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Hemifacial atrophy (Parry-Romberg syndrome) is an enigmatic craniofacial disorder characterized by progressive facial atrophy. Early age at onset is associated with significant skeletal involvement and jaw abnormalities. Standard reconstructive dogma dictates that the disease should "burn out," with at least 2 years of no disease progression, before pursuing reconstructive intervention. The purpose of this article is to present the senior author's (J.W.S.) experience treating preadolescent children with free soft-tissue transfer for reconstruction of progressing hemifacial atrophy, and to review surgical techniques in this patient population.Pediatric free tissue transfer cases performed by the senior author were reviewed. Free tissue transfer using a circumflex scapular adipofasciocutaneous flap was performed to treat deformities arising from hemifacial atrophy.Thirty-six patients aged 3 to 6 years underwent free tissue transfer in the presence of progressing, active disease. Follow-up ranged from 7 months to 25 years. There were no cases of flap loss. In all patients, the disease process seemed to be altered, with no symptoms recurring to date.The authors believe that early microsurgical correction of hemifacial atrophy in children as young as 3 years is reliable and effective. The authors theorize that the interposition of vascularized, healthy tissue may alter or even halt the progression of disease, and may also prevent the skeletal hypoplasia classically seen in older patients. Further study incorporating autologous fat grafting as a control procedure may provide additional insight into this challenging disease process.Therapeutic, IV.

Free tissue transfer to improve bulk and contour in facial deformities has been proven useful, yet refinements that turn an acceptable result into an excellent result are essential to reconstruction. The authors reviewed their experience and described these refinements.The charts of 371 free tissue transfer cases (1989 to 2010) performed by the senior author (J.W.S.) were reviewed. Free tissue transfer of a circumflex scapular variant flap or superficial inferior epigastric was performed to treat deformities arising from hemifacial atrophy (n = 126), hemifacial microsomia (n = 89), radiation therapy (n = 40), bilateral malformations including lupus and polymyositis (n = 50), other congenital anomalies (n = 25), facial palsy (n = 17), and burns and trauma (n = 24).Revision surgery planning began at initial flap operation where the flap was stretched maximally and interdigitated with recipient tissue. More tissue was required in the malar region. Revision refinement was indicated in all cases (after 6 months). Flap revision involved liposuction, debulking, reelevation, and release of tethering, followed by tissue rearrangement by means of advancement, rotation, transposition, and/or turnover flaps of subcutaneous tissues from the previous free flap. The jawline frequently required more debulking. Periorbital reconstruction was combined with lower lid support with or without canthal repositioning. Conventional face-lift techniques with the flap as superficial musculoaponeurotic system augmented the result. Autologous fat injection to the alar rim, medial canthus, upper eyelid, and lip was a useful adjunct. Severe lip deficiencies were addressed with local flaps.The keys to improving results were continual critical reassessment, open-mindedness to new approaches, and maintaining high expectations.Therapeutic, V.

Background: Free tissue transfer for adult mandibular reconstruction is a well-established technique; however, there are few reports of pediatric microvascular lower jaw reconstruction. Methods: This retrospective study was undertaken to review the range of indications, choices, safety, and efficacy of pediatric free tissue transfer to the lower jaw. All patients underwent a parascapular, scapular, or fibula free tissue transfer. Flap choice was based on preoperative clinical examination, radiographic findings, need for linear or multiplanar mandibular reconstruction, need for dental restoration, severity of soft-tissue deficit, and peroneal artery anatomy. Results: Over a 10-year period (1989 to 1999), we performed eightfree tissue transfers to reconstruct the mandibles of seven children, aged 6 to 17 years. Indications included radiation-induced hypoplasia (n = 1), postsurgical resection of fibrous dysplasia (n = 1), hemifacial microsomia (n = 3), Robin sequence with severe micrognathia (n = 1), and osteomyelitis (n = 1). The authors transferred four parascapular osseocutaneous, two scapular osseocutaneous, one fibular osseocutaneous, and one fibular osseous flap to reconstruct five ramus, four condyle, and two subtotal mandibular defects. All bony defects were successfully bridged and all osseous flaps successfully integrated. Postoperatively, mandibular symmetry and Angle class I occlusion were restored in all patients throughout the 10.5-year follow-up period (range, 9 to 14 years). Two patients received osseointegrated dental implants. Our only complication was the partial loss of a skin paddle. Conclusion: Microvascular reconstruction of the pediatric mandible, in selected patients, is a safe, reliable procedure that provides the bone stock and soft tissue necessary to restore normal maxillomandibular growth and dental rehabilitation.

Background: Silicone, in the form of injectable liquid and prosthetic blocks, has been used to correct facial contour defects. However, silicone also has been associated with many complications including malposition, dyschromia, dysesthesia, contractures, infection, and fistula. Complications related to injectable-liquid and prosthetic-block silicone use in treatment of facial deformities pose a challenging surgical dilemma. Methods: Over a 15-year period, microvascular free flap technique has been used successfully as a surgical tool to correct severe soft-tissue complications of the face resulting from silicone treatment of facial contour deformities. Surgical treatment guidelines, methods, and results for treating this difficult problem with free tissue transfer are presented. Results: In 23 patients, 24 free tissue transfers (22 inframammary extended circumflex scapular free flaps and two superficial inferior epigastric free flaps) were performed. Flap survival was 100 percent. Both hematoma and skin necrosis were encountered in three of 24 cases (12.5 percent). Revisional surgery combined with aesthetic surgical procedures was required in 20 of 24 cases (83 percent). Conclusions: We recommend the following surgical treatment guidelines for this unique subset of patients: silicone excision with immediate microvascular free flap reconstructive procedure when the skin and soft tissue are mildly to moderately affected, or silicone excision with delayed reconstructive procedure when the skin and soft tissue are severely affected. Free tissue transfer is a useful surgical tool for salvaging severe facial skin and soft-tissue deformities caused by previous silicone treatment.

Hypertrophic scarring is characterized by disordered collagen fibrils. In order to determine whether this is, in part, a result of changes in the population of proteoglycans that are thought to be involved in regulation of collagen fibril formation, we have compared PGs from post-burn normal and hypertrophic scar tissue, as well as from human dermis and epidermis. Efforts to separate the two major iduronic acid-containing proteoglycans, decorin [PG(IdoA)-II] and biglycan [PG(IdoA)-I], for quantitation were not successful. The different N-terminal sequences of these two iduronic acid-containing proteoglycans PG(IdoA-I and -II were utilized to estimate the relative amounts in the above PG(IdoA) preparations. Normal scar, dermis and epidermis were all found to contain primarily decorin with low (< 10%) levels of biglycan relative to decorin. In contrast, iduronic acid-containing proteoglycans from hypertrophic scar were found to be approximately 30% biglycan [PG(IdoA)-I]. This may be a proximal cause of altered collagen fibrils, or may result in alterations in the sequestration of growth factors, which then results in changes in collagen that effect the appearance of the scar. 1966 Elsevier Science Ltd.

Restoring soft-tissue contour in patients with facial asymmetry is a difficult problem for plastic surgeons. We report our experience with 57 consecutive patients who underwent 60 microvascular free flaps for the correction of facial asymmetry between July of 1989 and June of 1994. Etiologies of facial asymmetry included hemifacial microsomia, hemifacial atrophy, postradiation sequelae, burns and trauma, and selected congenital anomalies. Thirty-eight patients were reconstructed with a customized parascapular flap incorporating extensions of dorsal thoracic fascia. Other donor sites utilized were as follows: six superficial inferior epigastric flaps, three myocutaneous flaps, seven muscle flaps, and six fasciocutaneous flaps with bone. To correct facial asymmetry, the recipient site was dissected through a limited preauricular incision whenever feasible, and the superficial temporal artery and vein were used as recipient vessels. A monitoring skin paddle was rarely used. There were no flap losses in this series. Six patients experienced a postoperative hematoma, three of which were drained at the bedside. Limited skin slough occurred in three patients. No donor-site complications other than hypertrophic scarring were encountered. Flap revisions were performed in 22 of the 57 patients to maximize aesthetic results. Based on our experience, we feel that the operative approach presented here allows excellent and stable correction of facial asymmetry due to a variety of etiologies. Furthermore, this technique is applicable to other congenital craniofacial deformities such as Treacher-Collins syndrome and orbital-facial clefts.

Microvascular techniques are important in making routine anastomoses quicker and difficult anastomoses easier. The authors have developed three types of sleeve anastomoses for different size vessels: a three-stitch sleeve anastomosis, four-stitch sleeve anastomosis, and sidecut sleeve anastomosis. Arteriography, in vivo observation, pulsed ultrasound Doppler hemodynamic study, histology, and ultrastructural examination with scanning electron microscopy at 2 to 90 days demonstrated that all three groups of sleeve anastomoses do not stenose, do not show hemodynamically significant vasospasm, and are not complicated by aneurysm formation by 90 days. The hemodynamics were comparable to control sutured anastomoses at 2 to 4 hr postoperatively. The sleeve anastomoses left no suture material within the vessel lumen. Reendothelialization was comparable with controls at 14 days, and the long-term patency rates were similar (p > 0.05). The operative times for all three types of sleeve anastomoses were significantly shorter than sutured control anastomoses (p < 0.001). Although limited by available vessel length and diameter, the sleeve anastomosis is a useful technique for the microsurgeon.

Using a newly developed Doppler probe, we have found that a standard suture anastomosis in a rat femoral artery is accompanied by significant (30-60%) cross-sectional area stenosis, which dissipates to baseline levels within 24 hours. We hypothesized that spasm, deposition of coagulation products, or the suture technique itself was responsible. Topical vasodilators (papaverine, sodium nitroprusside, lidocaine) and intravenous thromboxane A2 synthetase inhibitor and receptor blocking agent (Ridogrel, 4 mg/ml), anticoagulants heparin and SC4992 (an experimental platelet inhibitor/arginine-glycine-aspartic acid analogue), were administered. No drug had any significant effect on preventing postoperative stenosis. Varied suture bites affected stenosis measurements. Scanning electron microscopy and light microscopy displayed "bunching" of vessel wall in the suture ties. This was confirmed with methyl methacrylate corrosion casts and microangiography. "Sham" anastomoses also produced stenosis, which was relieved when sutures were removed. We conclude that suture anastomosis of small vessels is accompanied by significant cross-sectional stenosis caused by the physical action of tensioned sutures. This effect dissipates over a 24-hour postoperative period. The mechanism behind these changes and the clinical importance of this effect are still under investigation.

Nonunion and avascular necrosis after scaphoid fractures continue to be problem sequelae because of unrecognized injuries, inadequate immobilization techniques, or insufficient treatment time. Screw fixation and inlay bone grafting techniques remain the options of choice, with successful union reported in approximately 90% of patients. However, prolonged immobilization with plaster up to 4 to 6 months is required with conventional techniques. With the use of standard latex injection techniques with vascular filling of vessels to less than 0.1 mm diameter in ten fresh cadaver dissections, we discovered a consistent vascularized bone graft source from the distal dorsoradial radius. We have used this vascularized bone graft source with good results in eleven patients with long-standing nonunion of the scaphoid. It is technically easy and seemingly offers the advantages of a decreased period of immobilization and a higher union rate.

Since their first review of microsurgical correction of facial contour deformities in 19 patients with craniofacial malformations, the authors have treated an additional 74 patients (n = 93). The authors review indications, choices, safety, efficacy, complications, and technical refinements. A treatment algorithm is presented.A retrospective chart review of all patients who underwent microvascular reconstruction of the face and all patients with craniofacial dysmorphology was performed. Between 1989 and 2004, a total of 93 patients with the following diagnoses were identified: craniofacial microsomia (n = 73), Treacher Collins syndrome (n = 8), and severe orbitofacial cleft (n = 12). All patients underwent microsurgical facial reconstruction with a superficial inferior epigastric, groin, or circumflex scapular flap. Flap revisions, complications, and non-free flap related surgery were reviewed.The mean age at microvascular reconstruction was 11 years (range, 4 to 27 years). Flap choices included the following: superficial inferior epigastric (n = 4), groin (n = 3), and circumflex scapular (n = 105). Seventy-six patients underwent unilateral and 17 patients underwent bilateral (one of 17 simultaneous) reconstructions. Postoperative complications included partial flap loss (n = 1), reexploration (n = 1), hematoma (n = 5), and cellulitis (n = 5). All patients had subjective improvement in facial contour, symmetry, skin tone, and color. Most patients underwent additional non-free flap procedures including mandibular distraction and ear reconstruction.Microsurgical flaps have markedly improved the authors' ability to restore craniofacial contour in patients with craniofacial malformations. In selected patients, the authors choose primary midface augmentation with free vascularized tissue to restore form and function. Microsurgical flaps in patients with craniofacial malformations are safe, effective, and reliable.

Multiple microvascular anastomotic techniques have been described with varying rates of success. This experimental study presents the results of a comparison of three types of venous microanastomotic techniques: the Unilink system, the sleeve technique, and the suture technique. Twenty male Sprague-Dawley rats, 40 femoral veins, were used for this study. In vivo observation and microvasculography demonstrated that patency rates between the Unilink system and suture techniques were comparable (p > 0.05) and were significantly superior to the sleeve anastomosis (p < 0.05). The anastomotic time for the sleeve technique was significantly shorter than for the suture technique (p < 0.001). Compared with suture and sleeve anastomoses, the anastomotic time employing the Unilink system was significantly the shortest (p < 0.001). The Unilink system proved to be the fastest method with the highest patency rate. These results suggest that the use of the Unilink system is superior with regard to anastomotic time and patency rate, when compared to suture and sleeve techniques for venous microanastomosis.

The correction of facial asymmetry in complex craniofacial malformations presents a challenging problem for reconstructive surgeons. Deficiencies of both the facial skeleton and the overlying soft tissue must be addressed to achieve the optimal reconstructive result. We present our experience with a minimum of 1-year follow-up over a 5-year period with 19 patients who initially underwent standard facial skeletal reconstruction and subsequently required microsurgical soft-tissue reconstructions for final correction of facial contour. From July of 1989 to June of 1994, 19 patients with craniofacial malformations underwent microsurgical correction of facial contour using 21 free flaps. The underlying malformations included 15 hemifacial microsomias, 2 orbitofacial clefts, 1 congenital temporomandibular joint ankylosis with micrognathia, and 1 Tessier no. 30 (lower midline mandibular) cleft. Sixteen patients had previous facial skeletal correction using craniofacial techniques. Age at operation ranged from 6 to 27 years. Twenty-one microvascular flaps were used on the 19 patients: 19 deepithelialized parascapular flaps, 1 superficial inferior epigastric flap, and 1 fibula with soleus muscle and large skin paddle for a severe Tessier no. 30 facial cleft with severe micrognathia. Of the 15 patients with hemifacial microsomia, 10 were treated with parascapular fasciocutaneous flaps, 3 with parascapular flaps with bone, 1 with a parascapular flap with teres major muscle for additional bulk, and 1 with a superficial inferior epigastric flap. Complications were two limited hematomas drained at the bedside and a partial skin paddle slough of the fibula flap. Correction of facial contour in complex craniofacial malformations is possible using microsurgical techniques. These free flaps "camouflage" the underlying skeletal deformity that persists despite traditional skeletal reconstruction while restoring symmetrical facial contour. We recommend the marriage of both skeletal and microsurgical soft-tissue reconstructions to achieve the optimal aesthetic result for craniofacial contouring in these challenging patients.

Bilateral facial contour deformities are difficult reconstructive problems to correct. This paper summarizes our experience with five adult patients who were operated on for the correction of bilateral contour deformities. The etiologies of the contour deformities were one case of systemic lupus erythematosus, three cases of hemangioma/lymphangiomas, and one case of systemic lipodystrophy. Patient ages at the time of surgical correction ranged from 19 to 65 years. In two patients, staged microvascular free-tissue transfers were performed. In three patients, a single free flap was used for reconstruction. Seven microvascular free flaps were used to reconstruct facial contour : three superficial inferior epigastric flaps and four inframammary extended circumflex scapular flaps. In three patients, recipient sites were dissected by means of a limited preauricular incision, and the superficial temporal artery and vein were utilized as recipient vessels. The two remaining patients underwent free-tissue transfer to branches of the external carotid system. There were no flap losses in this series. Follow-up ranged from 1 to 4 years. A stable restoration of facial contour was achieved in all five patients. Microsurgical correction of soft-tissue contour problems is possible in bilateral deformities, and superior results are easier to achieve than in unilateral facial contour deformities. Either single or staged reconstructions can restore facial contour depending on the distribution of soft-tissue requirements.

A new technique for microvascular four-stitch sleeve anastomosis of arteries is described. Modifications from previously described techniques include absence of suture material within the arterial lumen, and a decreased proximal to distal artery overlap. In 40 rat arterial anastomoses, 100% patency without evidence of stenosis or early aneurysm formation was seen up to 6 weeks postoperatively by in vivo observation, arteriography and Doppler flow study. This new anastomosis was also successful in repairing two clinical cases of complete radial artery transection as evident from physical examination and doppler flow study. We believe that this new four-stitch sleeve anastomosis is faster and easier to perform and has patency and flow characteristics similar to those of the conventional end-to-end anastomosis.

Romberg's disease is a progressive hemifacial atrophy of unknown etiology. Microsurgical reconstruction, focusing on the correction of facial asymmetry and restoration of contour, has become the gold standard. We report our experience with 15 patients involving 16 free-tissue transfers with a minimum of 1 year of follow-up who were treated from July of 1989 to January of 1993. All patients were classified as having severe atrophy. There were 7 males and 8 females in the series. Distribution of disease was a coup de sabre type or segmental pattern in 6 patients, whereas 9 patients had a hemifacial distribution. Fourteen patients had unilateral disease (7 right and 7 left), and 1 patient had bilateral atrophy. The average age of onset of disease was 11.9 years. The average duration of atrophy was 6.7 years. No patient was operated on with a quiescent interval of less than 2 years. Average age at operation was 28.7 years, with a range from 6 to 46 years. Follow-up ranged from 1 to 4.5 years. Two patients had facial hematomas as the only complication. No flaps were lost. Flap revisions consisting of minor contour corrections were performed in 10 patients. Limited recurrence of facial atrophy was seen in a single patient 2 years postoperatively. All patients rated their improvement as excellent. The deepithelialized extended parascapular flap with large fascial extensions of dorsal thoracic fascia is our procedure of choice. This fascia can be folded into variable thicknesses to correct subtle contour defects of the upper lip, medial canthus, eyelids, and ear that have reportedly been difficult to reconstruct. These extensions can be placed easily across the midline to interdigitate with normal tissues at the boundary of the facial deformity. As such, the transition from augmented areas of the face to uninvolved areas is natural in contour.

This study assessed the postoperative microvascular hemodynamics in end-to-side arterial anastomoses of varied angles in order to determine whether the angle of the anastomosis affects arterial flow. Thirty male rats were divided into three groups of ten. Carotid to carotid end-to-side anastomoses were performed with anastomotic angles of 45, 90, and 135 degrees. Postoperative flow was assessed using high frequency pulsed Doppler ultrasound (HFPDU) at 30 and 120 min postoperatively. Measurements at 30 min demonstrated significant differences in flow, with the 45 degrees grafted vessels utilizing 56.5% of total carotid flow, and the 90 degrees and 135 degrees anastomoses appropriating 46.5% and 43.2% of flow, respectively (comparing 45 degrees to both 90 degrees, P < 0.05, and 135 degrees, P < 0.002). The change from baseline in 45 degrees and 90 degrees groups dissipated over a 2 hr postoperative period, but flow in the grafted vessels in the 135 degrees group continued well below 50% at 39.9% (comparing to both 45 degrees and 90 degrees, P < 0.001), thereby displaying a significant difference in the postoperative arterial flow of varied angled microanastomoses.

This study reviews 21 microvascular free flaps to the diabetic foot in 19 patients over a 65-month period. All flaps were either to the plantar surface of the foot or to cover exposed Achilles tendon. Twenty of the flaps survived. The operations required a long, costly hospitalization with frequent recipient- and donor-site complications. All patients eventually ambulated on their flaps. Five patients came to proximal amputation from 6 to 37 months after surgery. Only one amputation was for flap breakdown.

Evolving microsurgical technique has allowed for the anastomosis of smaller diameter vessels. Standard suture anastomoses cause a measure of stenosis and intimal damage during application and therefore cannot be dependably used in the anastomosis of very small vessels. We developed and tested a fibrin glue-based anastomosis applied over a meltable stent made of mono- di- and tri-glycerides. In vivo rodent studies using the 0.35 mm diameter inferior epigastric artery have shown immediate and short-term patency rates better than those associated with suture technique. The stent technique is significantly faster and easier than the suture technique. The glyceride stent method suffers from decreased late patency due to aneurysm formation. In addition, we developed a glyceride-coated polyethylene glycol-based stent for use in lasered anastomoses. Work on both projects is ongoing.

Several researchers and clinicians have taken advantage of the omentum's rich vascular arcades to support skin grafts. We have previously described an experimental model using the omentum as a vascular carrier for prefabricated free flaps in the rat. In this study, we used this model to compare three different sizes of free flaps using the same size omental carrier. Twenty-four male Sprague-Dawley rats were used for this study. A 2.5 × 4 cm patch of omentum with gastroepiploic vessels and its rich vascular arcades was transferred under a bipedicled 2.5 × 6 cm (group I), a 2.5 × 8 cm (group II), and a 4 × 10 cm (group III) right abdominal panniculocutaneous flap. On the seventh postoperative day, the skin pedicles were divided and the skin flap raised as a composite island flap vascularized only by the underlying omental patch. The composite flap was then sutured back in place. Prefabricated flaps examined 7 days postoperatively demonstrated a dye florescence index percent (DFI) of 38.19 ± 7.52 and 98.13 ± 3.72% flap survival (FS) in the 6 ± 2.5 cm skin flap group; a DFI of 39.96 ± 6.81% and FS 94.88 ± 7.08% in the 8 ± 2.5 skin flap group (P > 0.05) and a DFI 29.71 ± 2.85% and FS 57.06 ± 9.52% in the 10 × 4 cm skin flap group (P < 0.05). India ink injection study and histologic examination confirmed revascularization of the overlying skin at 7 days. This study confirms that omentum can be used as a vascular carrier for prefabricated flaps. However, there is a limit to the size of the flap. A 10 cm2 carrier can support 57% of a 40 cm2 (10 × 4 cm) flap for a total area of 22.8 cm2, more than twice the area of the carrier. © 1994 Wiley-Liss, Inc.

We report on the use of dental x-ray equipment for micro-arteriography in 18 rat arterial anastomoses. Our experience has shown that an exposure of 70 kV, at 7mA, for 0.17 seconds, gives excellent results. This is an easy and useful technique for evaluating the patency and stenosis of microvascular anastomoses. © 1993 Wiley-Liss Inc.

A case of successful microvascular replantation of a traumatically amputated ear is presented. The postoperative course was complicated by venous thrombosis requiring the use of medicinal leeches and systemic heparinization for salvage. This is the tenth successful microvascular ear replantation reported in the literature. © 1993 Wiley-Liss Inc.

The omentum used as a vascular carrier is a new experimental model for prefabrication of free flaps in the rat. A 2.5 x 4 cm patch of omentum with gastroepiploic vessels and its rich vascular arcades was transferred under a bipedicled 2.5 x 6 cm right abdominal panniculocutaneous flap. At subsequent time intervals (postoperative days 0, 3, 5, 7, and 14), the skin pedicles were divided and the skin flap was raised as a composite island flap vascularized only by the underlying omental patch. The composite flap was then sutured back in place. Prefabricated flaps examined postoperatively demonstrated a dye fluorescence index (DFI) of 4.60% +/- 2.82% and 1.67% +/- 4.08% flap survival (FS) in the day 0 group; in the day 3 group, 9.83% +/- 1.47% of DFI and 15.00% +/- 10.35% of FS; in the day 5 group, 28.39% +/- 5.25% of DFI and 86.0% +/- 12.74% of FS (P less than 0.05); in the day 7 group, 38.19% +/- 7.52% of DFI and 98.13% +/- 3.72% of FS (P less than 0.05); and, in the day 14 group, 49.55% +/- 6.70% of DFI and 100% of FS (P less than 0.05). India-ink injection and histologic examination confirmed revascularization of the overlying skin by day 5.

This study describes our experience using an improved technique for microsurgical sleeve anastomosis of arteries. Modifications of previously described techniques include utilization of a sidecut and placement of the two stitches within separate vertical planes. In 40 arteries, we attained a patency rate of 97.5%. Histology, in vivo observation, and flow study using high-frequency pulsed ultrasound Doppler at 2 hr to 8 weeks demonstrate that the sidecut sleeve anastomosis shows patency and flow characteristics similar to those of standard end-to-end anastomosis, but with a dramatic decrease in operative time.