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Background Human immunodeficiency virus (HIV)-associated lipodystrophy is a known consequence of long-term highly active antiretroviral therapy (HAART). However, a significant number of patients on HAART therapy were left with the stigmata of complications, including fat redistribution. Few studies have described the successful removal of focal areas of lipohypertrophy with successful outcomes. This manuscript reviews the outcomes of excisional lipectomy versus liposuction for HIV-associated cervicodorsal lipodystrophy. Methods We performed a 15-year retrospective review of HIV-positive patients with lipodystrophy. Patients were identified by query of secure operative logs. Data collected included demographics, medications, comorbidities, duration of HIV, surgical intervention type, pertinent laboratory values, and the amount of tissue removed. Results Nine male patients with HIV-associated lipodystrophy underwent a total of 17 procedures. Of the patients who underwent liposuction initially (n=5), 60% (n=3) experienced a recurrence. There were a total of three cases of primary liposuction followed by excisional lipectomy. One hundred percent of these cases were noted to have a recurrence postoperatively, and there was one case of seroma formation. Of the subjects who underwent excisional lipectomy (n=4), there were no documented recurrences; however, one patient’s postoperative course was complicated by seroma formation. Conclusions HIV-associated lipodystrophy is a disfiguring complication of HAART therapy with significant morbidity. Given the limitations of liposuction alone as the primary intervention, excisional lipectomy is recommended as the primary treatment. Liposuction may be used for better contouring and for subsequent procedures. While there is a slightly higher risk for complications, adjunctive techniques such as quilting sutures and placement of drains may be used in conjunction with excisional lipectomy.

Background Microtia is an inherited condition that results in varying degrees of external ear deformities; the most extreme form is anotia. Effective surgical reconstruction techniques have been developed. However, these usually require multistage procedures and have other inherent disadvantages. Tissue engineering technologies offer new approaches in the field of external ear reconstruction. In this setting, chondrocytes are cultured in the laboratory with the aim of creating bioengineered cartilage matrices. However, cartilage engineering has many challenges, including difficulty in culturing sufficient chondrocytes. To overcome these hurdles, the authors propose a novel model of cartilage engineering that involves co-culturing chondrocytes and adipose-derived stem cells on an allograft adipose-derived extracellular matrix scaffold. Methods Auricular chondrocytes from porcine ear were characterized. Adipose-derived stem cells were isolated and expanded from human lipoaspirate. Then, the auricular chondrocytes were cultured on the allograft adipose matrix either alone or with the adipose-derived stem cells at different ratios and examined histologically. Results Cartilage induction was most prominent when the cells were co-cultured on the allograft adipose matrix at a ratio of 1:9 (auricular chondrocyte-to-adipose-derived stem cell ratio). Furthermore, because of the xenogeneic nature of the experiment, the authors were able to determine that the adipose-derived stem cells contributed to chondrogenesis by means of a paracrine stimulation of the chondrocytes. Conclusions In this situation, adipose-derived stem cells provide sufficient support to induce the formation of cartilage when the number of auricular chondrocytes available is limited. This novel model of cartilage engineering provides a setting for using the patient's own chondrocytes and adipose tissue to create a customized ear framework that could be further used for surgical reconstruction.

Defects involving the esophagus can pose a complex challenge to the reconstructive surgeon. Appropriate choice of recipient vessel lays the foundation for these operations. These cases often involve a “vessel-depleted” or “frozen” neck secondary to resection and treatment of malignancy, making knowledge of the various recipient vessel options vital. This chapter describes the recipient vessels available in esophagus reconstruction, and the pertinent anatomy, benefits, and downsides associated with each vessel option.

Vascular compromise and blindness are reported but rare complications of facial soft tissue filler injections. Stroke is an even rarer complication resulting from intraarterial injection of fillers. We present a case of a patient suffering all 3 complications following hyaluronic acid filler injection: forehead skin vascular compromise, unilateral blindness, and ipsilateral subclinical strokes. Were it not for a stroke workup protocol, the incidental strokes may have otherwise gone undetected, suggesting the incidence of stroke from intraarterial injection may be higher than reported. Further, we review the literature and recommendations for prevention and management of threatened tissue ischemia and vision loss from facial filler injection. Level of Evidence: 5

Background The role of surgical reconstruction following melanoma extirpation is well recognized. Although technical considerations depend on patient anatomy and surgeon preference, the optimal timing of reconstruction remains unclear. This study aims to evaluate clinical and oncologic outcomes in melanoma extirpation followed by immediate reconstruction. Methods We retrospectively identified patients who underwent immediate reconstruction following head and neck melanoma excision at our institution between January 2013 and December 2016. Demographic and clinical characteristics, operative variables, and outcome data were extracted. Results Overall, 197 patients (male 70.6%) underwent excision followed by immediate reconstruction. Of the 70 patients with a history of cutaneous malignancy, 46 (65.7%) had a prior melanoma and 26 (37.1%) had 2 or more types of skin cancers. Of the 202 lesions resected, 138 (68.3%) were invasive, whereas 64 (31.7%) were in situ. The most frequent anatomic location involved was the cheek (34.2%), followed by scalp (31.2%). Reconstruction technique varied, with 116 (57.4%) lesions repaired by adjacent tissue transfer, 24 (11.9%) by full-thickness skin graft, 23 (11.4%) by complex primary closure, 17 (8.4%) by split-thickness skin graft, and 22 (10.9%) by more than 1 technique. On postoperative pathologic assessment, 2 patients had positive margins and 5 experienced local recurrence (mean follow-up: 2.3 years). In an unadjusted bivariate analysis, history of melanoma (P = 0.015) was significantly associated with local recurrence. Conclusions Reconstruction at time of excision is an oncologically safe approach for the management of patients with malignant melanoma. A prior history of melanoma may be associated with local recurrence.

Diabetes mellitus (DM) is a chronic disease that results in a variety of systemic complications. Recently, stem cell-based therapies have been proposed as potential modalities to manage DM related complications. Mesenchymal stem cell (MSC) based therapies are often considered as an ideal stem cell-based treatment for DM management due to their immunosuppressive characteristics, anti-inflammatory properties and differentiation potential. While MSCs show tremendous promise, the underlying functional deficits of MSCs in DM patients is not well understood. Using the MEDLINE database to define these functional deficits, our search yielded 1826 articles of which 33 met our inclusion criteria. This allowed us to review the topic and illuminate four major molecular categories by which MSCs are compromised in both Type 1 DM and Type II DM models which include: (1) changes in angiogenesis/vasculogenesis, (2) altered pro-inflammatory cytokine secretion, (3) increased oxidative stress markers and (4) impaired cellular differentiation and decreased proliferation. Knowledge of the deficits in MSC function will allow us to more clearly assess the efficacy of potential biologic therapies for reversing these dysfunctions when treating the complications of diabetic disease.

BackgroundTamoxifen is an important adjunct therapy in breast cancer treatment; however, it has been implicated in increasing microvascular flap complications. Current recommendations on stopping tamoxifen are conflicting and do not address tamoxifen therapy that is continued perioperatively. The pu

There are two accepted theories that describe the pathophysiology of fat grafting results. The first is that once grafted, there is at least partial survival of the adipocytes to achieve a lipofilling effect. The second theory is that the grafted adipocytes undergo necrosis, and it is the remaining stromal components and stem cells that recruit host tissue to fill the void through adipogenesis, neovascularization, and fibrosis. The authors discuss decellularization of adipose tissue, characterization of decellularized human adipose tissue extracellular matrix (hDAM), emerging trends in basic science and translational applications, hDAM supplementation, decellularization, hDAM 3d architecture, and clinical implications. hDAM has the potential to promote the attachment and proliferation of progenitor cells. Creating the optimal microenvironment for tissue regeneration may prove to be tissue specific, and recent research on hDAM manipulation and supplementation with synthetic scaffolds is paving the way for novel therapies in the field of regenerative medicine.

BACKGROUND There are limited data regarding blood transfusion following abdominoplasty, especially in post-bariatric surgery patients. The purpose of this study was to evaluate (1) the frequency and outcomes of blood transfusion in post-bariatric surgery patients undergoing abdominoplasty and (2) the predictive risk factors of blood transfusion in this patient population. METHODS Using the Nationwide Inpatient Sample database, the authors examined the clinical data of patients with a history of bariatric surgery who underwent abdominoplasty from 2007 to 2011 in the United States. RESULTS A total of 20,130 post-bariatric surgery patients underwent abdominoplasty during this period. Overall, 1871 patients (9.3 percent) received blood transfusion. Chronic anemia patients had the highest rate of blood transfusion (25.6 percent). Post-bariatric surgery patients who received blood transfusion experienced a significantly higher complication rate (10.1 percent versus 4.8 percent; p < 0.01), longer mean hospital stay (4.0 days versus 2.4 days; p < 0.01), and higher mean total hospital charges ($49,116 versus $33,927; p < 0.01). Multivariate regression analysis showed that deficiency anemia (adjusted OR, 3.8), congestive heart failure (adjusted OR, 2.4), concurrent breast reduction (adjusted OR, 1.5), diabetes mellitus (adjusted OR, 1.4), coronary artery disease (adjusted OR, 1.4), African American race (adjusted OR, 1.4), Hispanic race (adjusted OR, 1.4), and female sex (adjusted OR, 1.3) were all independent risk factors for blood transfusion. CONCLUSIONS The blood transfusion rate in post-bariatric surgery abdominoplasty patients is not insignificant. Chronic anemia and congestive heart failure are the two major predictors of transfusion. Modifying risk factors such as anemia before abdominoplasty might significantly decrease the possibility of blood transfusion. CLINICAL QUESTION/LEVEL OF EVIDENCE Risk, III.

The objectives of this study were to evaluate 1) the rate of immediate breast reconstruction; 2) the frequency of immediate tissue expander placement; and 3) to compare perioperative outcomes in patients who underwent breast reconstruction after mastectomy for breast cancer with immediate tissue expander placement (TE) with those with no reconstruction (NR). Using the Nationwide Inpatient Sample database, we examined the clinical data of patients with breast cancer who underwent mastectomy with or without immediate TE from 2006 to 2010 in the United States. A total of 344,253 patients with breast cancer underwent mastectomy in this period in the United States. Of these patients, 31 per cent had immediate breast reconstruction. We only included patients with mastectomy and no reconstruction (NR: 237,825 patients) and patients who underwent only TE placement with no other reconstruction combination (TE: 61,178 patients) to this study. Patients in the TE group had a lower overall postoperative complication rate (2.6 vs 5.5%; P < 0.01) and lower in-hospital mortality rate (0.01 vs 0.09%; P < 0.01) compared with the NR group. Fifty-three per cent of patients in the NR group were discharged the day of surgery compared with 36 per cent of patients in the TE group. Using multivariate regression analyses and adjusting patient characteristics and comorbidities, patients in the TE group had a significantly lower overall complication rate (adjusted odds ratio [AOR], 0.6) and lower in-hospital mortality (AOR, 0.2) compared with the NR group. The rate of immediate reconstruction is 31 per cent. TE alone is the most common type of immediate reconstruction (57%). There is a lower complication rate for the patients who underwent immediate TE versus the no-reconstruction cohort.

BACKGROUND Venous thromboembolism (VTE) can be a significant cause of morbidity and mortality in autologous breast reconstruction surgery. The aim of this study was to evaluate the effect of patient characteristics, comorbidities, payer type, reconstruction type, reconstruction timing, radiation, chemotherapy, and teaching status of hospital on VTE (deep venous thrombosis and/or pulmonary embolism) in autologous breast reconstructive surgery. METHODS Using the Nationwide Inpatient Sample (NIS) database, we examined the clinical data of patients who underwent autologous breast reconstructive surgery in 2009 to 2010 in the United States. Univariate and multivariate regression analyses were performed to identify factors predictive of in-hospital VTE. RESULTS A total of 35,883 patients underwent autologous breast reconstructive surgery during this period. Overall rate of VTE was 0.13%. The highest rate of VTE (0.26%) was observed in pedicled transverse rectus abdominis myocutaneous flap. Patients who experienced VTE had significantly longer mean hospital stay (11.6 vs 3.9 days; P < 0.001) and higher mean total hospital charges ($146,432 vs $61,794; P < 0.001) compared with non-VTE patients; however, there was no significant difference observed in mortality rate (VTE, 0.0% vs non-VTE, 0.04%; P = 0.886). Using multivariate regression analysis, immediate reconstruction after mastectomy (adjusted odds ratio [AOR], 5.4), older than 65 years (AOR, 4.2), obesity (AOR, 3.7), history of chemotherapy (AOR, 3.5), and chronic lung disease (AOR, 2.5) were associated with higher risk of VTE. There was no association between race, payer type, diabetes, hypertension, liver disease, congestive heart failure, peripheral vascular disease, chronic kidney disease, smoking, reconstruction type, radiation, or teaching status of hospital on VTE. CONCLUSIONS In patients undergoing autologous breast reconstruction surgery, immediate reconstruction, older than 65 years, obesity, history of chemotherapy, and chronic lung disease are all independent predictors of higher VTE. Surgeons should consider these factors and use appropriate prophylaxis to minimize the risk of VTE development.

Background: Peripheral nerve injuries (PNI) are a major source of morbidity worldwide. The development of cellular regenerative therapies has the potential to improve outcomes of nerve injuries. However, an ideal therapy has yet to be found. The purpose of this study is to examine the current literature key points of regenerative techniques using human adipose-derived stem cells (hADSCs) for nerve regeneration and derive a comprehensive approach to hADSC therapy for PNI. Methods: A literature review was conducted using the electronic database PubMed to search for current experimental approaches to repairing PNI using hADSCs. Key search elements focused on specific components of nerve regeneration paradigms, including (1) support cells, (2) scaffolds, and (3) nerve conduits. Results: Strategic sequences were developed by optimizing the components of different experimental regenerative therapies. These sequences focus on priming hADSCs within a specialized growth medium, a hydrogel matrix base, and a collagen nerve conduit to achieve neuromodulatory nerve regeneration. hADSCs may exert their neuroregenerative influence through paracrine effects on surrounding Schwann cells in addition to physical interactions with injured tissue. Conclusions: hADSCs may play a key role in nerve regeneration by acting primarily as support for local neurotrophic mediation and modulation of nerve growth rather than that of a primary neuronal differentiation agent. V C 2013 Wiley Periodicals, Inc. Microsurgery 00:000‐000, 2013. The standard method of treatment of peripheral nerve injuries (PNI) with autologous nerve grafts has limitations, including donor site morbidity and suboptimal functional recovery. Tissue engineering provides an interesting alternative to current treatments and several variations of therapies have been studied, including nerve conduits, regenerative stimulants, and cellular components. However, intervening to change the natural physiologic course at this level requires a proper understanding of the timing and mechanisms of the events that occur during degeneration and regrowth after PNI. Nerve injury is accompanied by a sequence of events that precede the final outcome of nerve healing. 1 This outcome ranges from almost complete nerve regeneration to degeneration, nerve loss, neuroma formation, and incomplete or absent nerve regeneration. Each sequence within this nerve injury process is accompanied by biologic events that may influence the ongoing regenerative process. Thus, any strategy relating to nerve regeneration should consider these sequences individually and cumulatively as the process of regeneration unfolds. From this standpoint, it is pertinent to deconstruct PNI into sequences relating to degeneration, initial regeneration, and possible intervention strategies that may limit, speed up, or facilitate such sequences. This approach enables us to examine the process at different time frames and to plan combined approaches that consider most of these components when designing a comprehensive regenerative device. Human adipose tissue-derived stem cells (hADSCs) are a heterogeneous group of multipotent progenitor cells that can be harvested autogenously in high numbers with low donor site morbidity and have been used in several studies to promote nerve regeneration. 2‐6 This review focuses on the utilization of hADSCs as neurotrophic mediators, stimulating nerve regeneration from environmental cues rather than promoting the in vitro neuronal differentiation of hADSCs. The goal of this approach is to create an effective method of promoting nerve regeneration while minimizing the manipulation of autologous cells to move toward a transnational therapy.

There has been much debate concerning the pathologic consequences of diabetes on the plantar fat pad and its subsequent association with the development of a foot ulcer. This review article documents two theories regarding pathophysiology in diabetic foot ulcer formation as they are related to the plantar fat pad and discusses current treatment options for this pathophysiological phenomenon. Traditionally, fat pad atrophy in diabetic patients was thought to result as an irregular arrangement of collagen fibrils within the septal walls as a result of glycation as well as diminishing adipocyte size due to thickened septal walls. Contrary to this traditional theory, a model depicting distal fat pad migration from under the metatarsal heads has been described in the diabetic patient. Such pad migration renders the metatarsal heads vulnerable to increased pressure, which, in turn, predisposes to foot ulceration. This migratory fat pad theory plays a significant role in approaches to the prevention of diabetic foot ulceration and subsequent amputation. Various methods of fat pad supplementation and claw toe management are impacted by the pathophysiological changes described and new avenues of therapy may be based on these changes.

Background The purpose of this study was to determine the evidenced-based value of prophylactic drainage of subcutaneous wounds in surgery. Methods An electronic search was performed. Articles comparing subcutaneous prophylactic drainage with no drainage were identified and classified by level of evidence. If sufficient randomized controlled trials were included, a meta-analysis was performed using the random-effects model. Fifty-two randomized controlled trials were included in the meta-analysis, and subgroups were determined by specific surgical procedures or characteristics (cesarean delivery, abdominal wound, breast reduction, breast biopsy, femoral wound, axillary lymph node dissection, hip and knee arthroplasty, obesity, and clean-contaminated wound). Studies were compared for the following endpoints: hematoma, wound healing issues, seroma, abscess, and infection. Results Fifty-two studies with a total of 6930 operations were identified as suitable for this analysis. There were 3495 operations in the drain group and 3435 in the no-drain group. Prophylactic subcutaneous drainage offered a statistically significant advantage only for (1) prevention of hematomas in breast biopsy procedures and (2) prevention of seromas in axillary node dissections. In all other procedures studied, drainage did not offer an advantage. Conclusions Many surgical operations can be performed safely without prophylactic drainage. Surgeons can consider omitting drains after cesarean section, breast reduction, abdominal wounds, femoral wounds, and hip and knee joint replacement. Furthermore, surgeons should consider not placing drains prophylactically in obese patients. However, drain placement following a surgical procedure is the surgeon's choice and can be based on multiple factors beyond the type of procedure being performed or the patient's body habitus. Clinical question/level of evidence Therapeutic, II.

Pilomatrix carcinoma is a rare malignancy of the hair follicle characterized by aggressive local invasion, high rates of local recurrence, and metastasis in advanced stages. It is the malignant version of a pilomatrixoma. There is no consensus on optimal management, but current approaches typically involve wide local excision, sentinel lymph node biopsy and local reconstruction with skin grafting.

Background: The purpose of this study was to evaluate the influence of hypertonic and hyperoncotic saline solutions on ischemia-reperfusion injury after free tissue transfer. Methods: Twenty-eight Sprague-Dawley rats were used to design an inferior epigastric flap. After skin incision, microcirculation was investigated using orthogonal polarization spectral imaging. After free tissue transfer of the inferior epigastric flap to the right groin, a 7.5% hypertonic saline solution was administered to the flap at reperfusion in group A (n = 7). Groups B, C, and D (n = 7 each) received 6% dextran-70, hypertonic saline with dextran-70, and isotonic sodium chloride solution, respectively. Evaluation of microcirculation was again performed at reperfusion and 10, 20, and 40 minutes later. Flap survival was determined by measurement of viable flap area at day 2. Results: Group D demonstrated a decline in blood cell velocity, arterial vessel diameter, venous vessel diameter, and functional capillary density within 40 minutes after reperfusion. Groups A and B showed less of a decrease in these parameters. The administration of hypertonic saline and dextran-70 was able to maintain a sufficient microcirculation at all time points. At day 2, flap survival was decreased in group A by 12.7 percent, in group B by 32.8 percent, in group C by 3.9 percent, and in group D by 41 percent. Conclusions: The authors conclude that local administration with hypertonic saline and dextran-70 improves microcirculatory disturbances on reperfusion and increases overall free flap survival. These data demonstrate that a positive influence on no-reflow mechanisms is possible by extensive fluid shifts on the level of the microcirculation.

Facial paralysis is a relatively common disorder from which most people recover without complications. However, some are left with significant functional impairment and disfigurement, the treatment of which has challenged physicians for centuries. Within the spectrum of surgical procedures to reanimate the face is cross-facial nerve grafting. This article chronicles the history of cross-facial nerve grafting, including its past and present use, and describes various factors associated with its use. A brief discussion of aetiology and morbidity of facial paralysis and some fundamental surgical options will be presented. A complete review of these topics is beyond the scope of this manuscript.

It is widely known that ultraviolet light causes skin damage and melanoma. Different wavelengths of ultraviolet light penetrate the skin at different depths, causing varying levels of damage. Higher wavelengths tend to penetrate deeper and, consequently, are thought to induce a myriad of skin conditions, thereby playing a significant role in the photoaging process. Sunscreens containing the ultraviolet A blocker Mexoryl are important in impeding ultraviolet A light, potentially reducing many of the characteristics of skin aging and preventing biochemical changes that can lead to nonmelanoma carcinoma. Until now, sunscreen products sold in the United States focused on blocking ultraviolet B light. Those that did provide ultraviolet A filtering contained physical blocks (zinc oxide or titanium dioxide) or the chemical block Parsol 1789 (avobenzone). These broad-spectrum sunscreens have limitations, such as degradation under ultraviolet exposure, that resulted in decreased effectiveness. Mexoryl, a novel ultraviolet A filter, provides efficient ultraviolet A coverage, better photostability, and enhanced water resistance. Sunscreens containing Mexoryl are widely used in Europe and Canada. It was not until July 24, 2006, that the U.S. Food and Drug Association approved the compound.

A 37-year-old woman originally presented in May 2003 with a nonhealing, painless ulcer on the plantar surface of her right foot that had been slowly increasing in size for the previous 1.5 years. Two weeks before presentation, a biopsy of the lesion, performed at another institution, had indicated a probable verrucous carcinoma. After preoperative workup, the patient underwent resection of the lesion, with clear margins and full-thickness skin grafting. The final pathologic findings were not consistent with verrucous carcinoma. A recurrent lesion was noted during a follow-up visit, and a second biopsy revealed a hyperkeratotic papillomatous verrucous lesion, type unclassified. No viral particles were isolated in the random biopsy samples. This recurrent lesion was refractory to treatment with topical acyclovir. Subsequent treatments consisted of imiquimod and CO2 laser ablation, which succeeded in reducing the lesion. Verrucous lesions can be frustrating, and the diagnosis of epithelioma cuniculatum can be difficult to prove. We report a case highly suggestive of but not definitively diagnosed as epithelioma cuniculatum and summarize the literature on this entity. (J Am Podiatr Med Assoc 96(2): 148–153, 2006)

Guidelines for the repair of full-thickness defects of the lower abdominal wall have been established. However, lower abdominal defects associated with traumatic bladder herniation and pubic symphyseal diastasis or bony loss have not been addressed. Poor abdominal wall contour, protuberance, and recurrent hernias are likely when there is discontinuity of the midline pelvis in association with full-thickness lower abdominal defects and visceral herniation. We devised an operation that would not only restore bony continuity by providing a vascularized bone flap but also simultaneously maintain the integrity of the attachment of the tensor fascia latae muscle to the iliac crest and reestablish musculofascial continuity.

The ulnar forearm flap is not frequently utilized for oromandibular reconstruction. This study evaluated the usefulness of the ulnar free flap for reconstruction. A retrospective study of 32 patients was conducted. The ulnar forearm flap was combined with an osseous flap in 24 patients. Nine females and 23 males with a mean age of 58.15 years comprised our study population. Squamous-cell carcinoma was the diagnosis in 93.75% of cases (56.25% T4), of which 20% were recurrent. Functional evaluation of swallowing was based on the University of Washington Questionnaire (UWQ). The mean hospital stay was 9.8 days. The external carotid (100%) was the recipient artery, and the internal jugular (74.07%) was the main recipient vein. Overall flap survival was 96.8%. One flap was lost due to unsalvageable venous thrombosis. Major local complications were seen in 9.4% of cases and included partial flap loss, hematoma, and an orocutaneous fistula. At the time of this study, 21 patients were available for functional evaluation. Speech was rated excellent and good in 33.3% of patients. Swallowing was found good in 28.6% of patients. Chewing was rated excellent and good in 47.6% of patients. Cosmetic acceptance was rated good in 71.4% of cases. The ulnar forearm is a useful free flap in oromandibular reconstruction. It is available when the radial artery is the dominant artery of the hand. Being more hidden, it may be more cosmetically accepted. It affords pliable soft tissue for lining and/or covering of oromandibular defects, and can be used as a second choice after other free-flap failures.

Fifty cases of oromandibular reconstruction using vascularized free flaps to evaluate functional parameters of results were evaluated. There were 23 iliac crest flaps, 17 fibula flaps, 30 ulnar forearm flaps, and 3 radial forearm flaps with bone. Thirteen female and 37 male patients comprised the study, with a mean age of 57.66 years. Squamous-cell carcinoma (SCC) constituted 86% of cases, of which 60% were T4 lesions and 13.9% were recurrent. Anterolateral mandibular defects constituted 48.7%, and the mean bone gap was 8.13 cm. Functional evaluation was based on the University of Washington Questionnaire (UWQ) through phone calls and personal communication. The mean hospital stay was 12.42 days. The external carotid (75%) and facial (18.3%) were the main recipient arteries. The internal jugular (47.05%) was the main recipient vein. Overall flap survival was 95.9%. Three flaps were lost due to unsalvageable venous thrombosis. Major local complications such as partial flap loss, hematoma, and orocervical fistula constituted 10% of cases. Speech was classified as "excellent" and "good" in 43.3% of cases. Swallowing was identified as "excellent" and "good" in 53.3% of cases. Cosmetic acceptance was rated "good" in 63.3% of cases. Vascularized free flap reconstruction of oromandibular defects provides excellent functional and aesthetic results. The majority of patients are able to tolerate a regular diet. Intelligible speech and acceptable appearance are restored, providing patient satisfaction.

BACKGROUND The objective of this study was to define the impact of soft tissue flap reconstruction on multimodality therapy for patients with soft tissue sarcomas of the upper extremity. Treatment standards continue to evolve for these patients, and, with multimodality therapy, most of them are candidates for limb-preserving surgery. Consequently, the role of soft tissue flap reconstruction is expanding. METHODS A review was conducted of 100 consecutive patients with soft tissue sarcomas of the upper extremity who underwent surgery at several institutions between 1992 and 1997. RESULTS Seventy-one patients underwent direct closure of defects after tumor resection, and 29 patients required soft tissue reconstruction with flaps. These groups were similar in most respects, except that 52% of the patients who required soft tissue reconstruction presented with recurrent disease (P = 0.0004), and 79% of them had tumors measuring > 5 cm in greatest dimension (P = 0.0003). The patients who required flap reconstruction had larger skin deficits after undergoing tumor resection (140 cm2) compared with the patients who had wounds that were managed by direct closure (40 cm2; P < 0.00001). Margins around the resected tumors were larger (1.62 cm) when flaps were employed compared with margins when defects were closed directly (0.87 cm; P = 0.0005). However, the number of patients with intralesional, marginal, wide, and radical resections was the same regardless of wound management. Major complications occurred in 14% of patients, but none led to death or amputation. The median follow-up was 31 months, and 66% of patients had no evidence of disease at that time. Rates of local recurrence and survival were similar for patients who underwent flap reconstruction compared with patients who underwent direct closure. CONCLUSIONS Soft tissue flap reconstruction facilitates therapy for patients with soft tissue sarcomas of the upper extremity, so that patients with larger tumors can undergo resection, limiting complications and limb sacrifice. Cancer 2002;94:2256–64. © 2002 American Cancer Society. DOI 10.1002/cncr.10419

Background: Breast reconstruction often requires multiple surgeries, which demands additional expense and time and is often contrary to the patient’s expectation. The aim of this study was to review the number of operations that were needed for completion of breast reconstruction and to determine patient and clinical factors that influenced this number. Methods: We retrospectively reviewed the medical records of 254 cases of breast reconstructions (in 185 patients) that were performed between February 2005 and August 2009. We investigated the numbers of operations that were performed for individual case of breast reconstruction and analyzed the influence of variable factors. The purpose of the additional operations was also analyzed. Results: The mean number of operations per breast was 2.37 (range, 1–9). The mean number of operations for mound creation was 2.24. Factors associated with an increased number of operation were use of an implant, contralateral symmetrization, complications, and nipple reconstruction. Considering the reconstruction method, either the use of a primary implant or the use of free abdominal tissue transfer demonstrated fewer surgeries than the use of an expander implant, and the number of operations using free transverse rectus abdominis musculocutaneous or deep inferior epigastric perforator flaps was less than the number of operations using pedicled transverse rectus abdominis musculocutaneous flaps. Conclusions: These data will aid in planning breast reconstruction surgery and will enable patients to be more informed regarding the likelihood of multiple surgeries.

Thrombolytic agents have been demonstrated to improve free flap salvage in animal models. However, clinical evidence regarding their efficacy has been scant. The authors reviewed their experience with flap salvage using thrombolytic therapy in 1,733 free flaps from February 1990 to July 1998. Patients with intraoperative pedicle thrombosis were excluded from this review. Forty-one of the 55 free flaps that were reexplored emergently were identified as having pedicle thrombosis. Of these 41 flaps, 28 free flaps were salvaged (flap salvage group, 68%) and 13 free flaps failed (flap failure group, 32%). Thrombolytic therapy (urokinase in 7 patients, tissue plasminogen activator in 1 patient) was used in six flaps in the flap salvage group and two flaps in the flap failure group. Statistical analysis demonstrated no difference between the two groups with regard to thrombolytic therapy. There was also no difference between the two groups with regard to use of systemic heparin (100-500 U per hour) at the time of pedicle thrombosis or with regard to whether Fogarty catheters were used. Smoking, preoperative radiotherapy, and the use of interpositional vein grafts during initial flap reconstruction had no impact on the outcome of flap salvage. The flap salvage group was reexplored at a mean of 1.5 days compared with the flap failure group, which was reexplored at a mean of 4.2 days (p = 0.007). Early detection of pedicle thrombosis remains the most important factor in the salvage of free flaps. Although these numbers are small and definitive statements cannot be made, the role of thrombolytic agents in free flap salvage requires further clinical evaluation.

Modern head and neck cancer treatment is a carefully designed combination of surgery, radiation, and chemotherapy. This article briefly explains the rationale for multidisciplinary care and highlights the role of each member of the multidisciplinary team. Special consideration is given to the unique role of plastic surgeons with particular interest in head and neck reconstruction and microvascular surgery.

Ketorolac is frequently used as an adjunct for postoperative pain relief, especially by anesthesiologists during the immediate postoperative period. It can be used alone as an analgesic but is more often used to potentiate the actions of narcotics such as morphine or meperidine in an attempt to reduce the total dose and side effects of those drugs. The manufacturer of ketorolac cautions against its use in patients who have a high risk of postoperative bleeding, for fear of increasing the risk of hematoma, but the risk in transverse rectus abdominis musculocutaneous (TRAM) flap patients has never been reported. In a study of 215 patients who had undergone TRAM flap breast reconstruction, it was determined that patients who received intravenous ketorolac (n = 65) as an adjunct to their treatment with morphine administered by use of a patient-controlled analgesia device required less morphine (mean cumulative dose, 1.39 mg/kg) than did patients who did not receive ketorolac (n = 150; mean cumulative dose, 1.75 mg/kg; p = 0.02). There was no increase in the incidence of hematoma in patients who were treated with ketorolac. The data presented in this study suggest that the use of intravenous ketorolac does reduce the need for narcotics administration in patients undergoing TRAM flap breast reconstruction, without significantly increasing the risk of hematoma.

Eleven thousand Americans each year are affected by paralysis, a devastating injury that possesses associated annual costs of $7 billion (American Paralysis Association, 1997). Currently, there is no effective treatment for damage to the central nervous system (CNS), and acute spinal cord injury has been extraordinarily resistant to treatment. Compared to spinal cord injury, damage to peripheral nerves is considerably more common. In 1995, there were in excess of 50,000 peripheral nerve repair procedures performed. (National Center for Health Statistics based on Classification of Diseases, 9th Revision, Clinical Modification for the following categories: ICD-9 CM Code: 04.3, 04.5, 04.6, 04.7). These data, however, probably underestimate the number of nerve injuries appreciated, as not all surgical or traumatic lesions can be repaired. Further, intraabodominal procedures may add to the number of neurologic injuries by damage to the autonomic system through tumor resection. For example, studies assessing the outcome of impotency following radical prostatectomy demonstrated 212 of 503 previously potent men (42%) suffered impotency when partial or complete resection of one or both cavernosal nerve(s). This impotency rate decreased to 24% when the nerves were left intact (Quinlan et al., J. Urol. 1991;145:380-383; J. Urol. 1991;145:998-1002).

The objectives of this study were to evaluate reconstructive methods for patients receiving brachytherapy after cancer ablation. This retrospective review evaluated 19 patients who received brachytherapy and reconstruction between 1991 and 1998. The average age of the patient was 61.9 years and the average follow-up was 2.9 years. Lesions were located in the upper extremity (N = 6), trunk (N = 2), and lower extremity (N = 11). In all patients, early postoperative brachytherapy was initiated 5 days after wound closure. The average radiation dose was 47 Gy (range, 45-50 Gy) and was delivered over a 3 to 5-day period. In each case, varying numbers of catheters were employed (average, 8 +/- 5 catheters). Free flap coverage was performed in 8 patients, and the latissimus dorsi was used most often. Pedicled regional flaps were employed in 11 patients (58%). Sixteen patients (84%) had additional external beam irradiation, and 10 patients (52%) underwent preoperative chemotherapy. All flaps survived with a demonstrated low complication rate (10%). In 2 patients, partial flap necrosis and infection occurred. Three donor site complications were observed and included wound dehiscence in 2 patients and hematoma in 1 patient. Cumulative effects of external beam radiation and brachytherapy did not affect the complication rate. Location of the defect did not alter the incidence of complications. Wound complications did not delay functional rehabilitation in these patients; however, hospital stay was longer. In 8 patients local recurrence occurred (42%) between 6 and 36 months after surgery whereas in 6 patients (32%) distant metastasis was observed. Ten patients are currently alive without evidence of disease. One of the most important concerns about early postoperative brachytherapy is wound healing. With careful planning and precise reconstructive techniques, the use of brachytherapy as a part of salvage or primary surgery does not lead to increased wound morbidity. Reconstructive procedures and a multidisciplinary approach have allowed the delivery of brachytherapy in these complicated patients with low morbidity.

Total sacrectomies for cancer ablation often result in extensive defects that are challenging to reconstruct. In an effort to elucidate the criteria to select the most effective reconstructive options, we reviewed our experience with the management of large sacral wound defects. All patients who had a sacral defect reconstruction after a total sacrectomy at our institution between January of 1993 and August of 1998 were reviewed. The size of the defect, the type of reconstruction, postoperative complications, and functional outcome in each patient were assessed. A total of 27 flaps were performed in 25 patients for sacral defect reconstruction after a total sacrectomy. Diagnoses consisted of chordoma (n = 13), giant cell carcinoma (n = 2), sarcoma (n = 5), rectal adenocarcinoma (n = 4), and radiation induced necrosis (n = 1). The size of sacral defects ranged from 18 to 450 cm2 (mean, 189.8 cm2). Ten patients, including five who had preoperative radiation therapy, underwent transpelvic vertical rectus abdominis myocutaneous (VRAM) flap reconstruction for sacral defects with a mean size of 203.3 cm2. Of these, five patients (50 percent) had complications (four minor wound dehiscences and one seroma). Eight patients, including one who had preoperative radiation therapy, underwent bilateral gluteal advancement flap reconstruction for sacral defects with a mean size of 198.0 cm2. They had no complications. Two patients, both of whom had preoperative radiation therapy, underwent gluteal rotation flap reconstruction for sacral defects of 120 cm2 and 144 cm2. Both patients had complications (one partial flap loss and one nonhealing wound requiring a free flap). Three patients, including one who had preoperative radiation therapy, underwent reconstruction with combined gluteal and posterior thigh flaps for sacral defects with a mean size of 246 cm2; two of these patients had partial necrosis of the posterior thigh flaps. Three patients, all of whom had preoperative radiation therapy, underwent free flap reconstruction for sacral defects with a mean size of 144.3 cm2. They had no complications. Our experience suggests that there are three reliable options for the reconstruction of large sacral wound defects: bilateral gluteal advancement flaps, transpelvic rectus myocutaneous flaps, and free flaps. In patients with no preoperative radiation therapy and intact gluteal vessels, the use of bilateral gluteal advancement flaps should be considered. In patients with a history of radiation to the sacral area and in patients whose gluteal vessels have been damaged, the use of the transpelvic VRAM flap should be considered. If the transpelvic VRAM flap cannot be used because of previous abdominal surgery, a free flap should be considered as a last option.

The purpose of this study was to assess the effect of obesity on flap and donor-site complications in patients undergoing free transverse rectus abdominis myocutaneous (TRAM) flap breast reconstruction. All patients undergoing breast reconstruction with free TRAM flaps at our institution from February 1, 1989, through May 31, 1998, were reviewed. Patients were divided into three groups based on their body mass index: normal (body mass index25), overweight (body mass index 25 to 29), obese (body mass indexor =30). Flap and donor-site complications in the three groups were compared. A total of 936 breast reconstructions with free TRAM flaps were performed in 718 patients. There were 442 (61.6 percent) normal-weight, 212 (29.5 percent) overweight, and 64 (8.9 percent) obese patients. Flap complications occurred in 222 of 936 flaps (23.7 percent). Compared with normal-weight patients, obese patients had a significantly higher rate of overall flap complications (39.1 versus 20.4 percent; p = 0.001), total flap loss (3.2 versus 0 percent; p = 0.001), flap seroma (10.9 versus 3.2 percent; p = 0.004), and mastectomy flap necrosis (21.9 versus 6.6 percent; p = 0.001). Similarly, overweight patients had a significantly higher rate of overall flap complications (27.8 versus 20.4 percent; p = 0.033), total flap loss (1.9 versus 0 percent p = 0.004), flap hematoma (0 versus 3.2 percent; p = 0.007), and mastectomy flap necrosis (15.1 versus 6.6 percent; p = 0.001) compared with normal-weight patients. Donor-site complications occurred in 106 of 718 patients (14.8 percent). Compared with normal-weight patients, obese patients had a significantly higher rate of overall donor-site complications (23.4 versus 11.1 percent; p = 0.005), infection (4.7 versus 0.5 percent; p = 0.016), seroma (9.4 versus 0.9 percent; p0.001), and hernia (6.3 versus 1.6 percent; p = 0.039). Similarly, overweight patients had a significantly higher rate of overall donor-site complications (19.8 versus 11.1 percent; p = 0.003), infection (2.4 versus 0.5 percent; p = 0.039), bulge (5.2 versus 1.8 percent; p = 0.016), and hernia (4.3 versus 1.6 percent; p = 0.039) compared with normal-weight patients. There were no significant differences in age distribution, smoking history, or comorbid conditions among the three groups of patients. Obese patients, however, had a significantly higher incidence of preoperative radiotherapy and preoperative chemotherapy than did patients in the other two groups. A total of 23.4 percent of obese patients had preoperative radiation therapy compared with 12.3 percent of overweight patients and 12.4 percent of normal-weight patients; 34.4 percent of obese patients had preoperative chemotherapy compared with 24.5 percent of overweight patients and 17.7 percent of normal-weight patients. Multiple logistic regression analysis was used to determine the risk factors for flap and donor-site complications while simultaneously controlling for potential confounding factors, including the incidence of preoperative chemotherapy and radiotherapy. In summary, obese and overweight patients undergoing breast reconstruction with free TRAM flaps had significantly higher total flap loss, flap hematoma, flap seroma, mastectomy skin flap necrosis, donor-site infection, donor-site seroma, and hernia compared with normal-weight patients. There were no significant differences in the rate of partial flap loss, vessel thrombosis, fat necrosis, abdominal flap necrosis, or umbilical necrosis between any of the groups. The majority of overweight and even obese patients who undertake breast reconstruction with free TRAM flaps complete the reconstruction successfully. Both such patients and surgeons, however, must clearly understand that the risk of failure and complications is higher than in normal-weight patients. Patients who are morbidly obese are at very high risk of failure and complications and should avoid any type of TRAM flap breast reconstruction.

INTRODUCTION: Reconstruction after wide local excision of melanomas in the head and neck can be formidable. Many tumors lie close to vital structures, and excision must carefully balance preservation of form and function. For small defects, primary closure or skin grafting is satisfactory. However, it has become increasingly evident that more advanced reconstructive procedures can improve the outcome in terms of both function and aesthetics. This study was undertaken to determine the effectiveness of flap closure after wide local excision of melanomas in the head and neck and to develop a set of surgical recommendations on the basis of our experience. METHOD: We reviewed 35 patients who underwent 39 flap closures at The University of Texas, M. D. Anderson Cancer Center after wide local excision of head and neck melanomas. Local flaps were primarily used to close defects after the resection of superficial or intermediate-thickness melanomas. Pedicle and free flaps were used to cover larger defects resulting from the excision of extensive tumors. The flap closures were compared with an analogous database of 560 melanoma resections that underwent primary closure or skin grafting. RESULTS: The mean age of the patient population was 57 years. The most common location for tumor presentation was the cheek, followed by the ear, forehead, and lip. Pathologic findings most commonly demonstrated superficial spreading melanoma, and the average defect size was 30.7 cm(2). Local flaps were used most often for reconstruction. The only variable that significantly predicted local recurrence was the depth of the tumor. Local, pedicle, or free flaps did not decrease the ability of detecting local recurrence or increase this number compared with primary closure and skin grafting. Major postoperative complications were detected in seven patients. We found flap closure to achieve excellent functional and aesthetic results. CONCLUSION: Although primary closure is the ideal method of reconstruction for small defects, flap closure provides a versatile and safe alternative when simple closure would yield unsatisfactory results. With careful planning, flap closure offers an exceptional functional and aesthetic result and may even enhance contour defects after extensive neck or parotid dissections. Moreover, our experience with flap closure did not appear to delay the detection of local recurrence and may have even served to decrease the incidence of local failure after wide local excision of head and neck melanomas. Copyright 2000 John Wiley & Sons, Inc. Head Neck 23: 8-15, 2001.

The most common complication after abdominoplasty is seroma formation. The incidence of seroma formation in abdominal procedures as a whole, including abdominoplasty, panniculectomy and transverse rectus abdominis myocutaneous flap abdominal donor sites, ranges from 1% to 38%. A recent concern among surgeons is the possibility of a causal relationship between the use of continuous infusion devices such as local anesthetic pain pumps and the development of seromas. A case of postoperative, persistent, recurrent seroma formation after abdominoplasty with the use of continuous infusion local anesthetic pain pump is presented. After several attempts at aspiration and drain catheter placement, only open surgical excision of the seroma cavity was found to be definitively effective in treating the development of seroma.

In this study, the records of all patients at the University of Texas M. D. Anderson Cancer Center with T1 or T2 breast cancer who were treated between March of 1986 and November of 1990 with mastectomy followed by immediate breast reconstruction were reviewed for the presence of recurrent disease. Patients with in situ disease were not included. Patients were included in the study if a local recurrence occurred (regardless of the length of follow-up) or if a follow-up of 6 years or longer could be obtained. Patients were grouped according to the use or nonuse of skin-sparing mastectomy, by tumor stage, and by nuclear grade of the tumor. The series included 154 patients, of whom 114 had skin-sparing mastectomies and 40 had nonskin-sparing mastectomies. The local recurrence rate in the skin-sparing mastectomy group was 7.0 percent, whereas in the nonskin-sparing mastectomy group it was 7.5 percent. The sample size in the nonskin-sparing mastectomy group was too small for meaningful statistical analysis, but the data suggest that there is no clinically important difference in recurrence rates between the two groups. We conclude that the use of skin-sparing technique for early breast cancer patients does not significantly increase the risk of tumor recurrence after mastectomy.

One purported advantage of the free transverse rectus abdominis musculocutaneous (TRAM) flap for breast reconstruction is that, compared with the conventional TRAM flap, it has a better blood supply and therefore a lower incidence of fat necrosis. We tested this claim by reviewing the incidence of fat necrosis, both clinically and mammographically, in a group of 110 patients with 116 TRAM flap breast reconstructions who had undergone mammography of their reconstructed breasts. Of the 49 breasts reconstructed with free TRAM flaps, 4 (8.2 percent) had clinically evident fat necrosis, and 1 (2.0 percent) had fat necrosis that was detectable by mammography. Of the 67 breasts reconstructed with conventional TRAM flaps, 18 (26.9 percent) had clinically detectable fat necrosis, and 9 (13.4 percent) had fat necrosis that was detectable mammographically. Both of these differences were statistically significant (p = 0.0113 for clinical fat necrosis; p = 0.031 for mammographic fat necrosis). Fat necrosis was more common in patients who were obese or had a history of smoking, but neither association was statistically significant. We conclude that the use of the free TRAM flap reduces the incidence of fat necrosis in the reconstructed breast.

Background: Resection of primary and metastatic pelvic bone disease may result in large soft tissue deficits. Guidelines for soft tissue reconstruction following pelvic bone resection were evaluated in a retrospective study. Methods: Over a 5-year period 21 patients (31%) required soft tissue reconstruction following pelvic bone resection. Data on these patients were retrieved from case records. Results: Twelve patients underwent immediate, planned reconstruction, 1 a two-stage reconstruction, and 8 patients required a delayed procedure for complications after bone resection and primary closure. Soft tissue reconstruction was usually accomplished with muscle-based flaps; (25 flaps in 20 patients: 20 pedicled, 5 free), or with skin grafts alone (1 patient). Specific postreconstruction complications occurred in 9 patients, 5 in flaps based on the ipsilateral rectus muscle. Conclusion: Flap closure is indicated to achieve primary closure and eliminate deadspace. The ipsilateral rectus muscle should be used with caution and contralateral-based rectus flaps considered. Indications for free flaps include the size and location of the defect and availability of tissue from an amputated limb.

Branding is a form of body art wherein third-degree burns are inflicted on the skin to produce permanent scars. This method of scarification is a common practice among many indigenous cultures and has become exceedingly common in western societies. As with other forms of body art, branding is not a manifestation of a psychiatric disorder but, rather, a method of self-expression. The process can be performed through the use of electrocautery, laser, chemicals, freezing, and hot metal. Complications arising from the procedure include acute infection, transmission of blood-borne pathogens, allergic reactions, and sequelae arising from third-degree burns. In addition, skin branding has been shown to be associated with substance abuse and high-risk behaviors among adolescents. The purpose of this article is to present the following case report and review to familiarize clinicians with this dangerous method of body art.

Background: Acral lentiginous melanoma continues to be difficult to diagnose despite an overall trend toward early identification of smaller and thin lesions. The insidious nature of this lesion often precludes primary closure of the surgical defect once it is excised, adding to the reconstructive complexity. Local flaps on the plantar foot offer an option for reconstruction when the defect is of intermediate size. Methods: Eight patients (5 men and 3 women, with an average age of 58 years) who underwent plantar flap reconstruction for defects isolated to the weight-bearing heel were retrospectively reviewed. Results: The average depth of the melanoma was 2.82 mm. Surgical margins were 2 cm or less in seven of the eight patients. Partial flap necrosis occurred in one patient, and loss of part or all of the skin grafts was noted in two patients. Currently five patients are alive with no evidence of disease. Conclusion: The plantar flap can provide local well-vascularized tissue for weight-bearing areas where skin grafting alone may not be appropriate. Coverage of these areas with well-padded flaps led to ambulation in all of the patients studied. We believe this flap offers durable coverage for medium-sized defects in acral lentiginous melanoma.

Extreme arterial and venous constructions are common problems in microvascular surgery, often leading to tissue injury and flap failure. The ideal pharmacologic tool to counteract ischemia should exert its action both locally and distally in the microcirculation of the flap. In this study, the vascular properties of sodium nitroprusside, hydralazine, and cromakalin were evaluated and compared in in vitro and in vivo models in the rabbit carotid artery. In the in vitro study, 20 rings from the rabbit carotid artery were bathed in Krebs-Ringers solution, stretched progressively to an optimal tension of 3.7 to 4.2 gm, and their isometric contractile activity was measured. The specimens were precontracted with norepinephrine (1 microM) and a dose-response curve was established by adding cumulatively either sodium nitroprusside (n = 7), cromokalin (n = 7), or hydralazine (n = 7) at increasing concentrations. In the in vivo study, microvascular anastomoses were performed bilaterally in the rabbit carotid artery in 19 animals using 9-0 nylon suture and standard microsurgical techniques. In each animal, one side was treated with heparinized sodium chloride, and served as control. The other side was treated blindly with the topical application of 1 ml of either sodium nitroprusside (10 mg/ml, n = 5), hydralazine (20 mg/ml, n = 5), or cromakalin (25 mg/ml, n = 4), during and after the anastomoses. Blood-flow changes in the vessels were continuously monitored with the transonic Doppler applied to both carotid arteries for 60 min after the procedure. Sodium nitroprusside and cromakalin elicited a concentration-dependent relaxation of norepinephrine-precontracted carotid artery rings in vitro. Sodium nitroprusside was significantly more effective than cromakalin in inducing relaxation. Hydralazine elicited a biphasic response, with low concentrations (1.5 x 10(-5) to 1.5 x 10(-3) M) potentiating the norepinephrine-induced contraction, and high concentrations relieving this contraction. Microsurgical anastomosis in the rabbit carotid artery-produced a significant decrease of blood flow through the vessel as measured by the transonic Doppler for 30 min. Topical application of heparinized saline did not significantly change the blood flow after the microvascular anastomosis. Topical application of sodium nitroprusside and cromakalin significantly increased the blood flow in the vessel after the anastomosis; however, the topical hydralazine did not significantly alter blood flow, but demonstrated a trend toward increased flow values. The data support the conclusion that sodium nitroprusside and cromakalin could be used to relieve vascular constriction. It is suggested that further studies on the clinical use of these drugs in microsurgery is warranted.

Simultaneous reconstruction of a traumatic defect of the trapeziometacarpal joint and the first metacarpal with a composite dorsalis pedis flap is described. The transplant, consisting of the second metatarsal and the second metatarsophalangeal joint, was reversed at the defect site for the metatarsophalangeal joint to become a new trapeziometacarpal joint. A long vascular pedicle was necessary for direct micro-vascular anastomoses to the radial vessels at the wrist. This transfer can be expected to be effective in reconstructing composite hand defects involving the trapeziometacarpal joint and the entire first metacarpal bone.

Background: The nose is particularly vulnerable to cutaneous malignancies, making it the most common location for presentation. Recurrence of these cutaneous lesions is not uncommon, often compromising the timing of nasal restoration. It is the purpose of this report to reexamine the safety of primary nasal reconstruction in selected patients. Methods: Seventy-one patients who underwent nasal reconstruction at The University of Texas M. D. Anderson Cancer Center between 1987 and 1995 were retrospectively reviewed. There were 35 men and 36 women with an average age of 60 years. All nasal reconstructions were performed for defects secondary to malignancies. Basal cell carcinoma was the most common lesion (n = 49), followed by squamous cell carcinoma (n = 10) and melanoma (n = 7), with five additional variable malignancies. The most common location of the cutaneous lesions was the nasal dorsum, and the forehead flap was the most common adjacent tissue used for reconstruction. Immediate reconstruction was performed for 42 of the basal cell carcinomas, 6 of the squamous cell carcinomas, 6 melanomas, and 3 other lesions. Delayed restoration was performed for 7 basal cell carcinomas, 4 squamous cell carcinomas, 1 melanoma, and 2 additional lesions. The average time between surgical extirpation and the start of nasal reconstruction was 8.2 months for basal cell carcinoma, 29 months for squamous cell carcinoma, and 10 months for melanoma. Results: Twenty-six recurrent lesions were identified at an average of 36 months after extirpation. Despite these numbers, only three recurred after nasal reconstruction at our institution. Follow-up averaged 41 months, with none less than 1 year. Seventy patients are still alive with no evidence of disease. Conclusion: Primary reconstruction is safe in selected patients. Surgical delay in reconstruction should be considered if margins are questionable, the pathology is determined to be aggressive, if there is perineural or deep bony invasion, or if postoperative radiotherapy is to be initiated. Nasal reconstruction ultimately is based upon a complex series of issues but can be performed with few complications in an effort to restore self-image.

Limb-sparing surgery for cancer of the lower extremity has ushered the development of composite, one-stage reconstructions that employ a combination of autologous tissues, bone allografts, and endoprosthetic devices. The success of these efforts in preserving limb function has been generally good, yet the ultimate level of function is less than normal. Microsurgery has assumed a progressively greater role in the reconstruction of composite defects and allows much latitude in the surgical planning and in the management of delayed complications. Although patients who opt for limb salvage reconstructions frequently require more operative procedures and have longer hospitalizations than patients undergoing primary amputation, their functional outcome surpasses that of the amputation group and thus justifies the surgical effort.

Reconstruction of abdominal-perineal wounds after tumor extirpation presents the plastic surgeon with a variety of complex reconstructive options. These options are complicated by the resection of the bony pelvis. Two cases are presented that combine the use of synthetic mesh for pelvic ring and floor reconstruction with soft tissue to protect the intraabdominal viscera. Techniques and approaches to the patient undergoing such reconstruction are reviewed.

Repair of the lower back wound in the patient with cancer presents the surgeon with a plethora of challenges. Frequently, the wide range of the surgeon's armamentarium of flaps must be used to provide stable wound coverage. We present the reconstruction techniques used in five patients with cancer who had lower back wounds below T 10 and of at least 100 cm 2 . The approach we used to evaluate the lower back wound and to determine surgical techniques and options for reconstruction is discussed.

Aim: Reconstruction of the anterior skull base offers an especially complex challenge as the impermeable separation of the dural space and the upper aerodigestive tract must be maintained. We propose the use of the radial forearm free flaps (RFFF) as a superb method of re-establishing integrity in anterior skull base defects. Methods: Literature review and retrospective analysis of 4 single-institution cases of anterior skull base defects reconstructed with a RFFF. Data were collected on successful and unsuccessful defect repairs, complication rates, and length of hospitalization. Results: The indications for surgery were pneumocephalus, recurrent brain abscesses, recurrent frontal sinus mucoceles, and cerebrospinal fluid leak. Of the 4 cases, 1 was complicated by a small dehiscence of the craniotomy site, 1 developed infection, and 2 required further surgery. Conclusion: The use of RFFF is an excellent option for reconstruction of defects in the anterior skull base, especially those complicated by radiation, prior surgery, or infections. Patients with skull base defects are inherently at high risk for post-surgical complications. The RFFF transfers healthy, viable, well-vascularized tissue to prevent further infections and provides a reliable barrier between the dural and sinonasal spaces. This can reduce the need for repeat neurosurgical operations and hospitalizations.

Background: The radial forearm free flap has become a workhorse flap in head and neck reconstruction. Its lack of bulk, ease of dissection, vascularity, and malleability are among its many advantages. Patients and methods: A review of 157 radial forearm free flaps performed in 155 patients between March 1988 and June 1994 at The University of Texas M.D. Anderson Cancer Center was undertaken to determine outcome. Patient age ranged from 22 to 80 years (mean 56). There were 79 men and 76 women. Follow-up ranged from 2 to 75 months. The most prevalent neoplasm was squamous cell carcinoma (n = 129). Results: The most frequent tumor staging was T3, N0, M0. Various defects were observed; however, those requiring floor-of-mouth coverage were most common (n = 95). Partial or segmental mandibular resection was seen in 42. An osseous component was included in the radial forearm flap in 9 patients, and 64 patients had undergone some form of previous tumor resection. Fifty-seven patients received preoperative irradiation and 52, postoperative. The internal jugular vein (n = 131) and the external carotid artery (n = 134) were the most frequent recipient sites for microvascular anastomosis. Vein grafts were needed in 4 cases, and end-to-side anastomoses were most commonly performed. Total flap loss occurred in 7 cases (4.5%) and partial flap loss in 1 (0.6%). For total flap loss, salvage was accomplished by a second radial forearm free flap in 2 cases and alternative rotational flaps in 5. Other complications (infection, hematoma, fistula formation, etc.) were seen in 34%. Donor-site difficulties were seen in 21 cases. Conclusion: The radial forearm free flap offers a variety of reconstructive options for the head and neck. Its low flap loss and complication rates offer the best choice for oral lining restoration if bulk is not required.

Although most commonly seen with dental extractions, inferior alveolar nerve injury is occasionally seen with orthognathic surgery and facial trauma. Nerve grafting can be performed by lateral corticotomy without the use of maxillomandibular fixation. A case is reported with this technique and recovery of sensibility documented with quantitative sensory testing.