Microsurgical free-tissue transfer in the elderly patient.

During the 5-year period from July of 1984 to July of 1989, we performed 94 free-tissue transfers in 92 patients over the age of 50 whom we arbitrarily defined as "elderly." There were 32 patients in the age range between 50 and 59 years, 40 patients aged between 60 and 69 years, and 20 patients aged between 70 and 79 years. Seventy-one flaps were utilized for head and neck reconstruction, and 23 flaps were used in reconstruction of the trunk and extremities. There was 1 total flap loss, for a flap viability rate of 99 percent (93 of 94). Postoperative complications were classified into surgical (technical) and medical categories. There were 14 major surgical complications (15 percent) and 13 significant postoperative medical problems (14 percent). The majority of these complications occurred in head and neck cancer patients in the age group between 60 and 69 years, who had significant underlying medical problems and were preoperatively classified as ASA 3. There were 5 postoperative deaths, for a mortality rate of 5.4 percent (5 of 92 patients).     

Microvascular free-tissue transfer in children

We have reviewed our experience with 22 microvascular free-tissue transfers in children. Ages range from 2 to 14 years; the success rate was 96 percent. Two patients underwent reexploration for postoperative hemorrhage, possibly due to treatment with low-molecular-weight dextran. No vessel spasm was observed, compared with a 28 percent incidence in our adult series of 154 patients. The vessels were in pristine condition. Operative time was shorter (6.1 hours) than in our adult series (9.7 hours). Average hospital stay was 10 days (compared to 23 days for adults). All children have resumed almost normal activity within 2 months (4 months for adults). Results of this study indicate that microvascular free-tissue transfer can be accomplished safely and expeditiously in children. Care should be taken in preoperative and postoperative planning, however, especially concerning immobilization.     

Breast reconstruction with free-tissue transfer

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Understand the rationale for the use of free tissue transfer for breast reconstruction. 2. Understand the indications, advantages, and disadvantages of this method of reconstruction.The authors discuss the indications, advantages, and disadvantages of free-tissue transfer for breast reconstruction. The most common free flaps used today are individually discussed. Details about indications, contraindications, pertinent anatomy, pedicle characteristics, flap pliability, perfusion characteristics, advantages, and disadvantages for each of these flaps are presented. Details pertaining to the more common recipient vessels are presented. Future considerations are also briefly discussed.     

Split jejunal free-tissue transfer in oropharyngoesophageal reconstruction

From January 1, 1981 to July 1, 1981, ten patients underwent immediate reconstruction utilizing split jejunal free-tissue transfers following resection of large oropharyngeal neoplasms. All 10 flaps were successfully transferred. Three patients were irradiated preoperatively and six patients were irradiated 2 to 3 weeks postoperatively. Nine patients were available for follow-up until their death from 10 to 39 months postoperatively (average 26 months). All but two patients died of their original tumor. Six of the nine patients had a good early functional result; taking semisoft or soft diets allowed them to maintain or gain weight. Three patients had poor early results with limited oral feedings due to repeated aspiration in two and severe gastroesophageal reflux in another. Postoperative graft biopsies were obtained in five patients, showing normal mucosa or mild chronic inflammation histologically even following irradiation. Postoperative barium studies showed varying degrees of graft peristalsis. Complication rates were acceptable, and donor-site morbidity was minimal. Neither preoperative nor postoperative radiation affected the viability of the grafts. Therefore, this technique should continue to find application as a reliable method of providing like tissue for reconstructing a variety of large oropharyngeal defects.     

Factors affecting the outcome of human blastocyst vitrification

This study aimed to test the feasibility of a programme of semen collection and cryopreservation in Griffon vultures. Four wild-caught individuals kept in captivity because of unrecoverable traumas were used. Semen collection attempts were made twice a week during three consecutive reproductive seasons (December – March) using the abdominal massage method. Ejaculation was successfully induced between late January and late February. Semen collection efficiency was rather low (27.9%) and it did not vary among individuals (p > 0.05). No differences were found in ejaculate volumes (12.5 +/- 9.1 μl), spermatozoa concentration (28.4 +/- 30.9 million cells/ml) and viability (61.3 +/- 13.9%) among the 4 vultures. ATP values differed among the four vultures (p < 0.001); B showed higher nucleotide concentration than both C and D, while it did not differ form A, whose values were higher compared with D. After freezing and thawing, semen in vitro viability, DNA integrity and ATP intracellular concentration were determined. Spermatozoa viability after thawing did not differ among the four individuals (52.6 +/- 5.8 in A, 53.4 +/- 4.6 in B, 50.4 +/- 3.2 in C, 42.5 +/- 2.7 in D), but it decreased significantly compared to fresh semen (p < 0.05). During 4 hrs in vitro culture, spermatozoa collected from B maintained over time a higher viability in vitro when compared to A, C and D. As evaluated by the comet assay method, DNA fragmentation after freezing and thawing did not differ in the 4 vultures. ATP concentration in frozen/thawed semen was significantly lower than in fresh semen (p < 0.0001). This study indicates that semen cryopreservation can be considered as a useful tool in the conservation of Griffon vulture genetic resources, but further studies are needed to optimize this technique.     

Factors affecting the outcome of human blastocyst vitrification

With single blastocyst transfer practice becoming more common in ART, there is a greater demand for a convenient and reliable cryostorage of surplus blastocysts. Vitrification has emerged in the last decade as an alternative promising substitute for slow freezing. Blastocysts represent a unique challenge in cryostorage due to their size, multicellular structure and presence of blastocoele. The continuous acquisition of experience and introduction of many different technological developments has led to the improvement of vitrification as a technology and improved the results of its application in blastocyst cryostorage. The current information concerning safety and efficacy of the vitrification of blastocysts will be reviewed along with the variables that can impact the outcome of the procedure.     

Intraarterial chemotherapy: the effects on free-tissue transfer

Multimodal therapy including intraarterial chemotherapy is recognized as state-of-the art therapy for soft-tissue cancer. Multimodal therapy often involves regional limb perfusion followed by sarcoma surgery with reconstruction of the resulting defect. This study was performed in an effort to evaluate the potential of free flap reconstruction after intraarterial therapy. A retrospective chart review of 52 patients who had undergone limb perfusion between 1988 and 1998 at the University of Texas M. D. Anderson Cancer Center and the Division of Plastic Surgery, University of Bochum, Germany, identified 16 patients who had undergone intraarterial limb perfusion that was then followed by surgical resection and free flap reconstruction. There were seven women and nine men, with an average age of 37.9 years. All sixteen patients had received preoperative adjuvant systemic chemotherapy. Reconstruction of the lower extremity was performed most commonly with rectus abdominis and latissimus dorsi free flaps. All vessels used for donor recipient anastomosis had been previously perfused. A vein graft was used in one case. Split-thickness skin grafting over the free flaps was used in four cases. The average length of hospitalization was 21.75 days, with an average follow-up of 20 months. No flap loss or infection was observed. Two flaps demonstrated partial edge necrosis. Three patients developed partial split-thickness skin graft loss and one developed a seroma that required no treatment. A draining sinus tract required resection in one patient. The overall flap success rate was 100 percent, with no flap failures. The overall surgical outcome was considered to be good in 12 patients on the basis of improved function and ambulation, and fair in four who had limitations in function and/or ambulation on the basis of both the patient self-evaluation and the physical therapy evaluation. Seven patients had recurrence of their disease. The overall mean survival time after surgery was 20.6 months. Currently, 10 patients are alive and six have died from their disease. The results of this study indicate that preoperative intraarterial chemotherapy does not significantly increase the risk of immediate free flap complications. Although our numbers are small, we believe that there is no clinical evidence justifying hesitation or refusal of free flap reconstruction after limb perfusion and intraarterial chemotherapy. Routine care in vessel selection and microsurgical technique should be performed to maximize favorable outcomes. Vessels should be inspected for their suitability before undertaking any free flap reconstruction.     

Factors affecting the resistance to heat transfer provided by clothing

1. 1. This paper discusses the factors that affect the insulation and evaporative resistance provided by clothing.

2. 2. These include: fabric thickness and density, the amount of body surface area covered by garments, the evenness of the distribution of fabrics over the body surface, the increase in surface area for heat loss due to clothing, the looseness or tightness of fit, a person's body position (seated vs standing), body motion and wind.

Limb reconstruction by free-tissue transfer combined with the Ilizarov method.

In four complex cases of extremity reconstruction, we have been able to overcome the problems of combined bone and soft-tissue loss and length discrepancy by a combination of free-tissue transfer and the Ilizarov method of slow distraction. It is our observation that gradual distraction of a free tissue is a safe and viable procedure; the free tissue tolerates the pins of the circular external fixator well, and there is an equal degree of distraction and regeneration of the transferred free tissue and the native recipient tissue without evidence of wound dehiscence. Corticotomy through free tissue and in close proximity to vascularized bone is safe, with the subsequent bone regeneration not unlike that of normal bone. Manipulation by slow distraction does not appear to compromise the vasculature of the recipient bed for later microsurgical procedures or endanger the axial flow pattern of the transferred free tissue.     

Factors affecting the success of surgical and nonsurgical equine embryo transfer

Nonsurgical embryo recovery was attempted from light-horse and draft mares. Embryo recovery rates were not affected (P>.05) by technician or stallion but were lower (P<.05) from draft mares (44%) than light-horse mares (67%). Sham transfer of embryos on day 8 post-ovulation did not (P>.05) increase the number of mares returning to estrus by 22 days post-ovulation. Method of embryo transfer greatly affected pregnancy rates. Embryos transferred surgically during March–June resulted in 0 of 12 pregnancies versus 13 of 25 pregnancies obtained during July–September, This strongly suggests a seasonal influence on pregnancy rates. Technician influenced (P<.05) the success of nonsurgical transfer (46.2% vs. 7.7%). In addition, protection of the insemination rod with a sheath (guarded method) appeared to provide some advantage over an unguarded method of nonsurgical transfer (54% vs. 23%). Lastly, a preliminary experiment was conducted to evaluate transfer of embryos via flank incision. Four of 5 embryos transferred by this method resulted in a pregnancy at 50 days post estrus.     

Flap failure after microvascular free-tissue transfer: the fate of a second attempt

In most cases, the loss of a free-tissue transfer is a disaster for both the patient and the surgeon. Seven patients received a second microvascular free-tissue transfer after loss of the first. The indications for free-tissue transfer included chronic osteomyelitis of the lower leg (four patients), acute traumatic defect of the leg (one patient), acute traumatic defect of the arm (one patient), and esophageal defect after surgical excision (one patient). In three patients, the interval between the first and second procedures was less than 2 weeks. The remaining four patients had their second free-tissue transfer performed 5 weeks to 21 months after the first. Six of the seven free flaps were successful. Two patients with venous obstruction occurring after the second free-tissue transfer were salvaged by reexploration. Partial loss of the flap was noted in one of these patients. It is concluded from this select group of patients that failure of a free-tissue transfer does not contraindicate a second microtissue transfer does not contraindicate a second microvascular free-tissue transfer.     

Salvage of amputation stumps by secondary reconstruction utilizing microsurgical free-tissue transfer

During a 2-year period, 15 lower and upper extremity amputees were treated by microsurgical free-tissue transfer in an effort to salvage their amputation stumps. Salvage of length and restoration of contour to aid in prosthetic rehabilitation were the two main indications for reconstruction. Included in the 15 transfers were 3 scapular free flaps, 11 latissimus dorsi musculocutaneous flaps, and 1 groin flap. Thirteen of the patients in this group were refitted with prostheses following reconstruction and did well with no pain or skin breakdown of the resurfaced stumps. The follow-up period on these patients averaged 16 months. One patient, in whom the flap succeeded, underwent stump soft-tissue revision and myodesis. One patient, in whom the flap failed, continued to develop recurrent ulceration in his stump. This clinical experience followed an extensive laboratory study of 12 above-knee amputation patients using noninvasive Doppler ultrasound measurements to determine weight-loading and interface-pressure distribution between the stump and the socket of the prostheses and their relation to stump length and circumference.