Neil F. Jones

The osteocutaneous scapular flap for mandibular and maxillary reconstruction.

Microfil injections in 8 cadavers and clinical experience with 26 patients have demonstrated a reliable blood supply to the lateral border of the scapula based on branches of the circumflex scapular artery. This tissue has been used successfully for reconstruction of a variety of defects resulting from maxillectomy and mandibular defects from cancer and benign tumor excisions. Advantages of this tissue over previous reconstructive methods include the ability to design multiple cutaneous panels on a separate vascular pedicle from the bone flap allowing improvement in three-dimensional spatial relationships for complex mandibular and maxillary reconstructions. The lateral border of the scapula provides up to 14 cm of thick, straight corticocancellous bone that can be osteotomized where desired. The thin blade of the scapula provides optimum tissues for palate and orbital floor reconstruction. There have been no flap failures and minimal donor-site complications.

Chondrogenic potential of multipotential cells from human adipose tissue

The use of stem cells for cell-based tissue-engineering strategies represents a promising alternative for the repair of cartilaginous defects. The multilineage potential of a population of putative mesodermal stem cells obtained from human lipoaspirates, termed processed lipoaspirate cells, was previously characterized. The chondrogenic potential of those cells was confirmed with a combination of histological and molecular approaches. Processed lipoaspirate cells under high-density micromass culture conditions, supplemented with transforming growth factor-&bgr;1, insulin, transferrin, and ascorbic acid, formed well-defined nodules within 48 hours of induction and expressed the cartilaginous markers collagen type II, chondroitin-4-sulfate, and keratan sulfate. Reverse transcription polymerase chain reaction analysis confirmed the expression of collagen type II and the cartilage-specific proteoglycan aggrecan. In summary, human adipose tissue may represent a novel plentiful source of multipotential stem cells capable of undergoing chondrogenesis in vitro.

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

Rejection of the component tissues of limb allografts in rats immunosuppressed with FK-506 and cyclosporine.

&NA; One‐hundred and fourteen limb transplantations have been performed across a major histoincompatibility barrier between donor ACI (RT1a) and recipient Lewis (RT11) rats immunosuppressed with various dosages of FK‐506 and cyclosporine. Three‐hundred and thirty biopsy specimens from 64 animals have been evaluated histologically for signs of rejection. A new histologic grading system is introduced to classify the process of rejection in the component tissues (skin, muscle, bone, and articular cartilage) of a limb allograft. The results indicate that FK‐506 is a more potent immunosuppressive agent than cyclosporine in preventing the rejection of the skin component of a limb transplant. With twice‐weekly intermittent immunosuppression with FK‐506. the rejection of muscle, bone, and cartilage can be prevented for an indefinite time, although all longterm surviving animals died at around 300 days, probably of graft‐versus‐host disease. Based on the histologic stages of rejection in the different tissues at the same point in time, it is evident that each component tissue of a limb transplant rejects over a different time period. This probably reflects a hierarchy of antigenicity, with skin being most antigenic, muscle being intermediate in antigenicity, and bone and cartilage being least antigenic. Although this grading system is not the ultimate solution, it may allow a more objective comparison of experimental limb transplantation in the future. (Plast. Reconstr. Surg. 97: 139, 1996.)

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.

Healing of a critical-sized defect in the rat femur with use of a vascularized periosteal flap, a biodegradable matrix, and bone morphogenetic protein

BACKGROUND The purpose of this study was to evaluate the osseous healing of a critical-sized femoral defect in a rat model with use of recombinant human bone morphogenetic protein-2 (rhBMP-2), a matrix fabricated of D,D-L,L-polylactic and hyaluronan acid (OPLA-HY), and a vascularized periosteal flap. METHODS The carrier matrix OPLA-HY with or without rhBMP-2 was implanted in a 1-cm-long femoral defect and secured with a plate and screws. In some groups, a vascularized periosteal flap was harvested from the medial surface of the tibia. In group 1, the femoral defects in the animals were filled with the OPLA-HY matrix alone; in group 2, the OPLA-HY matrix was covered by the vascularized periosteal flap; in group 3, 20 mug of rhBMP-2 was added to the OPLA-HY matrix; and in group 4, the femoral defect containing the OPLA-HY matrix and 20 mug of rhBMP-2 was wrapped circumferentially by the vascularized periosteal flap. The presence and density of new bone formation in the femoral defect were evaluated radiographically, histologically, and with histomorphometry at four and eight weeks postoperatively. RESULTS Groups 1 and 2, which were not treated with rhBMP-2, showed no radiographic or histologic evidence of mature bone formation at four or eight weeks. Both groups 3 and 4, which were treated with rhBMP-2, demonstrated excellent bone formation. However, with the periosteal flap, group 4 demonstrated more bone formation on histomorphometric analysis at eight weeks (43.1%) than did group 3 (28.3%) (p < 0.01). Additionally, heterotopic bone formed outside the boundaries of the defect in eight of the fifteen animals in group 3, which had no periosteal flap. CONCLUSIONS Bone-tissue engineering with use of the OPLA-HY matrix and rhBMP-2 produced good bone formation in the rat femoral defect model. However, the addition of a vascularized periosteal flap significantly increased bone formation within the boundaries of the defect and prevented heterotopic ossification.

Reliability of the fibular osteocutaneous flap for mandibular reconstruction: anatomical and surgical confirmation.

&NA; There is ongoing controversy regarding the reliability of the skin island associated with the fibular osteocutaneous flap for mandibular reconstruction. Anatomical dissections and a clinical series of mandibular reconstructions using the fibular osteocutaneous flap have demonstrated unequivocally that a skin flap can be reliably harvested with the fibula based purely on the septal perforators, without needing to incorporate portions of the soleus or flexor hallucis longus muscles or to perform any intramuscular dissection or anastomosis of the muscle perforators. However, the skin island should be designed more distally over the distal third of the lower leg at the junction of the middle and distal thirds of the fibula. A fibular osteocutaneous flap was designed over the distal third of the fibula in 60 fresh cadavers, and each flap was completely isolated on the septum and all muscle perforators were ligated before dye injection. A major perforator through the soleus muscle or flexor hallucis muscle was identified in 41 of 60 dissections (67 percent) and discrete septal perforators were identified under loupe magnification in 45 dissections (75 percent). All 60 flaps demonstrated 100 percent reliable perfusion of the skin island after injection of the proximal peroneal artery with methylene blue or red latex. This anatomical study was corroborated with 100 percent survival of 34 fibular osteocutaneous flaps for mandibular reconstruction with the skin island designed over the distal third of the lower leg and based only on septal perforators without incorporating the soleus or flexor hallucis muscles. Reliability of this fibular osteocutaneous flap for mandibular reconstruction is attributed to (1) design of the skin island more distally over the distal third of the lower leg, (2) preoperative precision Doppler mapping of the perforators, and (3) design of the closing wedge osteotomies of the fibula to protect the septocutaneous perforators transversing through the posterior periosteum of the fibula. (Plast. Reconstr. Surg. 97: 707, 1996.)

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).

Postoperative medical complications: Not microsurgical complications: Negatively influence the morbidity, mortality, and true costs after microsurgical reconstruction for head and neck cancer

Background: Immediate reconstruction of composite head and neck defects using free tissue transfer is an accepted treatment standard. There remains, however, ongoing debate on whether the costs associated with this reconstructive approach merit its selection, especially considering poor patient prognoses and the high cost of care. Methods: A retrospective review of the last 100 consecutive patients undergoing microsurgical reconstruction for head and neck cancer by the two senior surgeons was performed to determine whether microsurgical complications or postoperative medical complications had the more profound influence on morbidity and mortality outcomes and the true costs of these reconstructions. Results: Two patients required re-exploration of the microsurgical anastomoses, for a re-exploration rate of 2 percent, and one flap failed, for a flap success rate of 99 percent. The major surgical complication rate requiring a second operative procedure was 6 percent. Sixteen percent had minor surgical complications related to the donor site. Major medical complications, defined as a significant risk to the patient’s life, occurred in 5 percent of the patients, but there was a 37 percent incidence of “minor” medical complications primarily caused by pulmonary problems and alcohol withdrawal. Postsurgical complications almost doubled the average hospital stay from 13.5 days for those patients without complications to 24 days for patients with complications. Thirty-six percent of the true cost of microsurgical reconstruction of head and neck cancer was due to the intensive care unit and hospital room costs, and 24 percent was due to operating room costs. Postsurgical complications resulted in a 70.7 percent increase in true costs, reflecting a prolonged stay in the intensive care unit and not an increase in operating room costs or regular hospital room costs. Conclusion: Postoperative medical complications in these elderly, debilitated patients related to pulmonary problems and alcohol withdrawal were statistically far more important in negatively affecting the outcomes and true costs of microsurgical reconstruction.

Free Rectus Abdominis Muscle Flap Reconstruction of the Middle and Posterior Cranial Base

A multidisciplinary approach by the neurosurgeon, ENT surgeon, and plastic surgeon has been used in seven patients with extensive tumors involving the middle and posterior skull base. Wide resection of these tumors was accomplished, and the resultant defect of the cranial base was reconstructed using free rectus abdominis muscle flaps. The free muscle flap has been used to reconstruct defects in the posterior and lateral walls of the nasopharynx, obliterate the exposed paranasal sinuses, and cover tenuous dural repairs or dural grafts overlying the temporal lobe and posterior fossa to prevent cerebrospinal fluid leakage and ascending meningitis.