suggests that in the delayed reconstructive setting, higher-risk patients benefit from free reconstruction over supercharged reconstructions. A second recipient vessel should be used when the thoracodorsal vessels are inadequate for planned free TRAM reconstruction. In these circumstances, we would recommend the use of the internal mammary vessels followed by the thoracoacromial vessels as reliable alternative recipient sites for delayed free TRAM reconstruction.     

Use of apron flap incision for neck dissection.

Neck dissection is one of the most commonly performed surgical procedures in the management of head and neck cancer. Different skin incisions with various modifications have been described in the literature. Three commonly used but conceptually different incisions were compared with respect to the incidence of wound dehiscence in a retrospective review. There were 166 patients with 184 neck dissections carried out using a triradiate (n = 85), modified MacFee (n = 25), or an apron flap incision (n = 74). The incidence of wound dehiscence in the three groups was 11 percent, 8 percent, and 0 percent for the triradiate, modified MacFee, and apron flap incisions, respectively. There was a statistically significant difference in the incidence of wound dehiscence between the apron flap incision and the triradiate incision groups (p = 0.004). The difference in wound dehiscence was not statistically significant between the apron flap incision and the modified MacFee incision groups (p = 0.06). Overall, there was a significant increase in the incidence of wound dehiscence in previously irradiated necks (p = 0.02), but this was significant only for the triradiate incision (p = 0.005) when analyzed individually. Comparison of triradiate, apron, and MacFee incisions did not show a statistically significant difference between the incisions with regard to other postoperative complications in terms of seroma, hematoma, wound infection, and fistula formation. The apron flap incision is the recommended approach in the presence of previous neck irradiation as it gives easier access than the MacFee incision. The robustness of the flap is because of the absence of a trifurcate point as well as a good vascular supply arising from arterial territory of the external carotid artery.     

Immediate breast reconstruction: why the free TRAM over the conventional TRAM flap?

Use of the transverse rectus abdominis myocutaneous (TRAM) flap for immediate breast reconstruction is controversial because of fear of flap loss and concern that a high complication rate could interfere with adjuvant therapy. One common complication of the TRAM, partial flap necrosis, can interfere with both institution of postoperative therapy and evaluation for recurrence. In an attempt to minimize this problem, we began using the free TRAM flap based on the inferior deep epigastric vessels. This study compares our experience with conventional superior-pedicled (cTRAM) flaps and free TRAM (fTRAM) flaps. A total of 68 breasts were reconstructed in 63 patients, of which 48 of 68 (71 percent) were conventional TRAM flaps and 20 of 68 (29 percent) were free TRAM flaps. Of the 48 conventional TRAM flaps, 26 (54 percent) were unipedicled and 22 (46 percent) were bipedicled. There were 39 of 48 (81 percent) conventional TRAM flaps and 17 of 20 (85 percent) free TRAM flaps with T1 or T2 lesions. Node-positive patients occurred in 14 of 48 (29 percent) conventional TRAM flaps and 2 of 20 (10 percent) free TRAM flaps. One-fourth of patients in both groups smoked cigarettes. Twenty-one of 48 patients (44 percent) with conventional TRAM flaps required postoperative chemotherapy, and 6 of 21 (29 percent) were delayed because of complications of the TRAM flap. Of the 7 of 20 (35 percent) free TRAM flap patients who required post-operative chemotherapy, only 1 of 7 (14 percent) was delayed because of TRAM flap complications.(ABSTRACT TRUNCATED AT 250 WORDS)     

Free tissue transfer in patients with renal disease

Several authors have cited renal disease as a risk factor for free flap failure. The authors performed a retrospective analysis of all patients who underwent free tissue transfer with concomitant renal disease, including acute renal failure, end-stage renal disease, chronic renal insufficiency, and functional kidney transplants, to determine what effect renal disease has on flap survival and overall reconstructive outcome. More than 1053 free flaps were examined. Renal disease was identified in 32 patients who underwent 33 free tissue transfers. Average patient age was 57 years (range, 36 to 80 years). Twelve patients (38 percent) were on chronic dialysis (end-stage renal disease), 18 patients (56 percent) had chronic renal insufficiency, and three patients (9 percent) had the diagnosis of acute renal failure at the time of surgery. Three patients in the chronic renal insufficiency group had a functioning renal transplant. Average follow-up was 16 months. Immediate postoperative complications occurred in 14 patients (42 percent of the 33 flaps). Overall perioperative mortality was 3 percent. Within the first 30 days there were two cases (6 percent) of primary flap failure; an additional four legs were lost as the result of complications related to their bypass grafts. There were no primary flap failures after 30 days; however, within the first year after surgery an additional seven limbs were lost as the result of progressive ischemia or infection, and an additional three patients died. This resulted in a 52 percent incidence of major morbidity or mortality during the first year and a 55 percent reconstructive success rate in survivors at 1 year. No significant difference was seen in postoperative morbidity or mortality when comparing the end-stage renal disease group to the chronic renal insufficiency group; however, patients with renal disease and diabetes tended to have poorer outcomes. Renal disease, especially renal disease associated with diabetes and peripheral vascular disease, can be a strong indicator of possible reconstructive failure. The surgeon and patient should be aware of the medical and surgical complications associated with this procedure at the outset.     

TRAM flap breast reconstruction: tumescent technique reduces blood loss and transfusion requirement

The tumescent technique has been shown to be efficacious in reducing both operative and postoperative bleeding without significant deleterious side effects in suction lipectomy. In this study, the effects of the tumescent technique on postoperative complications in transverse rectus abdominis myocutaneous (TRAM) flap breast reconstruction are investigated. All women who underwent a TRAM flap breast reconstruction by the senior author (J.B.) at the Emory Clinic during the years 1990 to 1996 were pooled (n = 386). Any woman who had a preincision infiltration of 0.25% epinephrine-containing saline solution (>200 cc) around the donor site was included in the tumescent group (n = 59). Medical records were reviewed, and rates of partial flap loss, fat necrosis (> or =10 percent flap volume), flap full-thickness skin loss, donor-site complication (skin loss, hernia, or infection), and blood transfusion were determined. Group rates were compared. The infiltrated group had a significantly lower transfusion rate as compared with the control group (0.34 units versus 1.32 units, p < 0.001). The rates of partial flap loss and fat necrosis were less in the tumescent group, but not significantly (0 percent versus 4 percent, p = 0.232; and 1.7 percent versus 10.4 percent, p = 0.058). There were no significant differences in the incidence of full-thickness skin loss or donor-site complications. Donor-site infiltration before incision with a 0.25% epinephrine-containing saline solution significantly reduced the transfusion requirement in TRAM flap breast reconstruction patients without adversely affecting either breast mound or abdominal donor-site complication rates.     

Abdominal dermolipectomies: early postoperative complications and long-term unfavorable results

A retrospective study was done on a population of 258 women who had undergone surgery for abdominal dermolipectomy between January of 1991 and May of 1996. The postoperative complications and flaws seen at long-term follow-up are discussed. The surgical techniques used, with or without lipoaspiration, were the infraumbilical plasty and full plasties with horizontal or inverted T scars. Six types of postoperative complications were noted: hemorrhage in 1.2 percent, lymphorrhea in 10.9 percent, infection in 7 percent, skin necrosis in 6.6 percent, secondary dehiscence of the scar in 2.3 percent, and thromboembolic accidents in 1.2 percent. No significant difference was found in the rate of necrosis development between patients who did and did not undergo lipoaspiration. However, a statistically significant difference was seen in the rate of skin necrosis between the T-type plasty (35.5 percent) and the other two procedures (1.43 percent for infraumbilical plasties and 4.60 percent for full plasties with horizontal scar). With regard to the flaws found at long-term follow-up, the rate of above-scar fat folds and/or dog-ears was 27.9 percent, and the rate of defective scars was 26 percent. No significant difference was found with regard to the rate of flaws. The rate of all secondary surgical procedures was 29.1 percent, but performance of secondary procedures depended on the willingness of the patient and on the surgeon's judgment. Abdominoplasty procedures involve a high risk of early complications. The rate of skin necrosis is clearly augmented in cases of T-type plasty. The need for secondary surgical correction is frequent, and the patient should be reminded of this possibility during preoperative consultation.     

Microsurgical scalp reconstruction in the patient with cancer

The literature regarding reconstruction of large scalp wounds with free tissue transfer consists mostly of case reports and small series, and none of the published reports focus on the particular problems of the oncology patient. Here the authors describe their experience with 37 flaps in 32 patients, all of whom required scalp reconstruction with free tissue transfer after tumor extirpation. Twenty-seven free flaps were performed at the time of the initial surgery and 10 were performed after a prior reconstruction failed. The authors describe the characteristics of the patients and procedures, including tumor type, wound size and complexity, flaps and recipient vessels used, preoperative and postoperative radiation therapy, and complications. Most (72 percent) of the tumors were recurrent or persistent. The free tissue transfer was successful in all patients. There was a 59 percent overall complication rate with 32 percent of patients requiring a secondary surgical procedure. Most of the complications were wound-healing complications. Although there were two cases of vein thrombosis, these were salvaged by revision, and no flaps were lost. Nine patients underwent postoperative radiation therapy that was well tolerated. Only four patients underwent cranioplasty at the time of the initial operation, and no secondary cranial reconstructions were performed. The authors conclude that preoperative and postoperative radiation therapies as well as the need for expedient tumor resection and immediate flap coverage are issues that make free tissue transfer attractive for the oncology patient who needs scalp reconstruction. Although the complication rate is relatively high and a significant percentage of patients require a secondary procedure, free flap coverage was efficacious for all patients in this group. Cranioplasty is not usually required but, if needed, alloplastic or autologous cranial reconstruction does not appreciably increase morbidity in the selected patient.     

The role of intrinsic muscle flaps of the foot for bone coverage in foot and ankle defects in diabetic and nondiabetic patients

Local muscle flaps, pioneered by Ger in the late 1960s, were extensively used for foot and ankle reconstruction until the late 1970s when, with the evolution of microsurgery, microsurgical free flaps became the reconstructive method of choice. To assess whether the current underuse of local muscle flaps in foot and ankle surgery is justified, the authors identified from the Georgetown Limb Salvage Registry all patients who underwent foot and ankle reconstruction with local muscle flaps and microsurgical free flaps from 1990 through 1998. By protocol, flap coverage was the reconstructive choice for defects with exposed tendons, joints, or bone. Local muscle flaps were selected over free flaps if the defect was small (3 x 6 cm or less) and within reach of the local muscle flap. During the same time frame, the authors performed 45 free flaps (96 percent success rate) in the same areas when the defects were too large or out of reach of local muscle flaps. Thirty-two consecutive patients underwent local muscle flap reconstruction for 19 diabetic wounds and 13 traumatic wounds. All wounds, after debridement, had exposed bone at their base, with osteomyelitis being present in 52 percent of the diabetic wounds and in 70 percent of the nondiabetic wounds. Wounds were located in the hindfoot (47 percent), midfoot (44 percent), and ankle (9 percent). Vascular disease was more prevalent in the diabetic group, in which 42 percent of the affected limbs required revascularization procedures before reconstruction (versus 7 percent in the nondiabetic group). Subsequently, 83 total operations were required to heal the wounds, of which 46 percent were limited to debridement only. Thirty-four pedicled muscle flaps were used: 19 abductor digiti minimi (56 percent), nine abductor hallucis (26 percent), three extensor digitorum brevis (9 percent), two flexor digitorum brevis (6 percent), and one flexor digiti minimi (3 percent). An additional skin graft for complete coverage was required in 18 patients (53 percent). One patient died and one flap developed distal necrosis, for a 96 percent success rate. The complication rate was 26 percent and included patient death, dehiscence, and partial flap or split-thickness skin graft loss. Twenty-nine of the 32 wounds healed. One patient died in the postoperative period; in two others the wounds failed to heal and required below-knee amputations, for an overall limb salvage rate of 91 percent. Diabetes did not significantly affect healing and limb salvage rates. Diabetes, however, did affect healing times (twofold increase), length of stay (2.7 times as long), and long-term survival (63 percent survival in diabetic patients versus 100 percent in the trauma group). Local muscle flaps provide a simpler, less expensive, and successful alternative to microsurgical free flaps for foot and ankle defects that have exposed bone (with or without osteomyelitis), tendon, or joint at their base. Diabetes does not appear to adversely affect the effectiveness of these flaps. Local muscle flaps should remain on the forefront of possible reconstructive options when treating small foot and ankle wounds that have exposed bone, tendon, or joint.     

Reversal of childhood idiopathic scoliosis in an adult, without surgery: a case report and literature review

Background

There are no reports describing complications with posterior spinal fusion (PSF) with segmental spinal instrumentation (SSI) using pedicle screw fixation in patients with neuromuscular scoliosis.

Methods

Fifty neuromuscular patients (18 cerebral palsy, 18 Duchenne muscular dystrophy, 8 spinal muscular atrophy and 6 others) were divided in two groups according to severity of curves; group I (< 90°) and group II (> 90°). All underwent PSF and SSI with pedicle screw fixation. There were no anterior procedures. Perioperative (within three months of surgery) and postoperative (after three months of surgery) complications were retrospectively reviewed.

Results

There were fifty (37 perioperative, 13 postoperative) complications. Hemo/pneumothorax, pleural effusion, pulmonary edema requiring ICU care, complete spinal cord injury, deep wound infection and death were major complications; while atelectesis, pneumonia, mild pleural effusion, UTI, ileus, vomiting, gastritis, tingling sensation or radiating pain in lower limb, superficial infection and wound dehiscence were minor complications. Regarding perioperative complications, 34(68%) patients had at least one major or one minor complication. There were 16 patients with pulmonary, 14 with abdominal, 3 with wound related, 2 with neurological and 1 cardiovascular complications, respectively. There were two deaths, one due to cardiac arrest and other due to hypovolemic shock. Regarding postoperative complications 7 patients had coccygodynia, 3 had screw head prominence, 2 had bed sore and 1 had implant loosening, respectively. There was a significant relationship between age and increased intraoperative blood loss (p = 0.024). However it did not increased complications or need for ICU care. Similarly intraoperative blood loss > 3500 ml, severity of curve or need of pelvic fixation did not increase the complication rate or need for ICU. DMD patients had higher chances of coccygodynia postoperatively.

Conclusion

Although posterior-only approach using pedicle screw fixation had good correction rate, complications were similar to previous reports. There were few unusual complications like coccygodynia.     

Otoplasty: anterior scoring technique and results in 500 cases

Corrective otoplasty is a commonly performed procedure to change the shape of the auricular cartilage. Many techniques use permanent sutures to maintain the cartilage folding, whereas other techniques rely on cartilage incisions (partial thickness or full thickness). At this institution, a cartilage cutting and anterior scoring technique has been used for more than 30 years with pleasing results. The surgical techniques published in the past have been reviewed and compared with the procedure used at this institution to point out the advantages, disadvantages, and differences of these various techniques. Also reviewed were 500 consecutive cases operated on under local or general anesthesia between January of 1993 and December of 1995 to determine the incidence of early and late complications. The patients were contacted by mail to return for a follow-up examination or answer a questionnaire, at least 2 years after the procedure. Early complications were bleeding in 13 cases (2.6 percent) and hematoma in 2 cases (0.4 percent). There were no infections or ear necrosis. A small cutaneous wound was present on the anterior skin in three patients (0.6 percent), and there was one wound dehiscence (0.2 percent). Late complications were keloids in two cases and inclusion cysts in three cases. Residual deformity was noted in 22 cases and asymmetry in 28 cases. Secondary surgery was performed in six cases. The questionnaire was answered by 387 patients (77.4 percent response rate): pain when the ear is touched was present in 22 cases (5.7 percent), hypesthesia in 15 cases (3.9 percent), occasional cutaneous irritation in 38 cases (9.8 percent), asymmetry in 71 cases (18.4 percent), and abnormal ear shape in 17 cases (4.4 percent). Twenty-nine patients (7.5 percent) also noted that the ear was more sensitive to cold or touch. The satisfaction rate was 94.8 percent: very satisfied, 74 percent; satisfied, 20.8 percent; dissatisfied, 4.2 percent; and very dissatisfied, 1 percent. These results were compared with other published series of complications and late results after otoplasty; the complication rates are similar or lower in this study. Therefore, it can be concluded that the cartilage cutting and anterior scoring technique otoplasty is a safe procedure with a high patient-parent-surgeon satisfaction rate.     

Clinical results of TRAM flap delay by selective embolization of the deep inferior epigastric arteries

Preoperative selective embolization of the deep inferior epigastric arteries constitutes a new technique in TRAM flap delay. Whereas surgical ligation of these vessels has proved to be an effective delay procedure in experimental and clinical settings, it requires an additional operative step under general anesthesia. Despite the introduction of the free TRAM leading to improved flap perfusion, this microsurgical technique is not always available because of the requirements of specialized equipment and staff, longer operating hours, and subsequently higher expenses. The search for a minimally invasive, easy, and inexpensive technique to improve perfusion of the pedicled TRAM flap led us to selective embolization of the deep inferior epigastric arteries by an angiographic procedure. After 4 years of experience with this technique, we now present the first clinical results. Breast reconstruction by a delayed pedicled TRAM flap was performed in 40 patients with a mean age of 48.4 years (range, 31 to 66 years). The mean interval between embolization and surgery was 3.6 months. Postoperative data concerning flap survival and complications were available for all patients. Embolization of the deep inferior epigastric arteries was performed bilaterally in 35 patients (87.5 percent) and unilaterally in 5 patients (12.5 percent). Radiotherapy had been applied in 21 patients (52.5 percent) before surgery. Postoperative flap complications consisted of partial necrosis in three (7.5 percent), fat necrosis in one (2.5 percent), impaired wound healing in five (12.5 percent), and postoperative bleeding in two patients (5 percent). Abdominal wound healing complications occurred in six patients (15 percent), abdominal wall weakness in eight (20 percent), and hernia formation in four (10 percent). Surgical corrections were performed at the breast (TRAM flap) in 22 patients (55 percent) and at the abdomen (donor site) in 9 (22.5 percent). Preoperative selective embolization of the deep inferior epigastric arteries constitutes an alternative delay procedure for the pedicled TRAM flap. It is superior to the conventional procedure without delay, offers several advantages compared with surgical ligation of these vessels, and represents an alternative to the free TRAM flap in selected cases.     

Prospective evaluation of late cosmetic results following breast reconstruction: II. Tram flap reconstruction

Although it is thought that transverse rectus abdominis muscle (TRAM) flap breast reconstruction produces excellent cosmetic results that are maintained over the long term, there is little objective evidence in the literature to support this. One hundred seventy-one consecutive patients who underwent TRAM flap reconstruction were prospectively analyzed over an 8-year period to assess their morbidity and late cosmetic outcome.The early patient complication rate (< 2 months) was 37.4 percent, the late hernia and fat necrosis rates (> 2 months) were 8.8 and 13.5 percent, respectively, and the contralateral symmetrization rate was 33.9 percent. The cosmetic results were evaluated prospectively using an objective five-point global scale. Each patient was scored at each visit once surgery was completed. Follow-up continued until a flap was lost, a patient died, or the point of last patient contact was reached. Six patients died during the study. The actuarial percentage cosmetic outcome remained stable during the study period, with an acceptable result in 96.4 percent of patients at 2 years and in 94.2 percent of patients at 5 years. Only five patients in this series obtained poor cosmetic outcomes, with three due to substantial flap necrosis and two because of poor flap design. Two free TRAM flaps were also lost. Log-rank analysis revealed that neither patient age nor timing of surgery significantly affected the cosmetic outcome. Single pedicle and supercharged (single pedicle) TRAM flaps produced slightly better results than bipedicle and free TRAM flaps. In this prospective longitudinal study, TRAM flap reconstructions were shown to produce aesthetically pleasing results. Moreover, with long-term follow-up, it was demonstrated that these reconstructions maintained their stability.     

Investigation of TRAM flap oxygenation and perfusion by near-infrared reflection spectroscopy and color-coded duplex sonography

Near-infrared reflection spectroscopy, used experimentally for investigation of tissue hemoglobin content and oxygenation in various flaps, was tested in the pedicled transverse rectus abdominis musculocutaneous (TRAM) flap, chosen as a simple clinical model because of its well-known vascular anatomy and clinical relevance. The study intended to answer the following questions: Does the near-infrared reflection spectroscopy system used in this study measure tissue hemoglobin content and oxygenation in the superficial skin layers only, as proposed by the manufacturer? Is near-infrared reflection spectroscopy able to detect differences of tissue hemoglobin content and oxygenation in distinct zones of the TRAM flap skin before, early, and late after surgery? Does tissue hemoglobin content and oxygenation correspond to blood flow in the supplying superior epigastric artery and to clinical signs of TRAM flap perfusion and viability? In 11 patients, tissue hemoglobin content and oxygenation in the lower abdomen/TRAM flap, mastectomy skin flap, and contralateral breast were measured by a new near-infrared reflection spectroscopy system preoperatively, early postoperatively, and late postoperatively. Simultaneously, systolic peak flow in the ipsilateral superior epigastric artery was obtained by color-coded duplex sonography. Routine clinical monitoring was performed throughout the early postoperative period. Tissue hemoglobin content and oxygenation in the lower abdomen, mastectomy skin flap, and contralateral breast were similar before surgery but varied considerably between different patients. There were no significant differences among preoperative, early postoperative, and late postoperative values of tissue hemoglobin content and oxygenation in the mastectomy skin flap and contralateral breast. However, near-infrared reflection spectroscopy measurements of the TRAM flap revealed significant differences between preoperative and early postoperative values of tissue hemoglobin content and oxygenation and among zones I, II, and III early after surgery. Tissue hemoglobin content in the TRAM flap skin increased and oxygenation decreased early after surgery. Near-infrared reflection spectroscopy values corresponded to clinical signs of venous congestion predominantly in zone III. Late postoperative return of hemoglobin content and oxygenation in the TRAM flap toward preoperative values can be attributed to improved venous return by reversed flow across regurgitant valves and development of collateral circulation. Finally, there was a significant increase of systolic peak flow in the ipsilateral superior epigastric artery early after surgery. This could be related to the opening of small-caliber choke arteries between the superior and deep inferior epigastric arteries following ligation of the dominant deep inferior epigastric artery and TRAM flap transfer to the chest. Systolic peak flow returned to preoperative values late after surgery. The near-infrared reflection spectroscopy system used in this study appeared to measure hemoglobin content and oxygenation in the superficial skin layers only. Near-infrared reflection spectroscopy was able to detect differences of tissue hemoglobin content and oxygenation in the TRAM flap between preoperative and postoperative measurements and between distinct zones of the TRAM flap early postoperatively. Postoperative changes in near-infrared reflection spectroscopy values corresponded to clinical observations and blood flow in the superior epigastric artery measured by color-coded duplex sonography. Further experience is needed before near-infrared reflection spectroscopy can be advocated for routine clinical flap monitoring.     

Nasal reconstruction--beyond aesthetic subunits: a 15-year review of 1334 cases

A retrospective analysis was performed on 1334 patients who underwent nasal reconstruction between 1986 and 2001. The senior author performed all reconstructions in this series after Mohs' histographic excisions. Only secondary reconstructions were performed without a preceding Mohs' excision. Methods of reconstruction, number of operations per patient, locations of defects, and complications were recorded. Using preoperative and postoperative photographs, aesthetic results were reviewed. Basal cell carcinoma was the most common lesion, followed by squamous cancer and melanoma. The average age of the patients was 51 years. Cancers most commonly arose on the dorsum, ala, and tip. Of 1334 cases, a 1.9 percent recurrence rate was documented. The average time between surgery and clinical recognition of recurrence was 39 months. All recurrent lesions were reexcised by the Mohs' technique. Eighty-one percent of reconstructions were completed in three or fewer stages. Seventy-five percent of reconstructions were completed in two stages. Primary dermabrasion or primary laserbrasion using carbon dioxide or erbium lasers was used in nearly every case. Early secondary dermabrasion or laserbrasion was used in a few cases where indicated. A 1.2 percent revision rate was noted (16 patients). Thirteen partial flap necroses required revision. Three patients experienced dehiscence at the donor site of paramedian forehead flaps. A preferred philosophy toward nasal reconstruction is described. The goal is to achieve optimal cosmetic and functional results while minimizing stages and resection of healthy tissue. Six core principles are advocated that guide efficient and successful nasal reconstruction: (1) maximal conservation of native tissue is advised; (2) reconstruction of the defect, not the subunit, is advised; (3) complementary ablative procedures, such as primary dermabrasion, enhance the final result and decrease the number of revisionary procedures; (4) primary defatting also decreases the number of revisionary procedures; (5) when possible, the use of axial pattern flaps is preferred; and (6) good contour is the aesthetic endpoint.     

Osteoradionecrosis of the mandible after oromandibular cancer surgery

Although postoperative radiotherapy has proved effective in improving local control and survival in patients with head and neck cancers, its complications, especially mandibular osteoradionecrosis, reduce the quality of life. Mandibular surgery before the radiotherapy adds an additional risk factor for osteoradionecrosis. This study reviews patients in Chang Gung Memorial Hospital, Taipei, Taiwan, over a 10-year period, who underwent intraoral cancer resection followed by postoperative radiotherapy and thereafter developed osteoradionecrosis of the mandible. A total of 24 men and three women with a mean age of 49.9 years were identified and included in the study. In 10 cases, tumor resection was performed with a marginal mandibulectomy; in eight cases, tumor resection was performed after mandibular osteotomy; and in three cases, a segmental mandibulectomy was performed, and the defect was reconstructed with a fibula osteoseptocutaneous flap. In six cases, tumor excisions were performed without interfering with the mandibular continuity. Patients received postoperative external beam radiotherapy into the primary site and the neck, with a mean dose (+/-SD) of 5900 +/- 1300 cGy in an average of 35 fractions during an average of 6.5 weeks. The average elapsed time between the end of radiation therapy and clinical diagnosis of osteoradionecrosis of the mandible was 11.2 months (range, 2 to 36 months). The time elapse between the end of the radiation therapy and the diagnosis of osteoradionecrosis was influenced by initial treatment (Kruskal-Wallis test: n = 27, chi-square = 12.884, p < 0.005), and this period was shorter if the mandibular osteotomy or marginal mandibulectomy was performed (the two lowest mean ranks in the test). However, if the initial surgery resulted in a segmental mandibulectomy reconstructed with a fibula osteoseptocutaneous flap, onset of the osteoradionecrosis was relatively late (Kruskal-Wallis test: n = 21, chi-square = 7.731, p = 0.052). After resection of osteoradionecrotic bone and surrounding soft tissue, 22 patients underwent reconstructive procedures with a fibula osteoseptocutaneous flap, and five patients underwent reconstructive procedures with an inferior genicular artery osteoperiosteal cutaneous flap. One fibula osteoseptocutaneous flap showed total failure and another showed a 25 percent skin loss; both were revised with pedicled flaps. The skin paddle of an inferior genicular artery flap was replaced with an anterolateral thigh flap because of anatomic variation of the skin vessel. Once the diagnosis of osteoradionecrosis is established, replacement of the dead bone and surrounding tissue with a vascularized free bone flap is inevitable, and a composite osteocutaneous free flap is a good option.