Nicholas G. Georgiade

Maxillary arch alignment in the bilateral cleft lip and palate infant, using pinned coaxial screw appliance.

An arch alignment appliance, capable of both maxillary expansion and premaxillary retraction, based on a pinned screw mechanism and capable of extraoral activation, is described and illustrated.

Long-term clinical outcome of immediate reconstruction after mastectomy.

Immediate reconstruction of a breast removed for treatment of carcinoma can be accomplished without altering the cancer-ablative surgical procedure. The theoretical possibility that reconstruction might compromise the cure rate has tempered enthusiasm for this approach. To test this issue, the relapse-free survival of 101 patients who underwent breast reconstruction in the immediate postmastectomy period was compared with that of 377 patients with breast cancer who underwent mastectomy without immediate reconstruction. This comparison was accomplished using multivariable statistical techniques to correct for baseline inequalities between the patient groups. After adjustment for the relevant prognostic factors, no significant difference remained between the two groups. We conclude that immediate reconstruction has no discernible adverse influence on the natural history of surgically treated breast carcinoma.

A rib-containing free flap to reconstruct mandibular defects

A composite free flap based on intercostal vessels may be used to reconstruct in one stage defects around the mandible in which skin, soft tissue and bone are missing. A delay procedure is recommended one week prior to transfer.

Comparison of free flaps with pedicled flaps for coverage of defects of the leg or foot.

The use of free flaps to repair defects of the leg or foot is a viable alternative to cross-leg flaps because (1) the total time of immobilization and hospitalization is less, (2) the total number of general anesthetics is less, and (3) the morbidity and cost are less. Increased experience will enhance the survival statistics for free flaps, making their use the method of choice for the reconstruction of defects in the distal part of the lower extremity.

Congenital giant nevi: clinical and pathological considerations.

A clinical and pathological review of 67 cases of congenital giant nevi and of 5 cases of malignant transformation in congenital giant nevi brings out the following. 1. The lesions should be regarded as premalignant. 2. An aggressive approach is advocated to remove the lesion before school age. 3. Staged excisions, combined with skin grafting and/or local rotation flaps, are advocated. 4. Any nodularity or ulceration developing within a congenital giant nevus should be regarded as an ominous sign. 5. A long-term follow-up is necessary in those patients having subtotal excisions.

Reduction mammaplasty utilizing an inferior pedicle nipple-areolar flap

A technique utilizing the inferiorly based dermal pedicle nipple-areolar flap is described. The advantages of this technique are: (1) predictable breast shape based on preoperative markings; (2) direct visibility of all areas for ease of resection and hemostasis; (3) retention of normal nipple duct connections; (4) no impairment of subjective sensation; and (5) adequate blood supply.This technique has particular application in younger women, in whom nipple sensation is quite important. The interruption of the intercostal nerve branches is usually limited because of the thickness and width of the inferior pedicles. Utilizing our modifications of the technique originally described, this versatile flap can now be used routinely in reduction mammaplasties requiring the removal of either small amounts (200 gm) or quite large amounts (2,500 gm) of tissue with consistently satisfactory aesthetic results and excellent patient satisfaction.

Reconstruction of the Lower Extremity with Vascularized Composite Tissue: Improved Tissue Survival and Specific Indications

A retrospective assessment of 50 vascularized composite tissue transfers was carried out with 48 patients. Factors responsible for improved tissue survival included (1) the evaluation and proper selection of recipient vasculature, (2) the increased dependence on the vacularized latissimus dorsi musculocutaneous flap, and (3) the frequent use, wherever possible, of an end-to-side arterial anastomisis. Specific indications for reconstruction of the lower extremity with vascularized composite tissue include (1) avulsive injuries to the distal tibia and foot, (2) the failure of conventional methods, (3) the treatment of extensive chronic osteomyelitis, (4) deficiency of both soft tissue cover and skeletal support, (5) the restoration of form and contour with minimal secondary deformity of the donor site, and (6) extensive loss of soft tissue only. Reconstruction of the lower extremity with vascularized tissue is a reliable method with acceptable patient and tissue morbidity statistics that should be considered when specific indications are present.

Vascularized Rib-Periosteal and Osteocutaneous Reconstruction of the Maxilla and Mandible: An Assessment

Three approaches to provide rib-periosteal or osteocutaneous composite tissue in maxillary or mandibular reconstruction are presented. All methods appear to be useful in replacing viable osteocytes and improving vascularity of maxillary or mandibular defects. Disadvantages include the bulk of the transplanted tissue, volume deficiency of bone, and the unreliability in viability of the associated cutaneous tissue, especially with the posterior and posterolateral approach. Significant patient morbidity and pulmonary complications in our series should indicate caution when considering these methods of reconstruction. At present, rib-periosteal transplantation is most often indicated to replace segmental defects of mandibular continuity when the recipient bed is avascular but the quantity of cutaneous cover is adequate. In those patients with deficient soft tissue and a small segmental mandibular loss, reconstruction with musculocutaneous flaps and nonvascularized bone grafts is indicated. With extensive deficiencies of both soft tissue cover and mandibular or maxillary continuity, an iliac osteocutaneous flap based on the deep circumflex iliac vessels may be the most effective. Lower patient morbidity statistics should be anticipated.

Microsurgical Composite Tissue Transplantation

: Since 1974, 69 patients with extensive defects have undergone reconstruction by microsurgical composite tissue transplantation. Using this method, donor composite tissue is isolated on its blood supply, removed to a distant recipient site, and the continuity of blood flow re-established by microvascular anastomoses. In this series, 56 patients (81%) were completely successful. There have been eight (12%) failures, primarily in the extremities. There have been five (7%) partial successes, (i.e., a microvascular flap in which a portion was lost requiring a secondary procedure such as a split thickness graft). In those patients with a severely injured lower extremity, the failure rate was the greatest. Most of these were arterial (six of seven). These failures occurred early in the series and were thought to be related to a severely damaged recipient vasculature. This problem has been circumvented by an autogenous interpositional vein graft, permitting more mobility of flap placement. In the upper extremity, all but one case were successful. Early motion was permitted, preventing joint capsular contractures and loss of function. Twenty-three cases in the head and neck region were successful (one partial success). This included two composite rib grafts to the mandible. Prolonged delays in reconstruction following extirpation of a malignancy were avoided. A rapid return to society following complete reconstruction was ensured. Nine patients presented for reconstruction of the breast and thorax following radical mastectomy. All were successfully reconstructed with this new technique except one patient. Its many advantages include immediate reconstruction without delayed procedures and no secondary deformity of the donor site. Healthy, well vascularized tissue can now be transferred to a previously irradiated area with no tissue loss. This new method offers many advantages to older methods of reconstruction. Length of hospital stay and immobilization are reduced. The total number of operative procedures required in achieving the desired result is also less, thus decreasing the cost of hospital care.

The inferior dermal-pyramidal type breast reduction: long-term evaluation.

The evolution of the technique of breast reduction using an inferior dermal pyramidal flap is discussed, including the changes we have found to enhance this procedure. The recommended use of a wide-based pyramidal breast parenchyma with a dermal pedicle nipple-areola flap is based on our 12-year study of 1,001 breast reductions in 519 patients ranging in age from 13 to 73 years; 37 of the patients underwent a unilateral breast reduction. The weight of tissue excised ranged from 207 g to 3,350 g from each breast. Occult carcinomas were found in two of the breast specimens. The longest sternal notch-to-nipple distance was 52 cm. The essential goals of predictability of the result, retainment of nipple sensitivity, excellent aesthetic results, and the possibility of lactation are satisfied by the use of this surgical technique. This technique appears to have continued application in younger women, in whom nipple sensation and lactation are particularly important.