Robert M. Pearl

Experience with the temporoparietal fascial free flap

The temporoparietal fascia is an ideal tissue source for free transfer to distant sites where ultrathin coverage is either desirable or mandatory. The fascias dependable vascular anatomy facilitates the technical aspects of microvascular transfer by means of its large vessels, ample pedicle, and ability to be grafted on either side. Furthermore, this highly vascular tissue is available in surprisingly large quantities, and its donor scar is hidden in the hair. The authors have found this flap useful (1) in covering exposed bone and tendon without adding unwanted bulk, (2) in providing thin flap coverage or lining in major facial reconstruction, (3) in covering vital structures such as exposed nerves and vessels, (4) in providing neovascularity both as a recipient graft bed and for control of chronic infection, and (5) in reestablishing gliding-tendon mechanisms. The authors have successfully employed this free flap in 15 cases which involved deformities of the ankle, foot, Achilles tendon, forearm, hand, nose, and contralateral ear and scalp. Seven cases are utilized to illustrate the broad application of this unique and versatile free flap.

The Vascular Supply to the Skin: An Anatomical and Physiological Reappraisal—part Ii

The subcutaneous vascular system demonstrated in the first part of this study augments skin flap survival when included within human abdominal flaps. Flaps with larger subcutaneous vessels will survive to a greater length than flaps supplied solely by the subdermal plexus. Knowledge of the subcutaneous vascular system is applicable to breast reduction, subcutaneous mastectomy, and abdominal lipectomy.

A unifying theory of the delay phenomenon--recovery from the hyperadrenergic state.

Flap necrosis occurs from a combination of reduced blood supply--a result of transection of the feeding vessels--and vasoconstriction. The vasoconstriction is secondary to the hyperadrenergic state that follows transection of the sympathetic nerves accompanying the vascular supply to the flap. A flap that has undergone surgical delay has had its stored neurotransmitter, norepinephrine, released and cleared from the tissues. At the time of the flap transfer, therefore, the hyperadrenergic condition does not reappear and the vascular flow is greater than in an undelayed flap.

Breast reconstruction following lumpectomy and irradiation.

The traditional approach to breast cancer has been the surgical mastectomy. The cosmetic deformity resulting from this procedure has led to the development of our current methods of breast reconstruction. The inherent attraction of lumpectomy and radiotherapy has been its equation with improved cosmesis. This procedure may be an effective alternative to surgery from the cancer perspective and does produce, in the majority of patients, an acceptable cosmetic result. However, this paper demonstrates that it may produce a result that is less optimal than mastectomy with postoperative breast reconstruction. The etiology of the increased deformity can either be the localized lumpectomy with marked internal derangement of breast volume or the radiation therapy itself. In addition, those who develop a combination require a solution to both. We describe three patients who illustrate these problems and believe that a greater awareness of these potential complications should be available to aid patients in choosing their cancer treatment.

Surgical management of volumetric changes in the bony orbit

This article demonstrates that the periorbital fat, instead of being continuous and freely flowing, is encased within 3 compartments: 1 anterior to the extraocular muscles, 1 external to the extraocular muscles, and 1 deep to the extra-ocular muscles. In addition, the study establishes that fat loss anterior to the axis of the globe does not affect the anteroposterior location of the eye itself. Only fractures located posterior to the axis produce enophthalmos, and only operative procedures that create bony enlargement and fatty displacement behind this axis correct exophthalmos. Furthermore, only adding volume behind the axis of the globe can correct enophthamos. Finally, if there is sufficient space between the top of the globe and the bony roof, volume additions at the axis of the globe can correct vertical dystopia without producing exophthalmos.

The Radial Forearm Flap: A Versatile Source of Composite Tissue

The radiovolar area of the forearm constitutes a versatile source of composite tissues for pedicle flap reconstruction of the hand and free-flap reconstruction for many areas of the body. The skin is thin and relatively hairless, and the vascular pedicle is long and of large caliber. The flap can be harvested to contain vascularized tendons and bone. The skin can be reliably reinnvervated. The principal disadvantage, that this is a conspicuous donor site, has not been a source of concern for our patients. Nineteen of the 20 (95%) free flaps survived completely.

An arterial medial arm flap--vascular anatomy and clinical applications.

We describe the vascular distribution to the skin of the arm as determined by cadaver dye injections and anatomical dissection. The superior ulnar collateral cutaneous artery provides a direct cutaneous branch that supplies the proximal two-thirds of the medial arm. An arterialized flap from the medial arm is very thin, elastic, and hairless--therefore excellent for hand resurfacing and facial reconstruction. Five examples of the use of arm skin from 21 patients using local and distant flaps are shown. The indications, methods, and anatomical bases for flap delay are detailed. The Doppler flow meter is used to determine artery position.

Efficacy of immobilization following aspiration of carpal and digital ganglions

In a prospective study 69 carpal and digital ganglions were aspirated, multiply punctured, and digitally ruptured. Fifty percent of the wrists and digits were immobilized for 3 weeks and 50% were mobilized early. Follow-up was 1 year. Immobilization in our study did not significantly improve the results of treatment. During the course of the study, 51% of all ganglions did not recur. The outcome was successful in 52% of the wrists and digits that were immobilized and in 50% of those that were not. Forty-six percent of the dorsal carpal ganglions did not recur. Treatment was successful in 48% of dorsal carpal ganglions in which the wrists were immobilized and in 45% of those that were not. Similar percentages were found for palmar and digital ganglions. From our results, we conclude that immobilization does not significantly improve the successful treatment of ganglions over perforation and aspiration alone.

A comparative analysis of the ability of five classes of pharmacological agents to augment skin flap survival in various models and species: an attempt to standardize skin flap research.

There is a myriad of research in the pharmacological manipulation of skin flap survival. However, skepticism exists as to whether any of these drugs is clinically useful. We evaluated the efficacy of five categories of agents in improving skin flap survival in five different rat flap models. Diltiazem, isoxsuprine hydrochloride, nitroglycerin, prazosin hydrochloride (two doses), and methyldopa were compared in a double-blind, randomized fashion. Their benefits were assessed in a musculocutaneous flap, axial flap, and three types of random flaps. The “best” drug was determined to be nitroglycerin. Its efficacy was verified in a primate model.

The effect of increased plastic surgeon supply on fees for aesthetic surgery: an economic analysis.

The size of the plastic surgery workforce has important effects on the financial environment of the specialty. Economic theory predicts that increasing the area supply of surgeons performing aesthetic surgery will result in lower fees for their services. This study tested that theory in the actual aesthetic surgery marketplace. The study examined the ratio of plastic surgeons to the general population of several states. It then traced the aesthetic surgery fees resulting from different densities of area plastic surgeons. This information was economically analyzed to project the fee effects of possible future changes in the number of practicing plastic surgeons. For the states of New York, California, and Texas, there is a proportional decrease in fees as the density of plastic surgeons increases. For example, New York has 34 percent more plastic surgeons proportionally than Texas, and its fees are 30 percent lower in real dollars. Economic analysis can project the fee effects of changing the supply of surgeons performing aesthetic surgery. The analysis reveals that a 30 percent national increase in the supply of plastic surgeons would lower fees by approximately 32 percent. Similarly, if the number of plastic surgeons increases by 50 percent, fees will decrease by approximately 53 percent. However, these fee effects can be mitigated by expanding the demand for aesthetic surgery. In conclusion, the size of the plastic surgery workforce has profound effects on the fees paid for aesthetic surgery, and the magnitude of these effects can be understood, predicted, and optimized using the tools of economics.