Edmond F. Ritter

Donor leg morbidity and function after fibula free flap mandible reconstruction

The purpose of this study was to determine the donor leg morbidity and function after removal of the fibula free flap for mandible reconstruction. In the past 24 months, 29 consecutive patients underwent a total of 30 fibula free flap mandible reconstructions. A muscle-sparing technique was used to harvest the fibula flap, and the proximal 6 cm and distal 8 cm of fibula were left intact. Patients included 20 men and 9 women; their mean age was 58.8 years (range 29 to 82 years); the mean length of fibula removed was 14.5 cm (range 8 to 25 cm); osteocutaneous flaps were used in 27 patients (90 percent); and 16 patients (53 percent) required skin grafts to the donor leg. Donor leg morbidity and function were determined by patient questionnaire, physical examination, and isokinetic testing, with the opposite, unoperated leg serving as a control. Immediate postoperative morbidity occurred in 5 patients (17 percent) (infection, wound separation, or partial graft loss); none required additional surgery for donor complications. Patient questionnaires were completed by all patients at an average of 7.3 months after surgery. Patients were able to ambulate pain-free an average of 5.1 weeks (range 2 to 32 weeks) postoperatively and were all fully able to engage in all daily and recreational activities. Most (21 patients, 72 percent) were free of any donor pain, and the remainder (28 percent) had only occasional mild discomfort. Other complaints included ankle stiffness (41 percent), mild ankle instability (10 percent), and transient peroneal motor (7 percent) or sensory (28 percent) loss, which resolved in all patients.(ABSTRACT TRUNCATED AT 250 WORDS)

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.)

MANAGEMENT OF THE BURIED PENIS IN ADULTS

PURPOSE Buried penis, most commonly seen in children, is particularly debilitating in adults, resulting in the inability to void standing and it affects vaginal penetration. The pathophysiology, including scar contracture of the distal soft tissue and skin envelope with concurrent descent of the abdominal fat pad, represents a surgical challenge. We developed a management algorithm to evaluate and treat adults with buried penis. MATERIALS AND METHODS From January 1, 1994 to May 1, 1996, 7 patients 23 to 66 years old presented with buried penis. Diabetes mellitus, a common co-morbid condition, was present in 5 patients, and 5 of 7 were morbidly obese. RESULTS Surgical correction was performed in 5 patients with excellent results in 3. Resection of scar contracture was sufficient to provide adequate length and none required release of the suspensory ligament. Panniculectomy was performed in 1 patient. One man requiring a graft to achieve adequate penile coverage required reoperation. This patient had undergone a previous attempted repair with extensive contracture. All patients regained potency postoperatively. CONCLUSIONS With appropriate planning and adherence to basic reconstructive surgical principles, correction of the buried penis can yield a high success rate.

Heparin coating of vascular prostheses reduces thromboemboli

BACKGROUND Synthetic conduits made from currently available materials are suboptimal for use in small-diameter vascular reconstruction because of their high surface thrombogenicity, which leads to failure. METHODS In this study control, heparin-irrigated, or heparin-bonded expanded polytetrafluoroethylene (ePTFE) grafts (4 mm long by 1 mm inner diameter) were implanted to reconstruct the iliac artery in male rats. The cremaster muscle was isolated as an island flap based on branches of the iliac artery downstream from the graft. Emboli were quantitated by using intravital fluorescent microscopy of the cremaster muscles microcirculation. RESULTS The mean number of emboli observed per animal during a 20-minute period was 91 for the control group, 84 for the heparin-irrigated group, and 22 for the tridodecylmethylammonium chloride (TDMAC)-heparin group. The mean area of each embolus was 1057 microns 2 for control, 940 microns 2 for heparin-irrigated, and 808 microns 2 for TDMAC-heparin-coated grafts (p < 0.05 for TDMAC-heparin versus control or heparin-irrigated). CONCLUSIONS A TDMAC-heparin coating of ePTFE microvascular prostheses significantly reduces downstream microemboli.

Heparin bonding increases patency of long microvascular prostheses.

&NA; The high thrombogenicity of synthetic biomaterials has limited their use for reconstructive microsurgery. Prime factors in the thrombogenicity of synthetic materials in contact with blood include gas nuclei at the blood gas interface as well as the inherent thrombogenicity of the materials themselves. Expanded polytetrafluoroethylene (ePTFE) vascular prostheses were denucleated by placement in acetone and ethanol followed by degassed saline or by placement in degassed saline subjected to hydrostatic pressure. Heparinized grafts were prepared by coating with tridodecylmethylammonium chloride (TDMAC), followed by immersion in heparin. Grafts were installed to reconstruct the femoral artery (1 × 10 mm) or as renaliliac bypasses (1 × 50 mm) in rats. In the femoral artery reconstruction model, control grafts thrombosed within 10 minutes of implantation. All acetone denucleated femoral grafts remained patent for 60 minutes but were occluded at day 1. All pressure denucleated femoral grafts remained patent for 60 minutes, whereas six were patent at 1 month. In contrast, 11 of 15 heparinized femoral grafts were patent at 1 month. In the renal iliac bypass model, all control grafts were thrombosed within 10 minutes, whereas all heparin bonded grafts remained patent at 1 month. This finding confirms that removal of air from small diameter ePTFE grafts decreases acute thrombogenicity and that heparin bonding further decreases thrombogenicity, suggesting that clinically useful lengths of microvascular prostheses may be possible. (Plast. Reconstr. Surg. 101: 142, 1998.)

Modulation of ultraviolet light-induced epidermal damage : Beneficial effects of tocopherol

&NA; Oxygen free radicals have been shown to result from and mediate deleterious effects of ultraviolet radiation on the skin. The purpose of this study was to determine if topical DL‐&agr;‐tocopherol (vitamin E) could reduce ultraviolet‐induced damage to the epidermis. Twenty mice were treated with either ethanol or a 1:1 mixture of tocopherol and ethanol. Treatments consisted of once‐daily 0.1‐ml topical applications for 1 week, followed by irradiation with 0.30 mW/cm2 of ultraviolet B irradiation. A statistically significant decrease in Schiff base formation was noted between tocopherol‐treated animals and their controls. Histologic study revealed a statistically significant increase in epidermal thickness in tocopherol‐treated skin versus controls or vehicle alone. The thicker epidermis was accompanied by the presence of parakeratosis, implicating increased proliferation as the cause of the increasing thickness. The number of sunburn cells was decreased by tocopherol treatment. Tocopherol protection from ultraviolet irradiation may have been due to both direct protection from free radicals and indirect protection by means of increased epidermal thickness. The demonstration of beneficial effects of tocopherol administration suggests that further studies in clinically relevant models to define optimal dosage, frequency of administration, vehicle, and quantitation of the possible protective effects afforded to Langerhans cells may be useful. (Plast. Reconstr. Surg. 100: 973, 1997.)

Enhancing fibula free flap skin island reliability and versatility for mandibular reconstruction.

Although the fibula osteocutaneous free flap has many advantages when used in mandibular reconstruction, many investigators have found the skin island is not always reliable. We present a technique that enhances skin island reliability by including a maximal number of skin perforators. This method has been used in 10 consecutive osteocutaneous free flaps without any skin loss. This technique also expands the usefulness of the fibula free flap, allowing it to be used for shorter bone defects or in cases when skin coverage is needed at a distance from the bone. In addition, this method provides additional vascularized soft tissue for neck contour restoration and coverage of fixation plates.

Decreased thrombogenicity of vascular prostheses following gas denucleation by hydrostatic pressure.

The high rate of thrombosis of 1.0-mm polytetrafluoroethylene (PTFE) grafts has limited their use in microvascular surgery. One possible reason for this is the blood-gas interface due to entrapped air in the interstices. The present study examines the effect on patency rates of elimination of this blood-gas interface by high pressurization. Comparing pressurized and nonpressurized grafts in the same animals showed a patency rate of 100 percent at 7 days for treated grafts, while the control (nonpressurized) grafts had all clotted by 1 hour. The implications for microvascular surgery as well as vascular surgery in general are discussed.

Utility of the inferior gluteal vessels in free flap coverage of sacral wounds

An improved technique for gaining access to the inferior gluteal vessels is presented. This method allows rapid isolation of these vessels, preservation of greater pedicle length, and improved access for the performance of microsurgery. The innervation and function of the gluteus maximus is also preserved. We believe the use of this technique makes the inferior gluteal vessels the receptor vessels of choice for microsurgical procedures in the sacral area. An illustrative patient is presented in whom these vessels were used for a combined serratus anterior-latissimus dorsi free muscle flap for sacral wound coverage.

High septal osteotomy in rhinoplasty for the deviated nose

When attempting to straighten a patients healed, deviated bony nasal dorsum, deviation of the central structure (high dorsal septum and medial nasal bones) must be addressed following the completion of medial and lateral osteotomies. When hump resection is not performed, blunt fracture (digitally or with forceps) of the deviated central structure is not a reliable method of mobilization, often leading to postoperative nasal drift. An intranasal osteotomy technique to mobilize the central structure of the nose is described, called “high septal osteotomy.” Review of 25 cases suggests high septal osteotomy, supplemented as needed by resection of overlapping septal elements, can be performed safely and efficaciously, permitting stable midline reduction of the nasal pyramid. The technique is not advocated when hump resection is performed, as it is unnecessary and could destabilize the dorsum. Even aggressive maneuvers to mobilize the bony dorsum may fail if not performed properly with meticulous attention to completion of all osteotomies.