Showing papers in "Annals of Plastic Surgery in 2007"

Lymphedema: a comprehensive review.

Abstract: Background: Lymphedema is a chronic, debilitating condition that has traditionally been seen as refractory or incurable. Recent years have brought new advances in the study of lymphedema pathophysiology. as well as diagnostic and therapeutic tools that are changing this perspective. Objective: To provide a systematic approach to evaluating and managing patients with lymphedema. Methods: We performed MEDLINE searches of the English-language literature (1966 to March 2006) using the terms lymphedema, breast cancer-associated lymphedema, lymphatic complications, lymphatic imaging, decongestive therapy, and surgical treatment of lymphedema. Relevant bibliographies and International Society of Lymphology guidelines were also reviewed. Results: In the United States, the populations primarily affected by lymphedema are patients undergoing treatment of malignancy, particularly women treated for breast cancer. A thorough evaluation of patients presenting with extremity swelling should include identification of prior surgical or radiation therapy for malignancy, as well as documentation of other risk factors for lymphedema, such as prior trauma to or infection of the affected limb. Physical examination should focus on differentiating signs of lymphedema from other causes of systemic or localized swelling. Lymphatic dysfunction can be visualized through lymphoscintigraphy; the diagnosis of lymphedema can also be confirmed through other imaging modalities, including CT or MRI. The mainstay of therapy in diagnosed cases of lymphedema involves compression garment use, as well as intensive bandaging and lymphatic massage. For patients who are unresponsive to conservative therapy; several surgical options with varied proven efficacies have been used in appropriate candidates, including excisional approaches, microsurgical lymphatic anastomoses, and circumferential suction-assisted lipectomy, an approach that has shown promise for long-term relief of symptoms. Conclusions: The diagnosis of lymphedema requires careful attention to patient risk factors and specific findings on physical examination. Noninvasive diagnostic tools and lymphatic imaging can be helpful to confirm the diagnosis of lymphedema or to address a challenging clinical presentation. Initial treatment with decongestive lymphatic therapy can provide significant improvement in patient symptoms and volume reduction of edematous extremities. Selected patients who are unresponsive to conservative therapy can achieve similar outcomes with surgical intervention, most promisingly suction-assisted lipectomy. (Less)

Inferolateral AlloDerm hammock for implant coverage in breast reconstruction.

Abstract: Purpose:Implant reconstruction is commonly performed to reconstruct mastectomy defects or to correct breast hypoplasia. We have been using an inferolateral AlloDerm hammock as an inferior extension of the pectoralis major muscle to provide a mechanical barrier between the implant and skin and to con

Analysis of complications from abdominoplasty: a review of 206 cases at a university hospital.

Abstract: The number of abdominoplasties performed in the United States has been steadily increasing over the past decade. A large proportion of these patients are bariatric patients who remain obese despite prior weight-reduction surgery. This study was done to review the experience of patients undergoing abdominoplasty at a university hospital. A retrospective chart review of 206 consecutive patients was performed. The overall complication rate was 37.4%. Major complications [hematoma requiring surgical intervention, seroma requiring aspiration or surgical drainage, cellulitis or abscess requiring hospitalization and intravenous (IV) antibiotics, deep vein thrombosis (DVT), and pulmonary embolism (PE)] occurred in 16% of patients. The rate of minor complications (hematoma or seroma requiring no intervention, epidermolysis, small-wound dehiscence, neuropathic pain, and minor cellulitis) was 26.7%. Obese patients had a significantly increased risk of developing major complications as compared with nonobese patients (53.4% versus 28.8%, P = 0.001). An in-depth analysis of all complications and risk factors was done.

The pathogenesis of burn wound conversion.

Abstract: Objective:Burn wound progression is a poorly understood process by which certain superficial partial-thickness burns spontaneously advance into deep partial-thickness or full-thickness wounds. Progression of an injury into deeper tissue is an important phenomenon in the treatment of thermal injury d

Intraoperative lymphography using indocyanine green dye for near-infrared fluorescence labeling in lymphedema.

Abstract: A new method for easy detection of functional lymphatic vessels in the superficial layer is reported. In a clinical trial, lymphography using indocyanine green dye for near-infrared fluorescence labeling in lymphaticovenular anastomoses was performed in 5 patients with lymphedema. The technique is simple and enables a minimally invasive operation to be performed. The results indicate that this technique is useful for acceptance as one of the examinations to evaluation of lymphedema.

Novel lymphography using indocyanine green dye for near-infrared fluorescence labeling.

Abstract: Lymphedema is known to be caused by many pathologic conditions; however, its diagnostic and therapeutic strategies remain to be unestablished. In this study, we investigated the usefulness of a novel lymphographic method based on fluorometric sensing using indocyanine green (ICG) dye for imaging lymphatic vessels using rat models. The real-time imaging system enabled visualization of superficial lymphatic vessels with a diameter of 0.1 mm in 33 frames/second. In addition, morphologic changes in lymphatic vessels in a radiation-induced lymphedema model were detected even at the latent stage. These results suggest that this imaging technique is acceptable as an evaluation method for the lymphatic system.

Genital Sensitivity After Sex Reassignment Surgery in Transsexual Patients

Abstract: Background: Tactile and erogenous sensitivity in reconstructed genitals is one of the goals in sex reassignment surgery. Since November 1993 until April 2003, a total of 105 phalloplasties with the radial forearm free flap and 127 vaginoclitoridoplasties with the inverted penoscrotal skin flap and the dorsal glans pedicled flap have been performed at Ghent University Hospital. The specific surgical tricks used to preserve genital and tactile sensitivity are presented. In phalloplasty, the dorsal hood of the clitoris is incorporated into the neoscrotum; the clitoris is transposed, buried, and fixed directly below the reconstructed phallic shaft; and the medial and lateral antebrachial nerves are coapted to the inguinal nerve and to one of the 2 dorsal nerves of the clitoris. In vaginoplasty, the clitoris is reconstructed from a part of the glans penis inclusive of a part of the corona, the inner side of the prepuce is used to reconstruct the labia minora, and the penile shaft is inverted to line the vaginal cavity. Material and Methods: A long-term sensitivity evaluation (performed by the Semmes-Weinstein monofilament and the Vibration tests) of 27 reconstructed phalli and 30 clitorises has been performed. Results: The average pressure and vibratory thresholds values for the phallus tip were, respectively, 11.1 g/mm(2) and 3 mu m. These values have been compared with the ones of the forearm (donor site). The average pressure and vibratory thresholds values for the clitoris were, respectively, 11.1 g/mm(2) and 0.5 mu m. These values have been compared with the ones of the normal male glans, taken from the literature. We also asked the examined patients if they experienced orgasm after surgery, during any sexual practice (ie, we considered only patients who attempted to have orgasm): all female-to-male and 85% of the male-to-female patients reported orgasm. Conclusion: With our techniques, the reconstructed genitalia obtain tactile and erogenous sensitivity. To obtain a good tactile sensitivity in the reconstructed phallus, we believe that the coaptation of the cutaneous nerves of the flap with the ilioinguinalis nerve and with one of the 2 nerves of the clitoris is essential in obtaining this result. To obtain orgasm after phalloplasty, we believe that preservation of the clitoris beneath the reconstructed phallus and some preservation of the clitoris hood are essential. To obtain orgasm after a vaginoplasty, the reconstruction of the clitoris from the neurovascular pedicled glans flap is essential.

Management algorithm and outcome evaluation of partial mastectomy defects treated using reduction or mastopexy techniques.

Abstract: Background:Reconstruction of the partial mastectomy defect has become increasingly popular becaue of poor cosmetic results in select patients. The purpose of this series was to try to create a treatment algorithm based on patient selection, diagnosis, margins, and recurrence in an attempt to maintai

A critical review of perioperative complications in 175 free deep inferior epigastric perforator flap breast reconstructions.

Abstract: BACKGROUND: The purpose of this study was to critically evaluate the perioperative complications for deep inferior epigastric perforator (DIEP) flap breast reconstruction. METHODS: From February 2002 until February 2006, 175 consecutive abdominal free tissue breast reconstructions were performed in 131 patients. Perioperative risk factors and complications were evaluated for the entire group. Data analysis was performed to compare subsequent chronologic groups for a learning curve effect. RESULTS: In 159 cases (90.9%) a DIEP flap could be raised. In 13 cases (7.4%), a mini-TRAM flap and in 3 cases (1.7%) a regular free TRAM flap was harvested. A learning curve was found showing a risk for flap complications in the first 30 DIEP flaps of 40% and in flaps 31 to 175 of 13.8% (P < 0.012). Microsurgical revision rate was 4% (n = 7), with a total flap failure rate of 0.6% (n = 1). Partial flap failure rate was 8.6% (n = 15), which was solved by debridement, medial advancement, and direct closure in 6.8% (n = 12) and latissimus dorsi flap transposition in 1.8% (n = 3). Multivariate analysis showed no significant influence of risk factors on development of postoperative flap complications. CONCLUSION: DIEP flap breast reconstruction is an excellent method, with limited donor-site morbidity. A definite learning curve was reflected in a larger number of flap complications in the beginning of our series.

The effect of postoperative anticoagulation on microvascular thrombosis.

Abstract: Background:Numerous protocols exist to prevent thrombosis after free-tissue transfer. Many surgeons advocate using aspirin or other antiplatelet agents, but little objective evidence supports this practice. This study evaluates the rate of microvascular thrombosis in patients undergoing free-tissue

Utilization of human cadaveric acellular dermis for abdominal hernia reconstruction.

Abstract: Background: Incisional hernias with history of recurrence or infection remain a challenge, with high postoperative morbidity and recurrence rates. The purpose of this study is to evaluate outcomes of patients treated with human cadaveric acellular dermis as an adjunct to abdominal wall reconstruction. Methods: We retrospectively reviewed 39 abdominal wall reconstructions with human cadaveric acellular dermis performed in 37 patients and compared them with 39 randomly selected cases. Results: There is a significant decrease in recurrence rates when human cadaveric acellular dermis is added as an overlay to primary closure plus rectus muscle advancement and imbrication in patients with medium-sized hernias. No differences were observed when adding human cadaveric acellular dermis as an overlay to patients with large-size hernias treated with underlay mesh. The use of human cadaveric acellular dermis did not increase postoperative morbidity rates. Conclusions: Improved results with human cadaveric acellular dermis are obtained by achieving tension-free repairs.

Postoperative radiation protocol for keloids and hypertrophic scars: statistical analysis of 370 sites followed for over 18 months.

Abstract: Background Before 2002, keloids and intractable hypertrophic scars were treated at our facility with postoperative irradiation of 15 Gy (the traditional protocol). Analysis of the therapeutic outcomes of patients treated with this protocol showed that the recurrence rates of keloids and intractable hypertrophic scars in the anterior chest wall, as well as the scapular and suprapubic regions, were statistically higher than at other sites, while the recurrence rates in earlobes were lower. Thus, we customized doses for various sites. This report describes our trial of postoperative radiation therapy. Methods Between January 2002 and September 2004, 109 patients with 121 keloid and intractable hypertrophic scar sites were treated with surgical excision following the new protocol: electron-beam irradiation at total doses of 10, 15, or 20 Gy, depending on the site. The recurrence rates and toxicities were historically followed in 218 patients with 249 keloid and intractable hypertrophic scar sites treated with the old protocol of surgical removal followed by irradiation at 15 Gy (without variation by site). The minimal follow-up time was 18 months. Statistical analysis was performed using Fisher exact probability test. Results Total recurrence rates were 29.3% before 2002 and 14.0% after 2003. The recurrence rate in the anterior chest wall was statistically reduced. Outcomes of earlobe did not differ between irradiation with 15 Gy or 10 Gy. Conclusions Keloids and intractable hypertrophic scars should be treated with dose protocols customized by site. Our results suggest that keloid and intractable hypertrophic scar sites with a high risk of recurrence should be treated with 20 Gy in 4 fractions over 4 days and that earlobe should be treated with 10 Gy in 2 fractions over 2 days.

The 180-degree perforator-based propeller flap for soft tissue coverage of the distal, lower extremity: a new method to achieve reliable coverage of the distal lower extremity with a local, fasciocutaneous perforator flap.

Abstract: Background:Traumatic and nontraumatic defects of the distal third of the tibia are challenging in regard to soft tissue coverage. While local, pedicled fasciocutaneous perforator flaps allow adequate coverage, the donor site often requires skin grafting. When a local perforator flap is designed as a

Facial attractiveness: visual impact of symmetry increases significantly towards the midline.

Abstract: Symmetry is thought to be a major prerequisite for an attractive face. Many faces are not symmetric, yet are still regarded as beautiful. What role, then, does asymmetry play in the perception of beauty? We studied the assessment of computer-manipulated images by independent judges (n = 200-250): part A: nevi located at different positions; part B: standardized changes of the orbital region. The results showed that slight lateral orbital and facial asymmetry does not impair attractiveness at all and that asymmetries close to the midline are significantly less attractive than those affecting the lateral aspect of the face (P < 0.001). A single nevus which is located laterally on the face is significantly more attractive than a nevus close to the midline (P < 0.001). Faces with a completely symmetric bilateral pair of nevi in the same lateral positions (perceived as attractive when alone), received the worst ratings (P < 0.001). Symmetry is a characteristic of the attractive face, but there are exceptions to the rule. Under certain conditions symmetry can be completely unattractive. The visual impact of symmetry on the perception of beauty increases significantly when approaching the midline.

Nonlinear finite element simulations to elucidate the determinants of perforator patency in propeller flaps.

Abstract: The propeller-type flap design is increasingly used in reconstructive surgery for various regions of the body. To date, determinants of perforator patency when subjected to twisting have not been elucidated. We propose a simulation model to study parameters affecting perforator patency under such conditions. Nonlinear finite element procedure was used to simulate a perforator consisting of an artery and a vein with both ends fixed. A rigid body was attached to the top of the perforator for applying prescribed angular displacement. The effect of the following parameters on the pedicle patency was determined: (1) increasing angle of twist, (2) vessel stiffness, (3) vessel length, (4) diameter, (5) intraluminal pressure, and (6) the presence or absence of blood flow during twisting. Simulation results were reported in effective stress and strain on the twisted pedicle. In the context of perforator patency, effective strain, which is a measure of vessel deformation or collapse, is the more relevant outcome. The vein was more prone to occlusion because of its weaker wall and lower intraluminal pressure. Four factors that affected perforator patency were identified: angle of twist, intraluminal blood pressure, and perforator diameter and length. There was no significant difference whether twisting was performed prior to or after restoration of blood flow (P > 0.05). Therefore, to optimize condition for maintaining perforator patency, the angle of twist should be kept 30 mm in length. We found that the propeller flap is a feasible design. This study defined the determinants of perforator patency and will serve as a useful guide when performing such flaps.

The safety of silicone gel-filled breast implants: a review of the epidemiologic evidence.

Abstract: Few implantable medical devices have been studied for their safety more extensively than silicone gel-filled breast implants. We summarize the epidemiologic evidence on the safety of breast implants, most of which is drawn from large cohort studies with long-term follow-up. The topics addressed in this report include cancer, breast cancer detection, connective tissue disease, suicide, offspring effects, neurologic disease, implant rupture, and local perioperative complications and additional surgery. We conclude that the weight of the epidemiologic evidence does not support a causal association between breast implants and breast or any other type of cancer, definite or atypical connective tissue disease, adverse offspring effects, or neurologic disease. Women with breast implants do not present with more advanced stages of breast cancer or suffer impaired survival after breast cancer diagnosis. The only study to examine an actual incidence rate of breast implant rupture reported rupture-free survival of 98% at 5 years and 83%-85% at 10 years for newer "third-generation" implants. Future studies are needed to determine whether the consistently observed excess of suicide among women with implants reflects underlying psychiatric illness prior to breast augmentation surgery or other factors.

Bacterial colonization is of major relevance for high-grade capsular contracture after augmentation mammaplasty.

Abstract: Many studies indicate that subclinical bacterial colonization plays a pivotal role in capsular contracture. Nevertheless, it has not been clarified whether bacterial stimuli are only associated with high-grade (Baker III/IV) or low-grade (Baker I/II) capsular contractures. The study included 45 female patients suffering from unilateral capsular fibrosis following augmentation mammaplasty with silicone implants (smooth: n = 28; textured: n = 17). In total, there were 16 (35.6%) bacterially contaminated swabs. No significant difference could be detected between colonization rates of smooth (52.9%) and textured (25.0%) implants (z = 1.575, P = 0.115). Interestingly, no colonization was detected for Baker I/II contractures, but the colonization rate for Baker III/IV contractures amounted to 66.7%, showing a highly significant difference between the 2 groups (z = 4.351, P < 0.001). Our study shows significant differences in bacterial contamination rates between high-grade and low-grade capsular contractures. One might speculate that bacterial stimuli accelerate the process of inflammation and fibrosis in patients who tend to develop capsular fibrosis.

Comparison of craniofacial measurements of young adult African-American and North American white males and females.

Abstract: Surgical correction of craniofacial disfigurements depends for its success on precise knowledge of the craniofacial norms of the patient's racial/ethnic groups. The norms of North American whites should be restricted to patients of Caucasian origin and not applied to members of other races. This study therefore sought to determine differences in anthropometric measurements of the craniofacial complex between African-American and North American white subjects of both sexes and of similar age (18-25 years old). The study group consisted of healthy young adult African-Americans, 50 males and 50 females. The analysis of craniofacial morphology was based on 51 anthropometric measurements: 9 cranial, 10 facial, 8 orbital, 14 nasal, 4 oral and 6 auricular. The results were compared with 51 norms previously established for North American whites in the same age group, generally based on 109 males and 200 females, fewer in comparisons of some nasal measurements (ac-ac, sbal-sbal, ac-sn, nostril axis). Highly significant differences between groups were found in every craniofacial region, especially in the orbital and nasal areas, and confirmed the need to establish separate norms for African-Americans to guide corrective surgery of the head and face.

The fate of lower extremities with failed free flaps: a single institution's experience over 25 years.

Abstract: Background: Lower-extremity reconstruction with microvascular free flap coverage is often the only option for limb salvage. Flap failure rates, however, continue to have higher complication rates than those to other anatomic sites; a significant number of flaps that fail result in amputation. This study retrospectively analyzed patients treated at a single institution who underwent attempted lower-extremity limb salvage with microsurgical techniques over a 25-year period. Of particular interest are the outcome data for patients who had initial free flap failure. Patients and Methods: A prospectively maintained database was used to identify patients who satisfy criteria. Every patient who was treated with a microvascular free flap to their lower extremities was identified and included in this analysis. All records were reviewed from 1980 through 2004. Patients who had free flaps to the lower extremity fail after the initial operation were identified and selected for further analysis. Results: Five hundred eighty-eight patients who underwent microsurgical reconstruction of lower extremity wounds had a failure rate of 8.5%. Trauma patients (83%) had a failure rate of 9%. On subset analysis, the failure rate for trauma patients decreased from 11% (1980-1992) to 3.7% (1993-2004). Of patients who had a failed free flap, 18% went on to limb amputation; the remainder was salvaged with secondary free flaps, local flaps, or skin grafting. Conclusion: This single institutional experience spanning 25 years represents the longest continual series of lower-extremity free flaps reported in the literature. The improved success rate seen in the second half of the study period is attributed to a more critical selection of free-flap candidates, improved understanding of the physiology surrounding acute trauma and a more sophisticated multidisciplinary team organization.

The use of bioimpedance analysis to evaluate lymphedema.

Abstract: Background Lymphedema, a chronic disfiguring condition resulting from lymphatic dysfunction or disruption, can be difficult to accurately diagnose and manage. Of particular challenge is identifying the presence of clinically significant limb swelling through simple and noninvasive methods. Many historical and currently used techniques for documenting differences in limb volume, including volume displacement and circumferential measurements, have proven difficult and unreliable. Bioimpedance spectroscopy analysis, a technology that uses resistance to electrical current in comparing the composition of fluid compartments within the body, has been considered as a cost-effective and reproducible alternative for evaluating patients with suspected lymphedema. Patients and methods All patients were recruited through the Beth Israel Deaconess Medical Center Lymphedema Clinic. A total of 15 patients (mean age: 55.2 years) with upper-extremity or lower-extremity lymphedema as documented by lymphoscintigraphy underwent bioimpedance spectroscopy analysis using an Impedimed SFB7 device. Seven healthy medical students and surgical residents (mean age: 26.9 years) were selected to serve as normal controls. All study participants underwent analysis of both limbs, which allowed participants to act as their own controls. The multifrequency bioimpedance device documented impedance values for each limb, with lower values correlating with higher levels of accumulated protein-rich edematous fluid. Results The average ratio of impedance to current flow of the affected limb to the unaffected limb in lymphedema patients was 0.9 (range: 0.67 to 1.01). In the control group, the average impedance ratio of the participant's dominant limb to their nondominant limb was 0.99 (range: 0.95 to 1.02) (P = 0.01). Conclusions Bioimpedance spectroscopy can be used as a reliable and accurate tool for documenting the presence of lymphedema in patients with either upper- or lower-extremity swelling. Measurement with the device is quick and simple and results are reproducible among patients. Given significant limitations with other methods of evaluating lymphedema, the use of bioimpedance analysis may aid in the diagnosis of lymphedema and allow for tracking patients over time as they proceed with treatment of their disease.

Postoperative seroma formation in breast reconstruction with latissimus dorsi flaps: a retrospective study of 174 consecutive cases.

Abstract: :The latissimus dorsi flap has been widely used in breast reconstruction surgery. Despite its potential advantages such as low donor morbidity and vascular reliability, the complication of donor-site seroma formation frequently occurs. Consecutive 174 patients who underwent breast reconstruc

Correction of hemifacial atrophy with autologous fat transplantation.

Abstract: Background: Autologous fat transplantation has frequently been used by many surgeons for facial recontouring in esthetic patients, with good long-term results. However, this technique has not been used primarily in treating patients with hemifacial atrophy, and its efficacy and long-term outcome remain unknown. Methods: In a 7-year period, 31 patients with hemifacial atrophy were treated with autologous fat transplantation in our institution. All patients had been in their stable phase of the disease for at least 1 year. Autologous fat grafts were harvested from the lower abdomen or thigh with our preferred low-pressure syringe technique and then spun at the lower speed. The fat grafts were injected into multiple areas in multiple tissue planes and tunnels to the diseased side of the face. The same procedure was repeated once or twice as necessary after each injection in at least 3 months. All patients were followed up to 5 years, and their outcomes were evaluated by the patients, plastic surgeons, and laypersons separately. Results: Obviously improved facial contour was evident in most patients after autologous fat transplantations. More than 65% of the patients in this series were assessed as satisfactory by all 3 groups. Between 10% and 30% of the patients were mostly satisfactory. Only less than 7% of the patients were unsatisfactory. No complications were seen in either donor sites or recipient sites in this series. Conclusions: Autologous fat transplantation can be a good treatment of choice for patients with hemifacial atrophy.

The versatility of the distally based peroneus brevis muscle flap in reconstructive surgery of the foot and lower leg.

Abstract: Soft tissue and bone defects of the lower leg, ankle, and heel region often require coverage by local or distant flaps The authors successfully used the distally based peroneus brevis muscle flap for the treatment of 15 patients with osteomyelitis (n = 5), melanoma (n = 1), Achilles tendon defects (n = 6), posttraumatic bone defects (n = 2), and chronic diabetic heel ulcer (n = 1) The size of the defects ranged from 6 to 60 cm All defects were covered successfully without major complications by the muscle flap The distally based peroneus brevis muscle represents a very reliable flap for coverage of small and moderate defects of the medial and lateral malleolus, the Achilles tendon, and the heel area This flap offers a convincing alternative for covering defects in the distal leg region and is often preferable to the use of free flaps because the surgery is rapidly performed and does not require microsurgical expertise

Nerve sources for facial reanimation with muscle transplant in patients with unilateral facial palsy: clinical analysis of 3 techniques.

Abstract: Ninety-one patients with long-standing unilateral facial palsy and submitted to reanimation of the face with muscle transplant were divided into 3 nonrandomized groups: group I: 2-stage facial reanimation, cross face followed by gracilis muscle transplant, 58 patients; group II: 1-stage reanimation with latissimus dorsi muscle transplant, 11 patients (a branch of the facial nerve on the nonparalyzed side of the face was used as the nerve source for reanimation in groups I and II); group III: 1-stage reanimation with gracilis muscle transplant and neural coaptation of the respective nerve and the ipsilateral masseteric branch of the trigeminal nerve, 22 patients. No microvascular complications were observed. The average interval between surgery and initial muscle contractions was 11.1 months, 7.2 months, and 3.7 months in group I, group II, and group III, respectively. The quality (intensity and shape) of the smile, voluntary or involuntary, obtained on the reanimated side in relation to the unaffected side was considered good or excellent in 53.4%, 54.5%, and 86.3% of the patients in groups I, II, and III, respectively. In group I, the average age of the patients with excellent or good results (19.8 + 10.5 years) was significantly lower than that of the patients with fair or poor results or absence of movement (36.5 + 13.3 years). The smile was considered emotional or involuntary in 34% of the patients in group I and 45% in group II. Most of the patients in each group were only able to produce "voluntary smiles". Crossed synkinesis with lip puckering was observed in 48% of the patients in group I and 90% in group II. The results obtained with 1-stage facial reanimation with masseteric nerve were more uniform and predictable than those obtained with the other techniques evaluated in this study.

Operation Iraqi freedom: A report on a series of soldiers treated with free tissue transfer by a plastic surgery service.

Abstract: Free flaps in combat wounds are predisposed to failure. Few reports are available on their use in American military combat wounds. We present our experience with free flaps during Operation Iraqi Freedom. This is a retrospective review of soldiers treated by plastic surgeons at Brooke Army Medical Center. Eight free flaps were for soft tissue coverage in which local tissue was not available. Causes of the wounds: 2 from a rocket-propelled grenade, 4 from explosive devices, 1 from a fall, and 1 from a helicopter crash. Indications for the flaps were 2 exposed calvaria, 3 lower-extremity fractures, 2 upper-extremity wounds, and 1 exposed Achilles tendon. Four latissimus dorsi muscle flaps and 4 radial forearm fasciocutaneous flaps were used. All flaps were successful. Three flap-related complications required operative intervention. Free flaps can be used successfully in combat wounds, with minimal morbidity, and should be considered in American soldiers with complex wounds.

Advances in autogenous breast reconstruction: the role of preoperative perforator mapping.

Abstract: Autogenous tissue is preferred to implants for breast reconstruction because it is part of the patient's body, so it does not incite rejection reaction as implants do. Most of the flaps used for breast reconstruction consist of skin and fat. These ingredients have similar consistency to that of

The internal mammary artery perforator flap: an anatomical study and a case report.

Abstract: The anatomic basis for the internal artery mammary perforator (IMAP) flap is described in this cadaveric study, together with a clinical case report. The IMAP flap is based on a single or double perforator of the internal mammary artery that is included in the pedicle for added length. It provides a very useful source of local tissue with skin of good texture and color for head and neck reconstruction and, being muscle free, is thin. With preservation of the anterior cutaneous branch of the intercostal nerve, the flap has the potential to be sensate. A large area can be covered, particularly if bilateral flaps are raised. The donor site can be closed directly. In selected patients, it offers an excellent option for use in head and neck reconstruction and should be considered as an alternative to the deltopectoral and pectoralis major flaps.

Sprayed cultured epithelial autografts for deep dermal burns of the face and neck

Abstract: The objective of this study was the assessment of clinical results after sprayed application of cultured epithelial autograft (CEA) suspensions onto deep dermal burn wounds of the face and neck. Nineteen patients with deep dermal burns of the face and neck were included into a prospective study. The average total body surface area burn was 15.1% (7%-46%; median: 13%). The average Abbreviated Burn Severity Index (ABSI) was 6.7 points (4-12 points; median: 7 points). The application of sprayed CEA suspension was performed onto an average body surface area of 2% (0.5-5%; median: 2%). Thirteen patients were recruited for clinical follow-up after an average of 10 months (3-18 months). The average Vancouver Scar Scale score at follow-up was 2.4 +/- 2.2 points (range, 0-8 points), and the average Donnersmarck and Horbrand score was 9.3 +/- 6.8 points (range, 0-22). Four patients had less than 9 months' follow-up. Excluding these patients from the analysis resulted in an average Vancouver Scar Scale score of 1.3 +/- 0.9 points (range, 0-3 points) and an average Donnersmarck and Horbrand score of 8.0 +/- 7.4 points (range 0-22) for the remaining 9 patients.Our data show that enzymatic and careful surgical debridement and consecutive application of CEA suspensions using a spray technique results in excellent cosmetic outcomes compared with any other method.

Securing skin grafts to microvascular free flaps using the vacuum-assisted closure (VAC) device.

Abstract: We performed microvascular free muscle flaps on 5 patients using the vacuum-assisted closure (VAC) device (KCI, San Antonio, TX) to secure a split-thickness skin graft to the external surface of the flap in each case. This method of skin-graft fixation was selected in each case because of the complex 3-dimensional shape of the flap or because of concerns of inadequate fixation provided by conventional tie-over bolster techniques in regions that experience a significant amount of shear stress. All 5 flaps remained viable throughout the treatment course and all 5 patients experienced excellent skin-graft take. Also, decreased edema was noted in all 5 flaps. We conclude that the VAC device is a useful tool in the fixation of skin grafts to microvascular free flaps and that its use does not compromise free-flap viability.

History of craniosynostosis surgery and the evolution of minimally invasive endoscopic techniques: the University of Florida experience

Abstract: Craniosynostosis is the premature and abnormal fusion of 1 of the 6 suture lines that form the living skull and can occur as part of a syndrome or as an isolated defect (nonsyndromic). The first reported surgical procedure for correction of craniosynostosis was performed in 1890 by Lannelongue who advocated releasing, but not resecting, the fused suture. Craniofacial surgery has developed its own identity in the last 3 decades, with the Frenchman Tessier seen as the founding father. There have been many new developments such as distraction osteogenesis, biodegradable miniplate fixation, and the development of minimally invasive endoscopic techniques. Through the pioneering work of Jimenez and Barone, minimally invasive approaches to the surgical correction of craniosynostosis are now gaining wider acceptance. Here the authors review the history of craniosynostosis, the current literature and technique for endoscopic repair of craniosynostosis, as well as their own experience at the University of Florida, with minimally invasive endoscope-assisted techniques.