James C. Yuen

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.

Free flap coverage for knee salvage.

Soft-tissue reconstruction using free flaps was reviewed in 11 consecutive knee wounds complicated by joint exposure or adjacent osteomyelitis and unavailability of adequate local flaps. Ten free muscle flaps and one fasciocutaneous flap were used successfully. Eight limbs presented with wide exposure of the knee joint, including 4 patients with wound infection involving the joint. Three other patients suffered osteomyelitis immediately adjacent to the knee. All knees were successfully salvaged with a single free flap operation, except for one knee that required a second free flap after flap necrosis. Follow-up in nine flaps ranged from 7 weeks to 19 months (mean, 12 months). For patients without preexisting conditions affecting the knee, free flap coverage provided excellent return of knee function. The choice of recipient vessels was determined mainly by the region of the knee requiring coverage. The recipient arteries utilized included the distal superficial femoral artery, anterior tibial artery, popliteal artery, and small arteries, which included the saphenous artery and descending branch of the lateral circumflex femoral artery. The use of small arteries and venae comitantes as recipient vessels increased the effective reach of the free flaps and eliminated the need for vein grafts.

Hypothenar hammer syndrome: an update with algorithms for diagnosis and treatment.

Hypothenar hammer syndrome is an uncommon cause of symptomatic ischemia of the hand secondary to the formation of aneurysm or thrombosis of the ulnar artery as a result of repetitive trauma to the hypothenar region. The injury to the palmar ulnar artery occurs in subjects who use the hypothenar part of the hand as a hammer; the hook of the hamate strikes the superficial palmar branch of the ulnar artery in the Guyon space. Such injuries of the ulnar artery may lead to severe vascular insufficiency in the hand with thrombosis and distal embolization of the digital arteries. Imaging of vascular lesions of the hand has greatly improved in recent years with the use of Doppler, multislice computed tomographic angiography, magnetic resonance imaging, magnetic resonance angiography, and digital subtraction angiography. The aim of this article is to describe a case report using current-day imaging and to present a review of literature. Algorithms for the diagnosis and treatment of hypothenar hammer syndrome will be proposed.

Techniques of external monitoring of buried free flaps.

Postoperative monitoring of free tissue transfer has proven to be crucial in enhancing the flap salvage rate in the event of thrombosis of the anastomosed vessels. Unfortunately, for buried flaps in the head and neck, direct monitoring of the flap can be extremely difficult, if not impossible. Utilizing various methods of flap exposure in a series of 55 buried free flaps of the head and neck, we demonstrate that we were able to provide a reliable means of direct postoperative assessment of the free flaps. Exteriorized components (indicator flaps) were established for 52 cases. An incision to create a skin window in the neck for monitoring was used for 3 cases. For the exteriorized flaps, in addition to clinical observation, adjunctive continuous monitoring using laser Doppler flowmetry was employed for 4–5 days. One free flap developed vascular thrombosis, which was re-explored and salvaged, giving a flap success rate of 100%. Fifty of 52 (96.2%) external components remained viable and therefore reliable for monitoring the main body of the flap. Two indicator flaps were unreliable after postoperative day 1 due to poor skin perfusion, while the subcutaneous component clinically remained viable. There was no return to the operating room for false-positive reexploration. This series reinforces the feasibility and reliability of direct monitoring of buried free flaps using the laser Doppler in practically all cases when modification is added to the flap design and inset.

Endovascular treatment of a pseudoaneurysm of a recipient external carotid artery following radiation and free tissue transfer.

Radical resection and reconstruction after preoperative radiation has become routine treatment for patients with certain types and stages of head and neck cancers. When microvascular flap reconstruction is required, the recipient vessels have been subjected to radiation, making them more thrombogenic and friable, thus increasing the risks of postoperative complications. The authors report a patient who received preoperative radiation therapy for rhabdomyosarcoma of the infratemporal fossa and who underwent a radical resection and free rectus musculocutaneous flap reconstruction. The free flap covered the base of the brain from the nasopharynx and closed an intraoral defect. The donor artery was anastomosed end to side to the external carotid artery stump. The patient developed a pseudoaneurysm of the external carotid artery stump 1 month postoperatively, which was treated with endovascular coil embolization without loss of the flap. Percutaneous transcatheter endovascular treatment of pseudoaneurysms that develop after free tissue transfer in head and neck reconstruction has not been reported previously. One month after surgery, endovascular occlusion of the main arterial supply to the flap did not compromise its viability because of collateral revascularization from the peripheral tissue bed, despite the patients history of radiation.

Reduced cost of extremity free flap monitoring.

We analyzed the results and cost-effectiveness of our protocol for free flap monitoring in extremity patients. Of 70 consecutive free flaps to the upper and lower extremity that were monitored by laser Doppler flowmeter, 62 were managed on the hospital ward immediately after recovery from general anesthesia. The duration of laser Doppler monitoring was 5 days. Perfusion compromise occurred in three flaps, two of which occurred in the recovery room and were initially detected by the laser Doppler and successfully salvaged by early exploration. The average equipment cost for the use of the laser Doppler flowmeter for 5 days was significantly less than the cost of an intensive care unit bed for a single day. Our experience confirms that monitoring free flaps with laser Doppler is cost-effective and indicates that a specialized care bed after the recovery room is not necessary in routine extremity cases. Since no vascular complication occurred beyond the second postoperative day, this study suggests that the duration of laser Doppler monitoring can be discontinued on the third postoperative day.

Critical leg ischemia resulting from interruption of collaterals by harvest of the rectus abdominis free flap : Endovascular salvage

In the setting of aortoiliac occlusive disease, the inferior epigastric artery may be an important pathway for collateral blood supply to the lower extremities. A 72-year-old man developed critical ischemia of both legs after harvest of a rectus abdominis free flap as a result of interruption of the inferior epigastric artery. In patients with aortoiliac occlusive disease, the contribution of the inferior epigastric artery to lower extremity blood flow should be evaluated noninvasively. In the setting of reversed flow, the inferior epigastric artery usually should not be divided.

Staged sequential reconstruction of a total lower lip, chin, and anterior mandibular defect.

The combination of a total lower lip, chin, and anterior mandibular defect following cancer resection is an extremely complex problem that requires a sequence of operations to optimize functional and aesthetic results. One patient is presented in whom the defect was reconstructed with a free fibular flap followed by a series of ancillary procedures using both modem and traditional techniques. At the time of tumor ablation, the through-and-through oromandibular defect was reconstructed with a fibular osteocutaneous flap. The lower lip and gingivolabial sulcus was reconstructed later with a tongue flap. Tissue expansion was subsequently used to replace the fibular skin with expanded submental hair-bearing skin. A polyethylene implant was added later to the fibular bone for chin augmentation. Subsequently the lower lip was supported with a tendinous graft suspended to the anterior masseter bilaterally. Lastly, the vermilion border was elevated by removing a rim of the tongue flap and covering the secondary wound with a full-thickness skin graft. At the end of the reconstructive procedures, lip seal and oral aperture were good with no drooling and excellent speech.

Double skin paddle fibular flap for a through-and-through oromandibular defect

The fibular osteocutaneous free flap has become the most versatile method for reconstructing composite defects of the mandible. The complexity of the reconstruction increases substantially when both intraoral and extraoral defects are present, possibly dictating the need for an additional flap. For the smaller through-and-through defects, a single skin island may be sufficient, but may be limited by inadequate reach. Although not routinely necessary, the skin island may be split completely to enhance the effective reach of the second paddle. One patient report is presented for which a moderately sized through-and-through defect of the mandible was reconstructed using a double skin paddle fibular osteocutaneous free flap.

Utilization of muscle flaps in the treatment of bronchopleural fistulas.

This paper reports the results of a series of 5 patients who underwent closure of persistent bronchopleural fistula using extrathoracic muscle flaps over a 6-year period. All patients had failed more conservative treatment. The surgeries were one- or two-stage procedures performed with the collaboration of cardiovascular and reconstructive surgical staffs. There were no associated mortalities. The muscle flaps utilized were the latissimus dorsi, serratus anterior, pectoralis major, pectoralis minor, and trapezius. The results have been encouraging and allowed the complete closure of the bronchopleural fistula in the majority of patients. The authors present the best management of this serious disease, as well as its pathophysiology and clinical aspects.