Donald Serafin

A rib-containing free flap to reconstruct mandibular defects

A composite free flap based on intercostal vessels may be used to reconstruct in one stage defects around the mandible in which skin, soft tissue and bone are missing. A delay procedure is recommended one week prior to transfer.

Comparison of free flaps with pedicled flaps for coverage of defects of the leg or foot.

The use of free flaps to repair defects of the leg or foot is a viable alternative to cross-leg flaps because (1) the total time of immobilization and hospitalization is less, (2) the total number of general anesthetics is less, and (3) the morbidity and cost are less. Increased experience will enhance the survival statistics for free flaps, making their use the method of choice for the reconstruction of defects in the distal part of the lower extremity.

Reduction mammaplasty utilizing an inferior pedicle nipple-areolar flap

A technique utilizing the inferiorly based dermal pedicle nipple-areolar flap is described. The advantages of this technique are: (1) predictable breast shape based on preoperative markings; (2) direct visibility of all areas for ease of resection and hemostasis; (3) retention of normal nipple duct connections; (4) no impairment of subjective sensation; and (5) adequate blood supply.This technique has particular application in younger women, in whom nipple sensation is quite important. The interruption of the intercostal nerve branches is usually limited because of the thickness and width of the inferior pedicles. Utilizing our modifications of the technique originally described, this versatile flap can now be used routinely in reduction mammaplasties requiring the removal of either small amounts (200 gm) or quite large amounts (2,500 gm) of tissue with consistently satisfactory aesthetic results and excellent patient satisfaction.

Reconstruction of the Lower Extremity with Vascularized Composite Tissue: Improved Tissue Survival and Specific Indications

A retrospective assessment of 50 vascularized composite tissue transfers was carried out with 48 patients. Factors responsible for improved tissue survival included (1) the evaluation and proper selection of recipient vasculature, (2) the increased dependence on the vacularized latissimus dorsi musculocutaneous flap, and (3) the frequent use, wherever possible, of an end-to-side arterial anastomisis. Specific indications for reconstruction of the lower extremity with vascularized composite tissue include (1) avulsive injuries to the distal tibia and foot, (2) the failure of conventional methods, (3) the treatment of extensive chronic osteomyelitis, (4) deficiency of both soft tissue cover and skeletal support, (5) the restoration of form and contour with minimal secondary deformity of the donor site, and (6) extensive loss of soft tissue only. Reconstruction of the lower extremity with vascularized tissue is a reliable method with acceptable patient and tissue morbidity statistics that should be considered when specific indications are present.

Vascularized Rib-Periosteal and Osteocutaneous Reconstruction of the Maxilla and Mandible: An Assessment

Three approaches to provide rib-periosteal or osteocutaneous composite tissue in maxillary or mandibular reconstruction are presented. All methods appear to be useful in replacing viable osteocytes and improving vascularity of maxillary or mandibular defects. Disadvantages include the bulk of the transplanted tissue, volume deficiency of bone, and the unreliability in viability of the associated cutaneous tissue, especially with the posterior and posterolateral approach. Significant patient morbidity and pulmonary complications in our series should indicate caution when considering these methods of reconstruction. At present, rib-periosteal transplantation is most often indicated to replace segmental defects of mandibular continuity when the recipient bed is avascular but the quantity of cutaneous cover is adequate. In those patients with deficient soft tissue and a small segmental mandibular loss, reconstruction with musculocutaneous flaps and nonvascularized bone grafts is indicated. With extensive deficiencies of both soft tissue cover and mandibular or maxillary continuity, an iliac osteocutaneous flap based on the deep circumflex iliac vessels may be the most effective. Lower patient morbidity statistics should be anticipated.

The free scapular flap

We present our early experience with a flap that should become important to the microsurgeon. The scapular flap is based on the circumflex scapular branch of the subscapular artery and is a versatile, hardy, easily dissected flap. We have used it in 14 cases where a fairly thin flap was indicated. Four of the 14 patients developed complications. Two developed hematomas after removal of the drains. These were evacuated without any loss of the flap. One patient had to be returned to the operating room because of thrombosis of the venous anastomoses, but the flap eventually survived in its entirety. One flap was lost from progressive venous insufficiency.

Microsurgical Composite Tissue Transplantation

: Since 1974, 69 patients with extensive defects have undergone reconstruction by microsurgical composite tissue transplantation. Using this method, donor composite tissue is isolated on its blood supply, removed to a distant recipient site, and the continuity of blood flow re-established by microvascular anastomoses. In this series, 56 patients (81%) were completely successful. There have been eight (12%) failures, primarily in the extremities. There have been five (7%) partial successes, (i.e., a microvascular flap in which a portion was lost requiring a secondary procedure such as a split thickness graft). In those patients with a severely injured lower extremity, the failure rate was the greatest. Most of these were arterial (six of seven). These failures occurred early in the series and were thought to be related to a severely damaged recipient vasculature. This problem has been circumvented by an autogenous interpositional vein graft, permitting more mobility of flap placement. In the upper extremity, all but one case were successful. Early motion was permitted, preventing joint capsular contractures and loss of function. Twenty-three cases in the head and neck region were successful (one partial success). This included two composite rib grafts to the mandible. Prolonged delays in reconstruction following extirpation of a malignancy were avoided. A rapid return to society following complete reconstruction was ensured. Nine patients presented for reconstruction of the breast and thorax following radical mastectomy. All were successfully reconstructed with this new technique except one patient. Its many advantages include immediate reconstruction without delayed procedures and no secondary deformity of the donor site. Healthy, well vascularized tissue can now be transferred to a previously irradiated area with no tissue loss. This new method offers many advantages to older methods of reconstruction. Length of hospital stay and immobilization are reduced. The total number of operative procedures required in achieving the desired result is also less, thus decreasing the cost of hospital care.

Long-term sequelae following median sternotomy wound infection and flap reconstruction.

Use of muscle and omental flaps has been shown to provide reliable reconstruction of infected median sternotomy wounds; however, few reports emphasize the long-term sequelae of the complication and its treatment. This study was performed to evaluate the long-term problems, including patient satisfaction and survival rate, in 88 patients with median sternotomy infections treated with muscle or omental flaps. Forty-two patients were available for long-term follow-up by telephone interview, with an average length of follow-up of 42 months. Forty-three percent complained of chronic chest wall pain or discomfort, and 45% complained of sternal instability. After pectoralis major muscle flap reconstruction in 32 patients, 25% complained of upper extremity weakness, and 56% complained of chest contour deformity. Delayed septic costochondritis or osteomyelitis occurred in 8%. Despite these unfavorable consequences, 72% and 83% of patients were satisfied with the cosmesis of the operation and the overall result, respectively. Furthermore, after hospital discharge, these patients seem to enjoy satisfactory longevity. By emphasizing the potential sequelae, further research interest may be stimulated in delineating their causes and in refining techniques of reconstruction.

Establishment of normal ranges of laser Doppler blood flow in autologous tissue transplants.

Over a 3-year period, 136 patients were monitored following free autologous tissue transplantation using a laser Doppler flowmeter linked to a computerized data-acquisition system. This monitoring system has indicated perfusion compromise in free flaps more rapidly than clinical observation alone. Most important, this has resulted in an increase in salvage rate from 50.0 to 82.4 percent. In addition, our overall success rate has increased from 92.6 to 97.8 percent since introducing this monitor clinically. Computerization also has facilitated the collection of data, which has enabled us to establish expected values for postoperative blood flow in several types of donor tissues used for microvascular reconstruction. Finally, this computerized monitoring system has relieved personnel from basing decisions on subjective data.

Soft-tissue fungal infections: Surgical management of 12 immunocompromised patients

&NA; Isolated fungal soft‐tissue infections are uncommon but may cause severe morbidity or mortality among transplant recipients and other immunosuppressed patients. Twelve immunocompromised patients illustrating three patterns of infection were treated recently at the Duke University Medical Center. These groups comprised (I) locally aggressive infections, (II) indolent infections, and (III) cutaneous manifestations of systemic infection. Patient diagnoses included organ transplant, leukemia, prematurity, chronic obstructive pulmonary disease, and rheumatoid arthritis. Time from immunosuppression to biopsy ranged from 5.5 to 31 weeks. Organisms included Aspergillus, Rhizopus, Fusarium, Paecilomyces, Exophiala, and Curvularia. Patients presented with necrotic ulcerations or nodules. Surgical treatment ranged from radical debridement to excisional biopsy to none. Antifungal chemotherapy also was employed in some cases. The mortality rate was 33 percent, two patients dying without evidence of fungal infection. Six of the eight survivors cleared their infections. Necrotic skin lesions with surrounding erythema in this population call for prompt examination, biopsy, and culture. Group I lesions mandate radical excision with rapid intraoperative microscopic control and systemic antifungal medication. Group II requires surgical control with or without antifungal therapy. Group III requires systemic antifungal therapy for metastatic infection. In our opinion, treatment of fungal soft‐tissue infection should be tailored to infection type and requires a team approach of surgeon and expert infectious disease consultation. (Plast. Reconstr. Surg. 97: 1391, 1996.)