Kenneth C. Shestak

The separation of anatomic components technique for the reconstruction of massive midline abdominal wall defects: anatomy, surgical technique, applications, and limitations revisited.

Learning Objectives: After studying this article, the participant should be able to: 1. Describe the anatomic muscle complex that is advanced toward the midline in the separation of components method of abdominal wall repair. 2. Understand the indications for components of separation reconstruction of the abdominal wall and the maximum transverse defect width that can be reconstructed at various levels. 3. Describe the course of the intercostal nerves lateral to the linea semilunaris line as they run posterior to anterior. 4. Understand the plane of dissection necessary to develop this muscle complex and be aware of the technical maneuver to increase the mobility of this complex at the costal margin, waist, and suprapubic area. Reconstruction of massive abdominal wall defects has long been a vexing clinical problem. A landmark development for the autogenous tissue reconstruction of these difficult wounds was the introduction of “components of anatomic separation” technique by Ramirez et al. This method uses bilateral, innervated, bipedicle, rectus abdominis-transversus abdominis-internal oblique muscle flap complexes transposed medially to reconstruct the central abdominal wall. Enamored with this concept, this institution sought to define the limitations and complications and to quantify functional outcome with the use of this technique. During a 4-year period (July of 1991 to 1995), 22 patients underwent reconstruction of massive midline abdominal wounds. The defects varied in size from 6 to 14 cm in width and from 10 to 24 cm in height. Causes included removal of infected synthetic mesh material (n = 7), recurrent hernia (n = 4), removal of split-thickness skin graft and dense abdominal wall cicatrix (n = 4), parastomal hernia (n = 2), primary incisional hernia (n = 2), trauma/enteric sepsis (n = 2), and tumor resection (abdominal wall desmoid tumor involving the right rectus abdominis muscle) (n = 1). Twenty patients were treated with mobilization of both rectus abdominis muscles, and in two patients one muscle complex was used. The plane of “separation” was the interface between the external and internal oblique muscles. A quantitative dynamic assessment of the abdominal wall was performed in two patients by using a Cybex TEF machine, with analysis of truncal flexion strength being undertaken preoperatively and at 6 months after surgery. Patients achieved wound healing in all cases with one operation. Minor complications included superficial infection in two patients and a wound seroma in one. One patient developed a recurrent incisional hernia 8 months postoperatively. There was one postoperative death caused by multisystem organ failure. One patient required the addition of synthetic mesh to achieve abdominal closure. This case involved a thin patient whose defect exceeded 16 cm in width. There has been no clinically apparent muscle weakness in the abdomen over that present preoperatively. Analysis of preoperative and postoperative truncal force generation revealed a 40 percent increase in strength in the two patients tested on a Cybex machine. Reoperation was possible through the reconstructed abdominal wall in two patients without untoward sequela. This operation is an effective method for autogenous reconstruction of massive midline abdominal wall defects. It can be used either as a primary mode of defect closure or to treat the complications of trauma, surgery, or various diseases.

Microsurgical reconstruction of the head and neck : interdisciplinary collaboration between head and neck surgeons and plastic surgeons in 305 cases

Three hundred five microsurgical free flaps have been performed for defects of the head and neck by a team of two head and neck surgeons and two plastic surgeons over a 9-year period, with a success rate of 91.2%. The most common flaps used were the jejunum (89), radial forearm (57), rectus abdominis (48), latissimus dorsi (40), scapular (32), fibula (15), and iliac crest (11). Thirty-three flaps required reexploration for anastomotic thrombosis or hematoma (10.8%), of which 18 flaps were salvaged (54.5%). Thirteen flap failures occurred in 113 patients who had received preoperative irradiation (11.5%), but this was not statistically significant. Seven flaps failed in 20 patients who required an interposition vein graft (35%) and this was statistically significant. Ninety patients (31.5%) developed a major complication other than anastomotic thrombosis or death. Despite postoperative intensive care nursing and monitoring, 18 patients died postoperatively in the hospital (6.3%). The average hospital stay was 21.1 days with a range from 5 to 95 days. During this 9-year time period, various free flaps have evolved as the preferred choice for free flap reconstruction of a specific defect of the head and neck. The latissimus dorsi muscle flap surfaced with a nonmeshed split-thickness skin graft is the optimal free flap for reconstruction of the scalp and skull, whereas a multiple-paddle latissimus dorsi musculocutaneous flap is the best flap for reconstruction of complex defects of the middle third of the face and maxilla. The radial forearm flap and free jejunal transfer have become the preferred choices for intraoral reconstruction and pharyngo-esophageal reconstruction, respectively. There still remains no universally accepted flap for mandibular reconstruction, but the fibular osteocutaneous flap and a reconstruction plate protected by a radial forearm flap have largely superseded the iliac crest and scapular osteocutaneous flaps. Radical resection of tumors of the head and neck with immediate reconstruction by microsurgical free tissue transfer followed by adjuvant radiation therapy provides the best possible chance for cure and functional and social rehabilitation of the patient. Jones NF, Johnson JT, Shestak KC, Myers EN, Swartz WM. Microsurgical reconstruction of the head and neck: interdisciplinary collaboration between head and neck surgeons and plastic surgeons in 305 cases. Ann Plast Surg 1996;36:37-43

Reconstruction of the Cervical Esophagus: Free Jejunal Transfer versus Gastric Pull-Up

Use of enteric grafts is a popular method for reconstruction of the cervical esophagus and hypopharynx. Free jejunal transfer (FJT) and gastric pull-up (GP) are the most popular methods used. This discussion is a retrospective review of our experience with 50 cases of free jejunal transfer and 15 cases of gastric pull-up. The graft survival rate was 94 percent (47 of 50) for free jejunal transfer and 87 percent (13 of 15) for gastric pull-up. Successful swallowing was achieved in 88 percent (44 of 50) of free jejunal transfers and 87 percent (13 of 15) of gastric pull-ups. Patients with free jejunal transfers were able to swallow and leave the hospital sooner: 10.6 versus 16.0 days and 22.3 versus 29.0 days, respectively. Fistulas occurred in 16 percent (8 of 50) of free jejunal transfers, most of which (6 of 8) healed spontaneously. Fistulas occurred in 20 percent (3 of 15) of gastric pull-ups, only one of which healed spontaneously. Stricture was the most common late complication for free jejunal transfers, 22 percent (11 of 50), whereas reflux was most common in gastric pull-ups, 20 percent (3 of 15). In patients with advanced cancer, extensive esopha-geal resection into the chest is often required, and gastric pull-up seems to be an easier and more direct form of reconstruction. In limited resection of the hypopharynx and esophagus, especially with proximal lesions, free jejunal transfer is simpler and avoids mediastinal dissection. This concept as well as other advantages and disadvantages of both techniques will be discussed.

Microsurgical free-tissue transfer in the elderly patient.

During the 5-year period from July of 1984 to July of 1989, we performed 94 free-tissue transfers in 92 patients over the age of 50 whom we arbitrarily defined as “elderly.” There were 32 patients in the age range between 50 and 59 years, 40 patients aged between 60 and 69 years, and 20 patients aged between 70 and 79 years. Seventy-one flaps were utilized for head and neck reconstruction, and 23 flaps were used in reconstruction of the trunk and extremities. There was 1 total flap loss, for a flap viability rate of 99 percent (93 of 94). Postoperative complications were classified into surgical (technical) and medical categories. There were 14 major surgical complications (15 percent) and 13 significant postoperative medical problems (14 percent). The majority of these complications occurred in head and neck cancer patients in the age group between 60 and 69 years, who had significant underlying medical problems and were preoperatively classified as ASA 3. There were 5 postoperative deaths, for a mortality rate of 5.4 percent (5 of 92 patients).

Ischaemia-induced expression of bFGF in normal skeletal muscle: a potential paracrine mechanism for mediating angiogenesis in ischaemic skeletal muscle.

To test the hypothesis that induction of endogenous bFGF can lead to angiogenesis in ischaemic skeletal muscle, we studied the expression of bFGF after transposition of a well-vascularized muscle flap onto an ischaemic hindlimb in the rabbit. The results indicated a marked induction of bFGF mRNA throughout the myoblasts of the well-perfused muscle flap but not the myoblasts of the ischaemic muscle. bFGF protein was detected in the muscle flap, particularly in the myoblasts located closest to a newly formed, adjacent interface, and in the interface itself. In contrast, bFGF expression was not induced after transposition of a well-perfused muscle flap onto healthy muscle tissue. These data provide evidence that the juxtaposition of ischaemic skeletal muscle with healthy mesenchymal tissue triggers an increased expression of bFGF in the myoblasts of the well-perfused muscle. This paracrine induction of bFGF, in turn, leads to increased angiogenesis and regeneration of the ischaemic skeletal muscle.

Hypopharyngeal reconstruction: A comparison of two alternatives

Gastric pull‐up or free jejunal interposition was used for reconstruction after total laryngopharyngectomy in 31 patients. Complications and functional outcomes of the two methods are compared. Primary swallowing was achieved in 86% of patients after gastric pull‐up and in 82% of patients after jejunal interposition. Patients who underwent jejunal interposition were able to swallow sooner and had a shorter hospital stay than patients who underwent gastric pull‐up. Esophageal tumor recurrence after jejunal interposition was not observed. Hepatic failure occurred in two gastric pull‐up patients, leading to perioperative death in one. Flap necrosis occurred in two jejunal interposition patients and one gastric pull‐up patient. Two additional fistulas occurred in jejunal interposition patients as a result of microvascular complications. Stricture developed in four jejunal interposition patients, requiring revision surgery in two. Minor complications were more common in the gastric pull‐up group. Long‐term speech and swallowing function are compared. Our current choice of jejunal interposition or gastric pull‐up for reconstruction after total laryngopharyngectomy primarily depends on the location of the tumor.

Endometrioma of the abdominal wall following combined abdominoplasty and hysterectomy : Case report and review of the literature

An unusual case is reported of abdominal wall endometrioma presenting in a lower abdominal scar following a combined hysterectomy and abdominoplasty performed 5 years earlier. Current diagnostic methods and recommended surgical management are outlined.

The cervicopectoral rotation flap: a valuable technique for facial reconstruction

Four cases of lower cheek reconstruction using the cervicopectoral rotation-advancement flap are reported. This fasciocutaneous flap can be raised quickly, provides excellent colour and texture match for the tissues of the face, and donor site morbidity is minimal. It is an especially useful method for lower cheek reconstruction following wide excision of melanomas of the cheek and for advanced parotid tumours where skin replacement is required following resection.

Immediate microvascular reconstruction of combined palatal and midfacial defects

We describe a method for immediate one-stage reconstruction of combined palatal and midfacial defects using latissimus dorsi musculocutaneous free-tissue transfer. It has consistently provided healed wounds, restoration of palatal function, and preservation of facial contour while obviating the need for a palatal prosthesis. This reconstructive method, which uses only autogenous tissue, may offer a significant advantage in cases where more than a hemimaxillectomy is required, for compound defects resulting from the sacrifice of facial structures along with the maxillectomy, and in situations where the resection involves cranial base structures with a resultant need to separate the cranial contents from the oral and nasal cavities. Finally, it provides an alternative to prosthetic rehabilitation for the elderly patient with decreased or absent vision.

The double opposing periareola flap: a novel concept for nipple-areola reconstruction.

Background: This report describes the authors’ currently favored method of nipple reconstruction that has been developed and used by the senior author over the past 26 months. Methods: A pull-out flap is derived as the lead edge of one of two opposing skin flaps contained in a circular design approximating the areola complex of the opposite breast. The larger flap gives rise to the nipple construct, a derivative of the skate flap design. The flap donor areas are closed by suture approximation centrally and peripherally within the areolar margins. The donor area resulting from elevating the central flaps that give rise to the nipple is closed by direct suturing; the opposing subcutaneous dermal pedicle flaps are advanced or “slid” toward each other centrally, and the peripheral area is closed by a purse-string suture placed in the periareolar incision. The only undermined area is the nipple flap itself. There is no undermining of the larger flaps or peripheral breast skin. The dissection is straightforward and the technique is rapid. Results: The procedure was used 47 times in 36 patients (unilateral reconstruction, 25 patients; bilateral reconstruction, 11 patients), with no flap losses or wound separations. In one case of redo bilateral nipple reconstruction, ischemia noted at the most anterior aspect (distal portion) of both flaps healed with the application of topical ointment. Conclusions: This novel design for nipple-areola complex reconstruction can be used in either primary or secondary nipple reconstruction. Of particular advantage, all of the scars are contained within the peripheral periareolar incision and thus can be completely camouflaged by an intradermal tattoo. Nipple projection has been consistently maintained and appears similar to that of a skate flap.