James Knoetgen

Long-term Outcomes and Complications Associated with Brachioplasty: A Retrospective Review and Cadaveric Study

Background: To determine the overall complication rates associated with brachioplasty, a retrospective review was performed of all brachioplasty procedures performed at the authors’ institution over a 16-year period. Methods: Hospital charts were reviewed for patient demographics. Ten fresh frozen cadaveric arm dissections were performed to better evaluate the anatomy of the medial antebrachial cutaneous nerve as it relates to brachioplasty. Results Forty bilateral brachioplasties were performed over the 16-year period. Average patient age was 47 years, and all patients were women. Average length of follow-up was 50 months. The revision rate was 12.5 percent. The overall complication rate was 25 percent. Ninety-five percent of the complications were classified as minor. None of the complications required correction with surgery. Complications noted were seroma, hypertrophic scarring, cellulitis, wound dehiscence, subcutaneous abscess, and nerve injury. Two patients (5 percent) developed an injury to the medial antebrachial cutaneous nerve during the procedure. Nerve injuries were classified as major complications. In cadaveric studies, the medial antebrachial cutaneous nerve was found to penetrate the deep fascia of the forearm at 14 cm proximal to the media epicondyle. Conclusions: Brachioplasty can be performed with a very low incidence of major complications, but both surgeon and patient should be aware of the possible risks associated with brachioplasty. Cadaveric dissections revealed that the medial antebrachial cutaneous nerve lies within the plane of dissection of the standard brachioplasty technique and is therefore at risk of injury.

Enhanced survival using the distally based sural artery interpolation flap

The reverse sural artery flap is frequently used for reconstruction of the distal third of the leg, ankle, and heel. The major disadvantage of the flap is compression of the pedicle within the subcutaneous tunnel and venous congestion. Others have cited a decrease in this problem by harvesting a midline cuff of gastrocnemius muscle, including more subcutaneous tissue and using a wider-than-usual pedicle. We describe an interpolation flap technique of simply avoiding a subcutaneous tunnel and exteriorizing the pedicle with no other alterations to flap design or elevation techniques. Seven distally based reverse sural artery flaps were performed on ambulatory patients between 2001 and 2002. Venous congestion did not occur in any of the flaps. All patients were ambulatory after surgery and did not require the use of a custom shoe. We conclude that transferring the flap in 2 stages without the use of a tunnel improves the reliability of the flap and eliminates venous congestion.

Outcomes of skin graft reconstructions with the use of Vacuum Assisted Closure (VAC®) dressing for irradiated extremity sarcoma defects

BackgroundFlaps are currently the predominant method of reconstruction for irradiated wounds. The usefulness of split-thickness skin grafts (STSG) in this setting remains controversial. The purpose of this study is to examine the outcomes of STSGs in conjunction with VAC therapy used in the treatment of irradiated extremity wounds.MethodsThe records of 17 preoperatively radiated patients with extremity sarcomas reconstructed with STSGs in conjunction with VAC® therapy were reviewed regarding details of radiation treatment, wound closure, and outcomes.ResultsSTSGs healed without complications (>95% of the graft take) in 12 (71%). Minor loss (6% – 20% surface) was noted in 3 patients (17.6%) and complete loss in 2 (11.7%). Two patients (11.7%) required flap reconstructions and 12 (88%) healed without further operative procedures.ConclusionAlthough flap coverage is an established treatment for radiated wounds, STSG in conjunction with liberal utilization of VAC therapy is an alternative for selected patients where acceptable soft tissue bed is preserved. Healing of the preoperatively radiated wounds can be achieved in the vast majority of such patients with minimal need for additional reconstructive operations.

Head and neck reconstruction with a second free flap following resection of a recurrent malignancy.

A retrospective analysis of 12 patients with a head and neck tumor recurrence within a previous free flap treated with extirpation and a second free flap is reported. A 15-year experience at Mayo Clinic, Rochester, from 1988 to 2003 of 12 patients (5 men, 7 women) who underwent 25 free flaps is reviewed. The overall flap survival rate was 92%, with a 100% survival rate in the first free-tissue transfer and 85% survival rate in the second free-tissue transfer. There was 1 minor complication (8%) and there were 2 major complications (15%) among the second free flaps. Overall, 10 of 13 (77%) second free flaps were anastomosed to ipsilateral neck vessels. Moreover, in 5 of 13 cases (38%) the same artery and in 7 of 13 cases (54%) the same vein were used for both the first and second free flaps. Reconstruction of the head and neck with a second free flap in patients with a recurrent tumor is safe and effective. The original recipient vessels can often be used for the second reconstruction.