Michael R. Lee

Vascular anatomy of the anterolateral thigh flap: a systematic review.

Background: The most untoward aspect of the anterolateral thigh is the complexity of the local vasculature. Failure to understand its variability can lead to vascular flap embarrassment and tissue loss. The authors present a comprehensive summary of the vascular anatomy of the anterolateral thigh. Methods: A MEDLINE search was performed for articles published between 1948 and 2012 on the anterolateral thigh flap. Two levels of screening and manual reference check identified 44 relevant studies. Results: The descending branch of the lateral circumflex femoral artery was variably found to originate from the deep femoral (6.25 to 13 percent) or common femoral artery (1 to 6 percent), instead of the lateral circumflex femoral artery. Dominant perforator supply to the anterolateral thigh was most commonly from the descending (57 to 100 percent), transverse (4 to 35 percent), oblique (14 to 43 percent), or ascending (2.6 to 14.5 percent) branch. Septocutaneous perforators were present in 19.8 percent (0 to 61.5 percent) of cases overall (n = 2486). No perforators were found in 1.8 percent of cases overall (n = 2895). The majority of perforators were found in the central third of the thigh. The previously undescribed musculoseptocutaneous perforator was observed in 21 to 52.3 percent of vascular mapping or anatomic studies, but not in clinical studies. Conclusions: As knowledge of pertinent vascular anatomy for the anterolateral thigh flap has increased, so has insight into the amount of existing variation. This systematic review summarizes the wide spectrum of normal and variant anatomy described in the literature to date. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Central segment harvest of costal cartilage in rhinoplasty.

Our objective was to review our experience with a conservative central boat harvest of costal cartilage in patients undergoing rhinoplasty. It involves taking only the central portion of the rib for reconstruction. When cartilage harvest is performed in the above manner, donor site morbidity is minimized without limiting aesthetic results. The key seems to be preservation of intact costal cartilage on three sides, limiting harvest to the central portion only. This central portion is straight and much less prone to warping than the cartilage toward the periphery.

Reconstitution of the nasal dorsum following component dorsal reduction in primary rhinoplasty.

Background: Dorsal hump reduction can lead to significant aesthetic and functional deformities if one does not preserve and subsequently restore proper position of the upper lateral cartilages. The senior author (R.J.R.) previously described the component dorsal hump reduction to preserve the integrity of the upper lateral cartilages, thereby avoiding routine use of spreader grafts. In this study, the authors introduce their algorithm for reconstitution of the nasal dorsum. Methods: The charts of 100 consecutive primary rhinoplasty patients from the senior author’s practice were reviewed. The technique used for dorsal reconstitution, complications, and revisions were analyzed. Preoperative and postoperative images of the dorsal aesthetic lines were examined for symmetry and contour. Results: Mean follow-up was 19 months. A dorsal hump reduction of 5 mm or more was performed in 39 patients (39 percent). No patients received spreader grafts. The technique used for dorsum reconstitution was upper lateral cartilage tension spanning suture (type 1) in 65 percent, reapproximation (type 2) in 25 percent, and spreader flaps (type 3) in 10 percent. There were no significant complications and 4 percent required revision. Dorsal aesthetic lines were symmetric in 69 patients (69 percent) preoperatively and in 94 patients (94 percent) postoperatively. The authors found 65 dorsal aesthetic lines (32.5 percent) without contour irregularities preoperatively compared with 194 (97 percent) postoperatively. Conclusion: Reconstituting the nasal dorsum with repositioning of the upper lateral cartilages that is based on the individual anatomy of the rhinoplasty patient can provide durable cosmetic and functional results without the need for routine use of spreader grafts. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Timing of traumatic upper extremity free flap reconstruction: a systematic review and progress report.

Background: The recommendations on the timing of microsurgical extremity reconstruction are as variable and numerous as the flaps described for such reconstruction. Original articles suggested that reconstruction should take place within 72 hours of injury. However, significant changes in perioperative and intraoperative management have occurred in this field, which may allow for more flexibility in the timing of reconstruction. This article aims to review current literature on timing of upper extremity reconstruction to provide the microsurgeon with up-to-date recommendations. Methods: A structured literature search including Spanish and English language articles published between January of 1995 and December of 2011 was performed using the MEDLINE and Scopus databases. The search strategy was conducted using groups of key words, and articles were subsequently reviewed for relevance. Bibliographies of selected articles were further reviewed for additional relevant publications. Rates of total flap loss, infection, hospital stay, and bony nonunion were recorded and analyzed according to emergent (<24 hours), early (<5 days), primary (6 to 21 days), or delayed (>21 days) reconstruction. Results: Fifteen articles met inclusion criteria. There was no significant association between timing of reconstruction and rates of flap loss, infection, or bony nonunion. Linear regression analysis displayed a significant association between length of hospital stay and timing of reconstruction. Conclusions: No conclusive evidence exists to suggest that emergent, early, primary, or delayed reconstruction will eliminate or decrease complications associated with posttraumatic upper extremity reconstruction. Earlier reconstruction may decrease length of hospital stay and limit associated medical costs.

External approach for secondary rhinoplasty: advances over the past 25 years.

Twenty-five years have passed since the landmark article outlining the benefits of the external approach for secondary rhinoplasty.1 At the time of publication, closed technique was the generally accepted approach, often requiring further surgical correction.2 Suchvariableoutcomeswerepostulatedto result from limited exposure and inadequate evaluation of the underlying osseocartilaginous framework.1,2 The absence of a comprehensive inspection was thought to limit diagnosis and treatment for the full spectrum of existing deformity. Moreover, the open approach provided a more substantial means for evaluation and intervention, whereby more consistent results could be obtained. Plastic surgeons and otolaryngologists have collectively been responsible for key advances in open rhinoplasty.3–5 Since the time of publication, the open approach for rhinoplasty has become the preferred technique not only for secondary surgery at our institution but also for primary operations. The complexity of rhinoplasty lies in the surgeon’s ability to obtain a predictable and consistent aesthetic result. Convolution of predictability is foremost related to the intrinsic forces of manipulated cartilage in the presence of wound healing dynamics.6,7 Furthermore, in secondary rhinoplasty, the surgeon is often confronted with distorted anatomy, existing scar formation, and sparseness of donor cartilage. Few operations benefit from years of experience to the magnitude that secondary rhinoplasty does. The purpose of this article is to communicate advances that have proven to be of significant benefit in patients undergoing secondary rhinoplasty. It is the experience of the senior author (R.J.R) that these practices uniformly improve aesthetic results in a predictable manner. The following has added another dimension in our ability to achieve better results in secondary rhinoplasty.

Effects of carving plane, level of harvest, and oppositional suturing techniques on costal cartilage warping.

Background: Cartilage warping has plagued reconstructive and cosmetic rhinoplasty since the introduction of extra-anatomical cartilage use. With the present level of knowledge, there is no evidence of the warping properties with respect to cartilage harvest and suture techniques and level of rib harvest. This report aims to improve understanding of costal cartilage warping. Methods: The sixth through tenth costal cartilages were harvested from six fresh cadavers aged 54 to 90 years. Warping characteristics were followed with respect to level of harvest (i.e., sixth versus seventh), carving orientation, and oppositional suturing. Digital photography of the specimens was performed at various time points (immediately, 1 hour, and 1 month postoperatively). Results: All specimens showed signs of warping beyond 1 hour of carving that continued in a linear fashion to 1 month. There was no statistical difference in the amount of warping specific to the level of harvest, orientation, or with or without oppositional suturing (p < 0.05). Conclusions: Cartilage warping remains a problematic obstacle in nasal reconstruction and revision rhinoplasty, but costal cartilage remains the workhorse graft and is an excellent autologous option. Our findings are the first to be described in the literature regarding warping characteristics of costal cartilage with regard to the level of harvest, orientation of carving, and oppositional suturing techniques in a cadaveric model.

Flap selection and functional outcomes in total glossectomy with laryngeal preservation.

Objective Reconstruction of total glossectomy defects has been revolutionized by the popularity of free flap use in the head and neck. Challenging defects can be addressed with a variety of different free and pedicled flaps. The purpose of this study is to review our method of flap selection in cases of total glossectomy defects with laryngeal preservation, with an emphasis on the variations of these defects and patient body habitus. Study Design Case series with chart review. Setting Tertiary care referral center. Subjects and Methods All patients undergoing total glossectomy with laryngeal preservation (TGLP) by the senior author (YD) from September 1997 to May 2012. Objective data regarding patient demographics, existing defect, method of reconstruction, adjuvant treatment, operative details, outcomes, and complications were recorded. Both means and frequency of prolonged tracheostomy or gastrostomy tube were used to assess outcomes. Results One hundred and three patients were identified. Ninety-four met inclusion criteria. All patients were T3 or T4 stage tumors. Mean follow-up was 3.4 years. Fifty-nine patients (62%) underwent free flap reconstruction while the remaining 35 (37%) were treated with a pedicled pectoralis myocutaneous flap. Tracheostomy decannulation and gastrostomy tube removal rates were 84% and 29%, respectively. No patients were converted to total laryngectomy. Conclusion Optimal reconstruction of TGLP defects may be accomplished with either pedicled or free-tissue flap reconstruction. Selecting an ideal flap for reconstruction of total glossectomy defects should be patient specific and based on matching donor flap bulk. This treatment approach demonstrates high tracheostomy and gastric tube independence.

A multivariate analysis of nasal tip deprojection.

Background: Projection of the nasal tip is a complex problem that often mandates attention during rhinoplasty. Occasionally, the goal is to decrease tip projection. Most published solutions to this problem involve division or manipulation of the lower lateral cartilages, although objective data on the efficacy of these techniques are limited. This study reviews a series of rhinoplasties and determines which maneuvers had the greatest effect on tip projection. Methods: One hundred twenty-five consecutive rhinoplasties performed by a single surgeon in a university setting were reviewed. Charts were analyzed for surgical indications and technical steps performed in the operating room. Preoperative and postoperative photographs underwent multivariate analysis to determine changes in nasal projection and which factors contribute to affecting tip projection. Results: Overall revision rate was 3.8 percent. Cartilage-splitting techniques were used in only 2.4 percent of cases. Multivariate dummy variable analysis revealed that only dorsal component reduction and caudal trim were associated with significant decreases in tip projection. Alar base resection did not change absolute tip position but did have a marked effect on the position of the alar-cheek junction and thus the overall balance of the nose with regard to length-to-projection ratios and projection proportions. Conclusions: Cartilage-dividing techniques are rarely necessary to reduce projection. Release of the soft-tissue attachments of the lower lateral cartilages and modification of the anterior septum are frequently sufficient to achieve a satisfactory aesthetic endpoint. Alar base resection has a complex interaction with nasal aesthetics with regard to tip projection. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Free tissue transfer to the traumatized upper extremity: Risk factors for postoperative complications in 282 cases

BACKGROUND Complex traumatic upper extremity injuries frequently possess compromised local vasculature or extensive defects that are not amenable to local flap reconstruction. Free tissue transfer is required to provide adequate soft tissue coverage. The present study aimed to evaluate risk factors that contribute to postoperative complications and flap loss in complex upper extremity reconstruction. METHODS Retrospective chart review was performed for all patients undergoing free tissue transfer for upper extremity reconstruction from 1976 to 2001. Data collected included patient demographic characteristics, timing of reconstruction, location of injury, fracture characteristics, operative interventions, and postoperative complications. Statistical analysis was performed using χ(2) and Fisher exact tests. RESULTS In total, 238 patients underwent 285 free tissue transfers and met inclusion criteria, from which 3 were excluded because of inadequate information (n = 282). Extremities were repaired within 24 h (75 cases; 27%), in days 2-7 (32 cases; 12%), or after day 7 (172 cases; 62%). Timing of reconstruction did not significantly affect postoperative outcomes. Proximal location of injury was significantly associated with superficial (relative risk [RR], 6.5; P < .01) and deep infection (RR, 5.3; P < .01), and osteomyelitis (RR, 4.0; P < .01), although not with flap failure (P = .30). Presence of an open fracture was significantly associated with developing superficial (RR, 3.1; P = .01) and deep (RR, 1.9; P < .01) infection, as well as osteomyelitis (RR, 1.6; P < .01). Having a closed fracture did not negatively influence postoperative outcomes. CONCLUSIONS This study supports the safety of early free tissue transfer for reconstruction of traumatized upper extremities. Injuries proximal to the elbow and open fracture were associated with a significantly higher infection rate. Gustilo grade IIIC fractures, need for interpositional vein grafts, and anastomotic revision at index operation resulted in significantly higher risk of flap loss, whereas the presence of fracture, fracture fixation, and injury location were not predictors of flap failure.

Role of upper lateral cartilage tension spanning suture in restoring the dorsal aesthetic lines in rhinoplasty.

Dorsal hump reduction can lead to significant aesthetic and functional deformities with distortion of the dorsal aesthetic lines without first preserving and subsequently restoring proper position of the upper lateral cartilages. The senior author (R.J.R.) previously described the component dorsal hump reduction to preserve the integrity of the upper lateral cartilages, thereby avoiding routine use of spreader grafts. In this study, the authors introduce an efficient and reproducible technique they call the upper lateral cartilage tension spanning suture to reconstitute the upper lateral cartilages into anatomical position. The authors have found this technique to consistently achieve smooth and symmetric contour to the nasal dorsum and pleasing dorsal aesthetic lines.