Elliott H. Rose

The versatile temporoparietal fascial flap: adaptability to a variety of composite defects.

The unique properties of the temporoparietal fascial flap (TPFF) offer adaptability in reconstruction of a variety of composite defects. The broad, thin sheet of vascularized tissue may be transferred alone or as a carrier of subjacent bone or overlying skin and scalp. As a pedicled flap, it is ideal for defects of the orbital, malar, mandibular, and mastoid regions. As a free-tissue transfer, the large vessels and lack of bulk find broad utility in reconstruction of the extremities. This flap is our choice for reconstruction of the dorsal hand and non-weight-bearing surfaces of the foot. A viscous gliding surface decreases friction for tendon excursion. The thin contour is aesthetically superior to thicker flaps, allowing unmodified footwear or gloves. The pliable fascia convolutes into surface defects (e.g., bone craters) or drapes over skeletal frameworks (e.g., ear cartilage). The rich capillary network offers nutrition to saucerized bone, cartilage or tendon grafts, and overlying skin grafts. The geometry of the skull lends to fabrication of membranous bone for complex facial puzzles. The donor site is well disguised by hair growth. Twelve cases performed over a 2-year period demonstrate the versatility of this flap. These include complex foot reconstruction, ear and scalp avulsion, shotgun wound of the cheek and orbit, posttraumatic jaw recontouring, chronic osteomyelitis of the hand and foot, and acute resurfacing of dorsal hand with tendon reconstruction.

Free toe-to-fingertip neurovascular flaps.

Six cases of free toe-to-fingertip neurovascular flaps are presented. The principal advantages of this procedure over rotation island flaps are (1) achievement of better two-point discrimination, (2) an acceptable donor defect, (3) no cortical reorientation is necessary, and (4) there is minimal tension on the nerve.

Autogenous fascia lata grafts: clinical applications in reanimation of the totally or partially paralyzed face.

Background: Although they are traditionally reserved for “aesthetic refinement” in the latter stages of facial reanimation surgery, the author uses a variety of autogenous fascia lata grafts in a very aggressive approach as the primary therapeutic option in static facial rebalancing and/or in conjunction with dynamic muscle transfers to achieve architectural integrity and functional restoration of the totally or partially paralyzed face. Methods: Forty-nine autogenous fascia lata grafts, harvested through serial incisions in the lateral thigh, were placed in 35 totally or partially paralyzed faces. The grafts were categorized by anatomical location: I and II, lateral lip in totally paralyzed and partially paralyzed faces, respectively; III, nostril suspension; IV, lower eyelid suspension; V, bimalar lower lip sling; and VI, platysma transfer/autogenous fascia lata extension for lower lip invagination. Results: In all group I and II cases, static balance of facial architecture was restored at 4 to 6 weeks (after swelling resolved). Average lip commissure displacement was corrected to within 0.5 cm of the horizontal axis. Subjective functional improvement in speech, fluid retention, and chewing was immediate in all cases. In group I (n = 10; median age, 10.5 years), a 60 to 100 percent symmetrical smile was achieved with voluntary gracilis contraction of 3 of 5 to 5 of 5. In group II (n = 20; median age, 33 years), with 16 sling only patients, one to two grades of voluntary risorius and lip elevator motion were achieved in most. When accompanied by a temporalis turnover flap, both risorius and lip elevator function improved two to three grades. In group III (n = 5), inspiratory collapse was ameliorated in all cases and nasal flow improved subjectively 80 to 100 percent. In group IV (n = 4), scleral show and keratitis were improved in all cases. In group V (n = 6), improved oral competence was achieved in all patients. In group VI (n = 4), static lip evagination was achieved in all cases; voluntary lip depressor function was two to four grades improved. Conclusions: Early placement of autogenous fascia lata restores static balance of the deeper facial architecture in repose. Functional improvement of chewing, fluid retention, speech articulation, smile symme-try, and ectropion is immediate. The psychological effect is also immediate, with achievement of self-esteem and acceptance by family and peers.

Application of High-Tech Three-Dimensional Imaging and Computer-Generated Models in Complex Facial Reconstructions with Vascularized Bone Grafts

We present a series of six patients with eight flaps in whom computer-generated models were used for fabrication of vascularized bone grafts in complex facial restorations. Preoperative CT data, digitalized on tape, were converted by the CEMAX (Santa Clara, Calif.) 1500 Integrated Hardware and Software System to a three-dimensional visualization of the bone and soft-tissue deficiencies. These data were transmitted by direct computer link to a CNC milling machine that produced full-size slices “stacked” into a three-dimensional template. The acrylic replica aided selection of appropriate donor sites and intraoperative “carving” of bone transfers. Reconstructions included three zygomas, two maxillae, two mandibles, and one frontal bone. Donor sites were iliac crest, scapula, and outer calvarium. Four were free flaps and four island pedicle flaps. All healed without infection. Bone resorption was less than 10 percent. One flap was lost to thrombosis. Other complications included a transient facial palsy in one patient and temporary radial palsy from shoulder traction in another. Computer-generated templates for vascularized grafts are expensive and thus are not indicated or necessary in every patient. The advantages, however, are several. Custom models facilitate preoperative planning, with less guesswork of size, contour, and orientation of the graft, which is especially desirable with vascularized grafts, since the position of the pedicle is critical. Anesthesia time is decreased. Grafts can be fitted exactly, without reshaping and “nibbling.” Nuances of depth and tapering are directly carved into the bone. By merging high-tech imaging and microsurgery, the best chance of optimal results can be achieved.

Local arterialized island flap coverage of difficult hand defects preserving donor digit sensibility.

Small to moderate-sized defects of the hand overlying joint surfaces, flexor tendons, Silastic implants, and tactile surfaces require full-thickness skin and subcutaneous tissue either for primary coverage or in anticipation of secondary reconstruction. In this report, six difficult hand wounds are resurfaced with an arterialized island pedicle from the lateral surface of the nearby digit in lieu of multistage distant pedicle flaps. The Littler neurovascular island flap has been modified to include only the digital artery and venae comitantes at its pedicle, preserving digital nerve intact in the donor digit. Microsurgical separation of the digital artery from the digital nerve minimizes the sensory loss of the donor digit. Cortical reeducation at the recipient site is unnecessary. The lengthy pedicle allows an arc of coverage over the palm, dorsum of the hand, and adjacent digits. Results in six cases have been favorable. Flap survival has been 100 percent. Maximum flap size was 5.5 X 2.5 cm. Two-point discrimination of the donor defect averaged 4.5 mm. No significant donor morbidity was noted, with the exception of one case in which there was a mild degree of hypertrophic scarring across the volar aspect of the proximal interphalangeal joint. The one-stage procedure minimizes the number of hospitalizations and disability time. Its proximity to injury, versatility, and relative speed with which it can be raised encourages its usage for primary coverage (two cases in this series). Preservation of near normal two-point discrimination of the donor site allows either the radial or ulnar surface of the nearby digit to be used.

Restoration of sensibility to anesthetic scarred digits with free vascularized nerve grafts from the dorsum of the foot

Five cases of segmental vascularized nerve grafts that bridge scarred beds for digital sensory nerve reconstruction where previous nonvascularized nerve grafts have failed are reported. Average follow-up in this study was 27 4/5 months. Three patients were men and two were women. Average age was 35 1/2 years. The thumb was the recipient digit in one patient; the index finger in two patients; and the long finger in two patients (primary opposing digit). Three digits had suffered amputation and two had crush lacerations. Average graft length was 6.6 mm. Pin prick, touch, and vibratory sensation were restored in all patients (slightly impaired in one). Average moving two-point discrimination was 7.2 mm; average static two-point discrimination was 9.5 mm. Von Frey monofilament cutaneous pressure averaged 4.03 gm. Donor morbidity was negligible except for a neuroma in one patient and slight superficial skin loss in another.

The Reversed Venous Arterialized Nerve Graft in Digital Nerve Reconstruction Across Scarred Beds

Conventional nerve grafts in complex digital injuries often yield poor results, particularly when placed in traumatized or avascular beds. Vascularized nerve grafts offer an option; experimental evidence suggests superior axonal regeneration across scarred beds with vascularized nerve grafts. We previously described a vascularized graft based on the dorsalis pedis artery-deep peroneal nerve “system.” Reluctance to sacrifice this major artery, combined with the recent description by Townsend and Taylor and Gu et al. of “reversed venous” arterialized nerve grafts, spurred us on to investigate the deep peroneal nerve-dorsalis pedis venae comitantes system. Fourteen neurovenous grafts were used in scarred or poorly vascularized beds for digital nerve reconstruction in 10 patients over a 4-year period. Graft length averaged 4.4 cm; interval from injury was 1 to 17 months. Sensory parameters of return included average static two-point discrimination of 8.3 mm, moving two-point discrimination of 5.8 mm, and median Semmes-Weinstein monofilament appreciation of 2.83. Two patients received three vascularized grafts and three conventional grafts for adjacent nerve injuries in the same digit, serving as internal controls. In these patients, the vascularized nerve grafts returned mean static two-point discrimination values of 9.3 mm and moving two-point discrimination values of 6.7 mm. The conventional nerve grafts averaged static two-point discrimination values of 14.3 mm and moving two-point discrimination values of 10.3 mm. These differences imply enhanced axonal regeneration through vascularized nerve grafts. These data suggest that the reversed neurovenous graft may be the procedure of choice in secondary reconstruction of digital nerves across scarred beds or following injuries with poor soft-tissue vascularity, especially in those patients with cold intolerance.

Successful replantation of two avulsed scalps by microvascular anastomoses.

Two cases of immediate replantation of avulsed scalps by microvascular anastomosis are presented. This method of treatment seems to offer significant economic, social, and psychological advantages over split-skin grafting of the calvarium, or other presently used treatments. The need for secondary reconstructive procedures after a successful replantation is minimal, or nil. The mechanism of scalping is reviewed, and it is related anatomically to the structure of the galea aponeurotica. Specific recommendations are made regarding the immediate care of the avulsed scalp and the denuded calvarium, the value of a team approach in replantation, and various technical aspects of the procedure and postoperative management. The more frequent use of interpositional vein grafts is urged.

One-stage arterialized nasolabial island flap for floor of mouth reconstruction.

A one-stage nasolabial island flap isolated on the facial artery and vein is described for floor of mouth reconstruction. The donor site is closed primarily. The advantages of the procedure are that the one-stage procedure obviates the need for division and inset of a distant flap, the arterialized flap brings its own blood supply to the irradiated area; the donor site in elderly patients provides a large amount of redundant skin, which stretches easily across the midline or to the roof of the palate; and the donor defect is cosmetically acceptable. A disadvantage is that the procedure yields transient upper lip palsy and drooling that persists for several weeks.

Excisional wound biomechanics, skin tension lines, and elastic contraction.

Confusion surrounding the concept of Langers lines can be reduced by careful distinction among the operational definitions of the phenomenon, the empirical descriptions, and the theoretical explanations. An experimental analysis of the mechanical parameters of excisional wounds in pigskin shows that the marginal retraction, the elastic modulus at the wound midline, and the closing tension are higher for wounds oriented at right angles to tension lines--but the elastic modulus of the terminal segment of the force displacement curve is independent of orientation. The regional distribution of these values shows two patterns. The modulus parameters and the closing tension share a common distribution related to the steepness of regional force-displacement curves, while retraction has a qualitatively different distribution. On the basis of similarities in the behavior of retracting wound margins and in the distortion of punch holes which define tension lines, we hypothesize that the same mechanism may be responsible in both cases.