Roger K. Khouri

a Prospective Study of Microvascular Free-flap Surgery and Outcome

&NA; Over a 6‐month period, 23 members of the International Microvascular Research Group participated in a prospective survey of their microvascular free‐flap practice. Data were recorded with each case for 60 variables covering patient characteristics, surgical technique, pharmacologic treatment, and postoperative outcome. A total of 493 free flaps were reported with a representative demographic distribution for age, sex, indications for surgery, risk factors, flap type, surgical technique, and pharmacologic intervention. Mixed effects logistic regression modeling was used to determine predictors of flap failure and associated complications. The overall incidence of flap failure was 4.1 percent (20 of 493). Reconstruction of an irradiated recipient site and the use of a skin‐grafted muscle flap were the only statistically significant predictors of flap failure, with increased odds of failure of 4.2 (p = 0.01) and 11.1 (p = 0.03), respectively. A postoperative thrombosis requiring re‐exploration surgery occurred in 9.9 percent of the flaps. The incidence of this complication was significantly higher when the flap was transferred to a chronic wound and when vein grafts were needed, with increased odds of failure of 2.9 (p = 0.02) and 2.5 (p = 0.02), respectively. There was a lower incidence of postoperative thrombosis when rectus/transverse rectus abdominis muscle (TRAM) flaps were used, where odds of failure decreased by 0.36 (p = 0.04), and when subcutaneous heparin was administered in the postoperative period, where odds decreased by 0.27 (p = 0.04). There was an overall 69‐percent salvage rate for flaps identified with a postoperative thrombosis. Intraoperative thrombosis occurred in 41 cases (8.3 percent) and was observed more frequently in myocutaneous flaps or when vein grafts were needed (5.5 and 5.0 greater odds, respectively; p < 0.001) but was not associated with higher flap failure (2 of 41 cases; 4.9‐percent failure rate). The incidence of a hematoma and/or hemorrhage was increased in obese patients and when vein grafts were needed [2.7 (p = 0.02) and 2.6 (p = 0.03) greater odds, respectively], whereas this complication was significantly decreased in muscle flaps (myocutaneous or skin‐grafted muscle), in tobacco users, when a heparinized solution was used for general wound irrigation, and when the attending surgeon performed the arterial anastomosis (in contrast to the resident or fellow on staff) (p < 0.05 for each factor). With the multivariable analysis, many factors were found not to have a significant effect on flap outcome, including the recipient site (e.g., head/neck, breast, lower limb, etc.); indications for surgery (trauma, cancer, etc.); flap transfer in extremes of age, smokers, or diabetics; arterial anastomosis with an end‐to‐end versus end‐to‐side technique; irrigation of the vessel without or with heparin added to the irrigation solution; and a wide spectrum of antithrombotic drug therapies. These results present a current baseline for free‐flap surgery to which future advances and improvements in technique and practice may be compared. (Plast. Reconstr. Surg. 102: 711, 1998.)

Reconstruction of the lower extremity with microvascular free flaps: a 10-year experience with 304 consecutive cases.

A retrospective review of 304 consecutive microvascular free flaps to the lower extremity was done to identify the patterns of usage, results, and problems. The most common indication (91%) was for the replacement of extensive tissue loss caused by motor-vehicle injuries. Most of the defects were below the mid-tibia (73%). The associated compound fractures were predominantly gradable as Gustilo type IIIb&c. The latissimus dorsi, the rectus abdominus, and the scapular skin were the flaps used most commonly for coverage (77%). The overall flap failure rate was 8%, compared with 3% for our series of non-lower extremity cases, and 0% for the non-traumatic lower extremity cases. The magnitude of the traumatic insult was the most significant factor associated with anastomotic failure. The rate of anastomotic thrombosis doubled in the presence of vascular trauma, increased threefold in the presence of larger bony defects, and increased fivefold when vein grafts were needed. Experience was important in reducing the complications and improving the results. Fourteen patients (6%) underwent an amputation within the first 3 months, ten of them because of flap failure. Of 85 patients followed up for over one year, 91% had recovered good to excellent leg function. The ability to add healthy and well vascularized tissue to the traumatized limb is critical for the achievement of: 1) early definitive wound healing and restoration of function; 2) salvage of many impending amputations; 3) better prosthetic stump reconstructions; 4) better esthetic results.

Brava and Autologous Fat Transfer Is a Safe and Effective Breast Augmentation Alternative: Results of a 6-year, 81-patient, Prospective Multicenter Study

Background: Breast augmentation by autologous fat transfer is an appealing alternative in need of scientific validation. Methods: In a prospective multicenter study, 81 women (age range, 17 to 63 years) wore the Brava device, a bra-like vacuum-based external tissue expander, for 4 weeks and then underwent autologous fat injection using 10 to 14 needle puncture sites into each breast in a three-dimensional fanning pattern (average, 277 ml volume injected per breast). Patients resumed Brava wear within 24 hours for 7 or more days. Pretreatment and posttreatment breast volumes were derived from three-dimensional volumetric reconstruction of magnetic resonance imaging scans, and outcomes were compared with a meta-analysis of six recent published reports on autologous fat transfer breast augmentation without expansion. Follow-up ranged from 12 months to 6 years (average, 3.7 years). Results: Breast volume was unchanged between 3 and 6 months. Seventy-one of the treated women were compliant with Brava wear and had a mean augmentation volume at 12 months of 233 ml per breast compared with 134 ml per breast in published series without Brava (p < 0.00001). Graft survival was 82 ± 18 percent compared with 55 ± 18 percent without Brava (p < 0.00001). There was a strong linear correlation (R 2 = 0.87) between pregrafting Brava expansion and the resultant breast augmentation. There were no suspicious breast masses or nodules. Magnetic resonance imaging recognized a 16 percent incidence of fat necrosis easily identified at 1-year mammographic evaluation. Conclusion: The addition of Brava expansion before autologous fat grafting leads to significantly larger breast augmentations, with more fat graft placement, higher graft survival rates, and minimal graft necrosis or complications, demonstrating high safety and efficacy for the procedure. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Prefabrication of composite free flaps through staged microvascular transfer : an experimental and clinical study

The feasibility of prefabricating free flaps by inducing, through the process of staged reconstruction, an arteriovenous bundle and its surrounding fascia to perfuse a selected block of tissue was investigated experimentally and clinically. Sixteen rat knee joints were wrapped with their ipsilateral superficial inferior epigastric (SIE) fascia. In 8 joints, the composite flaps were resected en bloc and were immediately replaced orthotopically pedicled upon the superficial inferior epigastric vessels. In the remaining joints, the resection and orthotopic transfer were performed 2 weeks later. Only the joints in the latter group, which benefited from the staging period, were found to be perfused. The long finger proximal interphalangeal joint of a child was reconstructed by the staged microvascular transfer of his second toe proximal interphalangeal joint. At the first stage, a temporalis fascia flap was wrapped around the toe proximal interphalangeal joint and revascularized to the dorsalis pedis vessels. Six weeks later, the joint and its temporalis fascia envelope were dissected, and the “prefabricated” joint flap was transferred to the hand and revascularized to the wrist vessels. Bony union progressed uneventfully with excellent recovery of the range of motion. We conclude that regardless of the indigenous vascular anatomy, an unlimited array of composite free flaps can be constructed and transferred based on induced large vascular pedicles.

Repair of calvarial defects with flap tissue: Role of bone morphogenetic proteins and competent responding tissues

Bone morphogenetic proteins 2 through 8 have the ability to induce the in vivo transformation of extraskeletal mesenchymal tissue into bone. The aims of this investigation were to determine the optimal responding tissue and the specificity of the inductive effect of bone morphogenetic protein 3. The optimal responding tissue was found to be skeletal muscle. The specificity of this response to bone morphogenetic protein 3 was compared with that of recombinant human basic fibroblast growth factor, recombinant platelet-derived growth factor, and recombinant insulin-like growth factor. Bone morphogenetic protein 3 was the only factor that induced de novo bone formation. This ability to transform muscle into bone was tested in 7 x 7 mm irradiated skull defects in the rat. After 1500 rads of exposure, these defects showed no significant signs of healing by 8 months. When these defects were treated with the microvascular transfer of a nonirradiated muscle flap, they had 8 percent healing at 4 months and 37 percent healing by 8 months. Defects treated with 30 micrograms bone morphogenetic protein 3 (without the muscle flap) achieved 50 percent healing by 4 months and 64 percent healing by 8 months. When the defects were treated with both the muscle flap and bone morphogenetic protein 3, there was 96 percent healing by 4 months and 100 percent healing by 8 months (p < 0.015, compared with bone morphogenetic protein 3 alone at both time points). At 8 months, the transplanted muscle was entirely transformed into bone and healed the skull defect with newly generated bone indistinguishable from the surrounding calvarial tissue. These findings suggest a potential clinical utility of bone morphogenetic protein 3-induced bone formation in skeletal reconstructions. Furthermore, they also show that there is a collaborative requirement for both the osteoinductive factor bone morphogenetic protein 3 and the presence of competent responsive cells in the well-perfused muscle.

Monitoring of Free Flaps with Surface-Temperature Recordings: Is It Reliable?

Surface-temperature recording (STR) is one of the oldest and simplest methods of postoperative monitoring of free flaps. Its usefulness, however, remains poorly documented, and its problems, not well understood. To assess its value, we reviewed our series of 600 consecutive free flaps where surface-temperature recording was the main method of monitoring used and a detailed temperature record was kept. Seventy flaps suffered a postoperative microvascular compromise necessitating a surgical reexploration. Of these, 62 charts were satisfactory for review and were matched with 62 charts from similar but uncomplicated flaps. The derived value CΔT, which represents the change in temperature difference (ΔT) between flap and control sites over a specified time period, was calculated at each time point. Of 10,000 derivations, only once did CΔT > 1.8°C fail to identify a microvascular thrombosis, and 17 times a false alarm was given. Therefore, when properly applied and interpreted, the sensitivity of surface-temperature recording is 98 percent, and its predictive value is 75 percent, making it a simple, inexpensive, and highly reliable technique of free-flap monitoring. The thermodynamics behind surface-temperature recording is reviewed, pointing out the pitfalls that have to be avoided in order to improve the reliability of this technique.

Nonsurgical breast enlargement using an external soft-tissue expansion system.

Less than 1 percent of the women interested in having larger breasts elect to have surgical augmentation mammaplasty with insertion of breast implants. The purpose of this report is to describe and test the efficacy of a nonsurgical method for breast enlargement that is based on the ability of tissues to grow when subjected to controlled distractive mechanical forces. Seventeen healthy women (aged 18 to 40 years) who were motivated to achieve breast enlargement were enrolled in a single-group study. The participants were asked to wear a brassiere-like system that applies a 20-mmHg vacuum distraction force to each breast for 10 to 12 hours/day over a 10-week period. Breast size was measured by three separate methods at regular intervals during and after treatment. Breast tissue water density and architecture were visualized before and after treatment by magnetic resonance imaging scans obtained in the same phase of the menstrual cycle. Twelve subjects completed the study; five withdrawals occurred due to protocol noncompliance. Breast size increased in all women over the 10-week treatment course and peaked at week 10 (final treatment); the average increase per woman was 98 ± 67 percent over starting size. Partial recoil was seen in the first week after terminating treatment, with no significant further size reduction after up to 30 weeks of follow-up. The stable long-term increase in breast size was 55 percent (range, 15 to 115 percent). Magnetic resonance images showed no edema and confirmed the proportionate enlargement of both adipose and fibroglandular tissue components. A statistically significant decrease in body weight occurred during the course of the study, and scores on the self-esteem questionnaire improved significantly. All participants were very pleased with the outcome and reported that the device was comfortable to wear. No adverse events were recorded during the use of the device or after treatment. We conclude that true breast enlargement can be achieved with the daily use of an appropriately designed external expansion system. This nonsurgical and noninvasive alternative for breast enlargement is effective and well tolerated.

The effect of basic fibroblast growth factor on the neovascularisation process: skin flap survival and staged flap transfers

Forty-two male Sprague-Dawley rats were utilised to determine whether the angiogenic property of basic fibroblast growth factor (bFGF) could be applied to improve the survival of the ischaemic portion of a random skin flap and to accelerate the process of staged flap transfer. In the ischaemic flap model, bFGF enhanced the development of vascular connections between the bed and the flap and prevented marginally perfused areas from undergoing necrosis. No effect was observed in the staged reconstruction model using the same dosage of bFGF. A speculative explanation is given for the differential effect of BFGF in these two models. The application of angiogenic factors may improve the survival of the random portion of skin flaps. Further investigations are needed to determine whether exogenously applied angiogenic factors can have a beneficial effect in staged flap reconstructions.

Extensive percutaneous aponeurotomy and lipografting: A new treatment for dupuytren disease

Background: Surgical resection of Dupuytren contracture is fraught with morbidity and prolonged recovery. This article introduces a novel minimally invasive alternative for Dupuytren disease and its outcome. Methods: The procedure consists of an extensive percutaneous aponeurotomy that completely disintegrates the cord and separates it from the dermis. Subsequently, the resultant loosened structure is grafted with autologous lipoaspirate. After 1 week of postoperative extension splinting, patients are allowed normal hand use and are advised to use night splints for 3 to 6 months. The authors treated and report on their experience with 91 patients (99 hands) operated on in Miami and Rotterdam; from 50 patients, the authors report on goniometry (average follow-up, 44 weeks). Results: The contracture from the proximal interphalangeal joint improved significantly from 61 degrees to 27 degrees, and contracture from the metacarpophalangeal joint improved from 37 degrees to –5 degrees. Ninety-four percent of patients returned to normal use of the hand within 2 to 4 weeks and 95 percent were very satisfied with the result. No new scars were added, and a supple palmar fat pad was mostly restored. Complications were digital nerve injury in one patient, postoperative wound infection in one patient, and complex regional pain syndrome in four patients. Conclusions: This new minimally invasive technique shortens recovery time, adds to the deficient subcutaneous fat, and leads to scarless supple skin. By its ability to treat multiple rays, it addresses the abnormality in the entire hand. The procedure is safe and effective, especially for primary cases. Currently, comparative prospective randomized studies are in process to fully determine its role in the treatment of Dupuytren contracture. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV. Figure. No caption available.

Facial reconstruction with prefabricated induced expanded (PIE) supraclavicular skin flaps.

The prefabricated induced expanded (PIE) supraclavicular flap refers to the staged transfer of an expanded supraclavicular skin with a fascia flap used as the carrier. In three patients, we utilized PIE supraclavicular flaps to successfully reconstruct a total forehead and two major nasal defects. Our first PIE flap confirmed the feasibility of the method but necessitated two microvascular free flaps. In the ensuing two patients, we reduced the need for microvascular anastomoses by using simple pedicled flap transfers in either or both stages. Whenever feasible, the preferred method consists of transferring a temporoparietal fascia flap to a subcutaneous pocket in the ipsilateral supraclavicular fossa and simultaneously placing a skin expander under both the fascia flap and the supraclavicular skin. After adequate expansion, the fascia becomes incorporated within the capsule of the expander, and the composite capsulofasciocutaneous flap can be safely transferred to the facial defect as the PIE flap. These patients show that supraclavicular PIE flaps can provide ample amounts of vascularized cutaneous tissue for the reconstruction of major facial defects. The necessary tissue is generated by expanding the most desirable tissue type available, and a selected vascular pedicle is induced to perfuse and carry that generated tissue. Compared with conventional expansion and adjacent flap transfers, PIE flaps allow the transfer of expanded skin to distant sites as island or free flaps perfused by the induced vascular pedicles. (Plast. Reconstr. Surg. 95: 1007, 1995.)