Damir Kosutic

In search of the ideal method in perforator mapping: noncontrast magnetic resonance imaging.

A reliable method for precise identification of the dominant perforator would be extremely valuable in perforator flap surgery. During the past 5 years, multidetector-row computed tomography has demonstrated excellent results in preoperative planning of abdominal free flap breast reconstruction, significantly reducing operative time and complications. The main drawbacks of computed tomography are unnecessary radiation to the patient and possible allergic reactions to intravenous contrast material. To circumvent these limitations, we performed noncontrast magnetic resonance imaging for abdominal perforator mapping. The aim of our study was to assess the accuracy and reliability of this technique in preoperative planning of breast reconstruction with deep inferior epigastric artery perforator flaps. From October 2007 to February 2009, noncontrast magnetic resonance preoperative mapping was performed in 56 female patients who underwent breast reconstruction after mastectomy with deep inferior epigastric artery perforator flaps. Imaging results were compared with the intraoperative clinical findings in all patients. Preoperative magnetic resonance imaging without the contrast showed no false-positive or false-negative results. In all cases, the perforator chosen as dominant according to magnetic resonance images corresponded with the perforator chosen intraoperatively (100% predictive value). Preoperative imaging techniques make perforator flap surgery safer for the patient. Noncontrast magnetic resonance imaging provides reliable information on the vascular anatomy of the abdominal wall, facilitating selection of the most appropriate deep inferior epigastric artery dominant perforator. It avoids radiation to the patient and also the need for intravenous contrast medium as required for the multidetector-row computed tomography. In our opinion, noncontrast magnetic resonance imaging is an ideal method for preoperative planning of breast reconstruction with deep inferior epigastric artery perforator flaps.

Preoperative computed tomographic angiogram for deep inferior epigastric artery perforator flap breast reconstruction.

Precision in preoperative evaluation of the abdominal wall vascular anatomy is of utmost importance in successful planning and execution of perforator flap surgery for breast reconstruction after mastectomy. We performed a study in 357 patients scheduled for deep inferior epigastric artery perforator (DIEAP) flap breast reconstruction to review our 5-year experience with the technique we developed based on our previous research confirming accuracy of a computed tomographic (CT) angiogram (multidetector row computed tomography [MDCT]) in preoperative planning of abdominal perforator flap surgery. Images obtained from the radiological study were used to create an accurate map of dominant abdominal perforators of the deep inferior epigastric artery, showing their location, size, and anatomic considerations of relevance for the preoperative flap design. Anatomic dissection of all perforators was performed in the first 36 cases to compare the data with preoperative MDCT findings. In the following 321 patients, the dominant perforator was chosen solely on the basis of MDCT and dissected directly. Exact correlation between surgical and radiological results was found in the first 36 cases. A significant reduction in average operating time and postoperative complications was noted in the following 321 patients. CT angiogram provides important preoperative information on inferior abdominal wall vascular anatomy, facilitating DIEAP flap harvest, saving operative time, and reducing complications and costs. It proved to be an invaluable tool in the preoperative algorithm for DIEAP flap breast reconstruction.

Anatomical aspects of the arterial blood supply to the sinoatrial and atrioventricular nodes of the human heart.

Classic anatomical dissection of 150 hearts from adults aged 18–80 years was performed. The sinoatrial (SA) node artery was most frequently a large atrial branch of the right coronary artery (63%), arising at a mean distance of 1.2 cm (range 0.2–2.2 cm) from its beginning, with a mean external diameter of 1.7 mm (range 1–3 mm). In 37% of cases the SA node artery was a branch of the left coronary artery or one of its branches, with an initial mean external diameter of 2.2 mm (range 2–3 mm). The origin of the SA node artery was not related to coronary arterial dominance. The atrioventricular (AV) node artery was the first and longest inferior septal perforating branch of the right (90%) or left (10%) coronary artery, arising from the U- or V-shaped segment of the corresponding artery at the level of the crux cordis. Mean external diameter was 2 mm (range 1–3.5 mm). The origin of the AV node artery was dependent on coronary arterial dominance. Identification of the anatomical variants of the arterial blood supply to the SA and AV nodes may help in overcoming potential difficulties in treating arrhythmias and in mitral valve surgery.

Madelung syndrome (benign lipomatosis): clinical course and treatment

Madelung syndrome is a rare disease found predominantly in the Mediterranean area. It has a distinctive clinical appearance. Staged surgery is the treatment of choice, which produces substantial improvement in both functional and aesthetic appearance. Recurrences usually occur when it is impossible to resect the disease completely.

Preoperative antiseptics in clean/contaminated maxillofacial and oral surgery: prospective randomized study

In order to show the effectiveness of preoperative antiseptic mouthwash the authors undertook a prospective study in 120 patients who underwent elective surgery under general or local anesthesia. Patients were allocated toone of 4 groups, depending on whether the oral cavity was washed preoperatively with 1% cetrimide, chlorhexidine, povidon-iodine or sterilized normal saline solution (control group). Aerobic and anaerobic bacterial samples were taken from the inferior vestibulum mucosa before surgery, 5 min after the start of the operation and at the end of the procedure. The results show a statistically significant reduction in bacterial counts during procedures in which antiseptics are used to wash the oral cavity preoperatively. 1% cetrimide solution was the most successful in reducing intra-oral bacterial counts and produced the longest lasting antiseptic effect. Chlorhexidine is a good option for procedures longer than 1 hour, while povidon-iodine is recommended for procedures lasting up to 1 hour. Normal saline reduced bacterial counts in the specimen taken 5 min after washing but this short-lasting effect is due to mechanical cleansing rather than the antiseptic effect.

Complete mapping of lateral and medial sural artery perforators: Anatomical study with Duplex-Doppler ultrasound correlation

INTRODUCTION The precise vascular anatomy of posterior lower leg skin is not well understood. Despite being a potential donor site for sural artery perforator flaps, this region is rarely used and underestimated. The aim of this study was to provide exact preoperative planning for medial and lateral sural artery perforator flap harvest. METHODS An anatomical study on 16 cadaveric lower legs was performed to determine the number and location of all medial and lateral sural artery perforators in relation to five fixed points (medial and lateral maleolus, calcaneus, medial and lateral condyle). A Duplex study on 32 lower legs determined the number and location of dominant medial and lateral sural artery perforators in relation to same anatomical points. Results of the two studies were correlated. RESULTS A total of 234 perforators were found in the anatomical (134) and Duplex studies (100). A dominant lateral sural artery perforator was found in 9.4% of all lateral perforators in 31% of dissected legs. A dominant medial sural artery perforator was found in 37% of all medial perforators in 94% of legs. The difference in the number of dominant medial and lateral perforators was significant (p < 0.001) in the anatomical study, while no significant difference was found in the Duplex study (p = 0.920). CONCLUSION The anatomical study showed relative unreliability of sural region regarding number of dominant perforators. Therefore, harvest of medial and particularly lateral sural artery perforator flap is unsafe without preoperative perforator mapping. No significant difference in location of dominant perforators was found between Duplex and anatomical studies. Duplex proved reliable for planning of sural artery perforator flaps due to high precision in detecting location of dominant perforators.

Latissimus dorsi-scapula free flap for reconstruction of defects following radical maxillectomy with orbital exenteration.

A total of 21 patients with latissimus dorsi-scapula free flap reconstruction immediately following radical maxillectomy together with orbital exenteration are presented. Orbital exenteration was performed in all patients due to tumour invasion at the time of diagnosis. There was no total flap failure. Two tissue components subdivided into separate flap units with individual vascular pedicles linked by a single vascular source provide an ideal reconstructive solution for massive defects of the mid-face and orbit. Separate arcs of rotation of each flap unit permit greater mobility necessary for complex three-dimensional reconstruction. A vertically positioned angle of the scapula enables simultaneous reconstruction of the malar eminence and alveolar ridge whereas spontaneous intraoral epithelialisation of the latissimus dorsi muscle requires no additional procedure. For these reasons, in our opinion, combined latissimus dorsi-scapula free flap should be considered the first choice in reconstruction of defects following total maxillectomy with orbital exenteration.

True submental artery perforator flap for total soft-tissue chin reconstruction

Reconstruction of large chin defects requires a flap suitably matched with the contour, colour, and tissue texture of this important aesthetic facial unit. Numerous cervical and local flaps have been described, most being associated with limited mobility, disappointing results, and significant donor site scarring, making ideal replacement of ‘‘like with like’’ in this difficult area elusive. In 1993, Martin et al. described the submental artery pedicled flap from an anatomic study based on 24 cadaveric dissections. Since this first description, the submental artery flap has been used as both a free and pedicled flap, and has proven to be a reliable and versatile reconstructive option for defects of the oral cavity and lower two-thirds of the face. However, to the best of our knowledge, there have been no reports on true perforator submental flap, based exclusively on submental artery perforator, without more proximal dissection of the pedicle— submental and, usually, facial artery. Both clinical and anatomical evaluations have validated that one or two reliable perforators are present in the unilateral submental territory originating from the submental artery. In these studies, the location of reliable perforators was constant at the lateral and/or medial border of the anterior belly of the digastric muscle, but their locations were not always symmetric on both sides in the submental territory. Questions remain, however, as to the number of perforators that must be preserved, and their impact on perfusion. We describe the case of a 34-year-old Asian female, with extensive post-burn hypertrophic scarring of her entire chin following debridement and split thickness skin grafting 3 years ago in other institution (Fig. 1a). Two submental perforators were detected and labeled using a hand-held Doppler only, and the flap was designed around them. Extensive scarring was excised down to healthy tissues leaving a soft-tissue defect encompassing entire chin. Dissection revealed a single robust perforator arising from the submental vessels through platysma and into the skin in the midline (Fig. 1b). The flap was islanded on this perforator, without any proximal dissection of the submental pedicle, and transposed underneath the skin bridge into the chin defect (Fig. 1c). Transposition of the flap did not affect its vascularization, which was checked clinically and with intraoperative Doppler before direct closure of the donor-site and suturing the flap in place (Fig. 1d). Post-operative course was uneventful (Fig. 2a), and follow-up exam showed superb aesthetic outcome of reconstructed chin as well as donor site healed with inconspicuous scar, both to patients great satisfaction (Figs. 2b–2d). True perforator submental flap can provide reconstruction of difficult soft-tissue defects of the chin by replacing entire facial aesthetic subunit with tissues of perfectly matched color, texture, and pliability, without the need for proximal dissection of submental/facial pedicle. Its minimal donor site morbidity, excellent aesthetic match, and relative ease of dissection have definite *Correspondence to: Damir Kosutic, M.D. Ph.D., Consultant Plastic and Reconstructive Surgeon, Department of Plastic Surgery, St James’s Hospital, James’s Street, Dublin 8, Ireland. E-mail: dkosutic@hotmail.com Received 17 January 2012; revised 10 February 2012; accepted 16 February 2012 Published online 31 March 2012 in Wiley Online Library (wileyonlinelibrary.com). DOI 10.1002/micr.21983

Thoraco-acromial artery perforator 'propeller' flap.

Axillary scar contracture following trauma presents a reconstructive challenge since the restoration of normal arm mobility along with acceptable aesthetic outcome is of utmost importance. We report the first successful use of a thoraco-acromial artery perforator pedicled flap, harvested and designed solely using the concept of free-style perforator flaps, for the reconstruction of axillary defect after excision of scar contracture in a patient previously affected by poly-trauma. The flap was based on two

Lag screw fixation for straight midline mandibulotomy: four-year experience.

The authors’ experience with 2-lag screw technique for the stabilization of a straight midline mandibulotomy approach for oral cavity and oropharyngeal tumors is presented. Fixation is performed with 2.0-mm pretapped screws. A washer is used to prevent sinking of the screw head into spongy bone and to provide equal pressure distribution of the screw head to the bone edges. Lag screw fixation was used in 24 patients, 18 of whom underwent a full dose of irradiation therapy postoperatively. Two patients developed salivary fistula and 1 developed a local infection. In all patients there were no signs of mandibulotomy site instability, no disturbance of the occlusion, and radiography showed excellent bone healing. There were no indications for tooth extraction to complete the osteotomy. Lag screw fixation proved to be an uneventful and straightforward procedure for the stabilization of a straight midline mandibulotomy approach.