Ramazi O. Datiashvili

Efficacy and cost-effectiveness of a high-powered parallel waterjet for wound debridement

Current concepts of wound healing acknowledge the essential role of wound bed preparation in achieving a wound with good healing potential. Critical to wound bed preparation is the removal of necrosis, unhealthy tissue, foreign matter, and infection. One of the accepted methods of wound bed preparation is surgery. The high‐power parallel waterjet is a new surgical device, which allows the operator to remove very precisely undesirable tissue and debris with maximal preservation of viable tissue. A retrospective study was performed to evaluate the efficacy, safety, and economic impact of using this technique of surgical debridement. Forty patients who had waterjet debridements were compared with 22 patients with matched wounds who had conventional surgical debridement. The waterjet group had significantly fewer procedures (p<0.002) than the conventional group. Based on these outcomes, the use of the new device in appropriate patients is expected to lead to cost savings of approximately

Reconstruction of a complex defect of the hand with two distinct segments of the scapula and a scapular fascial flap transferred as a single transplant.

1,900 per patient.

Reconstruction of musculoskeletal defects following oncologic resection in 76 patients.

To repair multiple defects of the metacarpal bones in combination with skin defects, a combined scapular free flap on a single vascular pedicle--the subscapular artery and the accompanying veins--can be used successfully. This flap includes two distinct bone segments of the lateral border of the scapula and a scapular fascial flap. Because of its long and mobile vascular pedicle, such a transplant can be used for one-stage reconstruction of the first and other metacarpal bones of the long fingers of the hand. The scapular fascial flap included in the transplant provides good functional and aesthetic results in combined injury of the skin of the hand.

Immediate reconstruction of oncologic hemipelvectomy defects.

Between 1990 and 2002, 76 patients underwent 102 muscle flap reconstructions for extremity sarcomas. The patients had radical resection with immediate reconstruction. Reconstructions were performed by the Musculoskeletal Oncology and Plastic Surgery services. The mean age of our patients was 39.1 years. Patients were studied for a mean of 25.4 months. There were 79 pedicle flaps and 23 free flaps. Complications occurred in 23.7% of patients, including wound necroses, seromas, postoperative bleeding, postoperative infections, and flap loss. Five patients required a secondary flap procedure. The overall flap survival rate was 98%. Three patients had local recurrences. Sixteen patients (21.1%) have died of their disease. Five patients are alive with metastases. In 54 patients, Musculoskeletal Tumor Society (MSTS) functional evaluation scores averaged 27.1 (range, 12–30). In this large series of patients, we have demonstrated that, although minor complications are common, functional limbs can be salvaged following oncologic resection from the extremities.

Simultaneous replantation of both lower legs in a child: a long-term result.

Background:Soft tissue and bony tumors of the pelvis are rare, but when they occur, treatment presents both an oncologic surgical and a reconstructive challenge. After reconstruction, soft tissue defects can be large and there is usually exposed bone and/or joint. A retroperitoneal abdominal wall defect may also be present. Flap mobilization is generally necessary to eliminate dead space and cover the exposed bone, viscera, and/or prosthetic orthopedic material. We performed immediate reconstruction on 11 patients after radical pelvic resections for tumor. Patients and Methods:Eleven cases of radical pelvic resection and immediate reconstruction were identified during the period from 1992 to 2002 at University Hospital, Newark, New Jersey. All patients were treated by both the orthopedic oncology and plastic surgery teams. A retrospective review of office charts and hospital records was performed. Data were gathered regarding the following: tumor type and oncologic history, extent of resection, reconstructive modality, complications, and outcome. Results:All patients underwent radical resection of pelvic masses depending on the tumor type and location. Tumor types included chondrosarcoma (6), Paget osteosarcoma (1), giant cell tumor (1), metastatic uterine carcinoma (2), and invasive squamous cell carcinoma arising in a chronic decubitus ulcer (1). The reconstructive procedures performed were the following: rectus abdominus flaps (6), gluteus maximus musculocutaneous flaps (3), and thigh fillet flaps (2). The retroperitoneal defects were repaired with primary tissue approximation of the surrounding available musculature. Additionally, Gore-Tex mesh was used in 2 cases, tensor fascia lata was used in 2 cases, and acellular dermal matrix in 1 case. Blood loss for the combined procedures ranged from 400 mL to 1400 mL. The follow-up period in this series ranged from 24 to 114 months. Complications included skin flap loss with subsequent infection (1), local cellulitis controlled with antibiotics (1), regional recurrence (2). The postoperative course was uneventful for the remainder of the cases. Conclusion:Soft tissue reconstructions after extensive pelvic resections always present as complex reconstructive problems. Reconstruction is dictated by the size of the defects and by tissue availability. The extent and type of resections vary according to tumor size and location. In our experience, local pedicled muscle-based flaps, if available, usually provide adequate tissue mass to eliminate dead space, cover the extent of the wound, and close the retroperitoneal defect. Microvascular tissue transfer is always an option but was reserved in our series for cases with no suitable local alternative.

Management of Complicated Wounds of the Extremities with Scapular Fascial Free Flaps

The progress of contemporary medicine and operative techniques makes it possible to successfully perform the simultaneous replantation of major segments of two extremities, especially in young patients, taking into consideration their high biologic potential. An adequate antishock management, hemotransfusion therapy in particular, at all stages of treatment is an indispensable condition of a favorable outcome of such operations. The method of lengthening the extremities using a distraction apparatus is rather promising for the improvement of functional results of replantations of major segments of the lower extremities. The use of this method makes it possible to broaden the scope of indications for such operations.

Examination of possible predictors of complications after free tissue transfer to the head and neck for oncologic defects.

Management of complicated open wounds of the extremities represents a reconstructive challenge. The goal of reconstruction is to provide coverage of exposed vital structures with well-vascularized tissues for optimal restoration of its form and function. We present our experience with the use of scapular fascial free flaps in the reconstruction of complicated open wounds of the extremities. During the period 2001 to 2009, a total of 12 reconstructions utilizing scapular fascial free flaps were performed: nine for upper extremity wounds and three for lower extremity wounds. Two flaps failed: in one case due to intractable vasospasm, in the other case due to lack of adequate recipient vessels. In the ten successful cases, good functional and aesthetic outcomes were achieved. Based on our experience, we conclude that the scapular fascial free flap, although technically demanding, could be considered as the flap of choice for reconstruction of complicated open wounds of the extremities; it provides ample thin and well vascularized soft tissue coverage with restoration of function and a natural contour of the extremity.

The radial forearm fasciocutaneous free flap for head and neck reconstruction: an examination of the effects of radiation therapy on outcomes.

IntroductionThe advent of vascularized free tissue transfer marked an incredible addition to the breadth of options available to the reconstructive surgeon when treating head and neck defects. The goal of this study is to determine if readily available laboratory tests may be used to stratify the risk for developing complications after free tissue transfer in specific patients. MethodsInstitutional review board approval was obtained for a retrospective chart review of all patients who underwent free tissue transfer for reconstruction of oncologic head and neck defects between 2001 and 2010 by the senior author (R.O.D.). ResultsThere were 107 free tissue transfers to the head and neck for oncologic defects during this period. A significant relationship was found between a preoperative hemoglobin less than 10 mg/dL and a postoperative albumin less than 2.5 mg/dL and complications. ConclusionsPreoperative hemoglobin less than 10 mg/dL and postoperative albumin less than 2.5 mg/dL seem to be useful as indicators of an increased likelihood of developing postoperative complications. Correction of these values preoperatively and postoperatively may lead to improved surgical outcomes.

Simultaneous replantation of both lower legs in a child: 23 years later.

for Head and Neck Reconstruction: An Examination of the Effects of Radiation Therapy on Outcomes Sir: F tissue transfer is a mainstay in head and neck reconstruction following surgical oncologic tumor resection. Perhaps one of the most versatile free flaps that exists for head and neck reconstruction is the radial forearm fasciocutaneous flap, which allows for a thin, pliable piece of tissue to be transferred on a long vascular pedicle with a reliable blood supply.1,2 The reasons for this versatility lie in the aforementioned features, specifically, a long vascular pedicle that allows anastomosis to be performed outside of the zone of resection that may involve irradiated tissues. After obtaining institutional review board approval, a retrospective review of all cases of radial forearm fasciocutaneous free flaps for reconstruction of oncologic head and neck defects performed by the senior author (R.O.D.) between 2001 and 2010 was conducted. The retrospective review returned 55 patients. Of this, 15 (27 percent) were women and 40 (73 percent) were men. The average age of the patients was 58 years (range, 31 to 80 years). The average size of the oncologic defect was 63.1 cm2 (range, 30 to 120 cm2). In total, there were three flap failures (5.5 percent). There were 25 other complications noted in addition to the flap failures. There were 12 complications related to the recipient site other than flap failures. Of the 55 patients, 23 (42 percent) underwent preoperative radiation therapy. A two-sample t test revealed no relationship between the size of the defect and whether or not there was a complication of any nature (p 0.32) or a complication at the recipient site (p 0.23). A relationship approaching significance was noted between preoperative radiation therapy and complications at the recipient site (p 0.052) (Fig. 1). The management of oral and airway malignancies is controversial, with radiation therapy and surgery being the favored options. In general, lower grade malignancies are regarded as better treated through radiation therapy alone, whereas higher grade malignancies are treated with surgery. This paradigm presents a problem when surgery is indicated following either failed radiation therapy or recurrent disease after radiation therapy. The competency of the vasculature in the region of the defect is often of concern following radiation therapy. Free flaps to the head and neck have been shown to be adversely affected by radiation therapy.3 Interestingly, in our review, there was no relationship found between preoperative radiation and the occurrence of complications. This may be explained by the extremely long pedicle that is possible with the radial forearm flap that provides the opportunity to bring the site of anastomosis for both the vein and artery away from the field of preoperative radiation and oncologic resection. In general, the vessels outside of this area are likely to be healthier and more suitable for microvascular anastomosis. This is especially important given that this patient population tends to be advanced in age and may suffer from concomitant peripheral vascular disease. Varying degrees of atherosclerosis were noted in each patient in this series. The radial forearm fasciocutaneous free flap remains a reliable and relatively easy flap to use for reconstruction of head and neck oncologic defects. Preoperative radiation therapy does not appear to affect the rate of complications following reconstruction with this flap. The flap’s long pedicle allows for the site of anastomosis to be placed outside the area of tissue damage. DOI: 10.1097/PRS.0b013e31823af059

Biobrane in the management of critical microsurgical wounds of the upper extremity

Function is the single most important determinant in the assessment of the results of extremity replantations. Accordingly, the indications for extremity replantations are based on the prediction of sustained satisfactory functional outcome. There are limited reports in the literature regarding replantations of major segments of lower extremities and, particularly, long-term results of those surgeries. However, this analysis is extremely important in refinement of indications for major limb replantations. In this article, evaluation of a patient 23 years after simultaneous replantation of both lower legs is presented.