Amputation stump salvage using a "banked" free-tissue transfer.

A free radical forearm flap was salvaged from a nonreplantable amputated extremity and banked on the ipsilateral chest wall. Later, the flap was simply rotated to provide coverage of the proximal humeral stump, eliminating the need for a second microvascular procedure.     

Inhibitory effects of low-level laser therapy on skin-flap survival in a rat model

BACKGROUND:Although several studies have demonstrated the effects of low-level laser therapy (LLLT) on skin flap viability, the role of higher doses has been poorly investigated.OBJECTIVE:To investigate the inhibitory effect of the LLLT (λ=670 nm) on the viability of random skin flaps in a rat model using an irradiation energy of 2.79 J at each point.METHODS:Sixteen Wistar rats were randomly assigned into two groups: sham laser irradiation (n=8); and active laser irradiation (n=8). Animals in the active laser irradiation group were irradiated with a 670 nm diode laser with an energy of 2.79 J/point, a power output 30 mW, a beam area of 0.028 cm², an energy density of 100 J/cm², an irradiance of 1.07 W/cm² for 93 s/point. Irradiation was performed in 12 points in the cranial skin flap portion. The total energy irradiated on the tissue was 33.48 J. The necrotic area was evaluated on postoperative day 7.RESULTS:The sham laser irradiation group presented a mean (± SD) necrotic area of 47.96±3.81%, whereas the active laser irradiation group presented 62.24±7.28%. There was a significant difference in skin-flap necrosis areas between groups (P=0.0002).CONCLUSION:LLLT (λ=670 nm) increased the necrotic area of random skin flaps in rats when irradiated with an energy of 2.79 J (100 J/cm²).     

The risk:benefit of autotransfusion--comparison to banked blood in a canine model

Recent enthusiasm for intraoperative autotransfusion has overshadowed critical assessment of its potential risks. In this study, adult mongrel dogs underwent controlled intraperitoneal hemorrhage of twice their estimated blood volume over a 4-hour period. The blood was replaced by an equal volume of banked blood (Group I, n = 5), or collected and reinfused via the Sorenson System (Group II, n = 6), or the Haemonetics Cell Washing Device (Group III, n = 6). Acid citrate dextrose was the local anticoagulant for Groups I and II, and heparin for Group III. Pulmonary capillary wedge pressure and cardiac output were maintained at baseline values with crystalloid infusion. Core temperature, pO2, and systemic pH remained normal throughout the 4 hours of evaluation. Red blood cell recovery was efficient in all animals, and the 2,3 DPG levels remained normal in the autotransfused dogs. Thrombocytopenia, however, developed uniformly and was more pronounced after autotransfusion. Platelet numbers decreased nearly 45% in the Sorenson as well as Haemonetics animals. Additionally, platelet dysfunction occurred after one blood volume exchange as evidenced by prolonged bleeding times and loss of the secondary wave on Sonoclot profiles. Coagulation studies revealed progressive consumptive coagulopathy and fibrinolysis in autotransfused dogs. The P.T., P.T.T., and T.T. lengthened, and levels of factors II, V, VIII, and fibrinogen fell. Autotransfusion clearly eliminates the infectious and incompatibility problems of banked homologous blood. Despite advances in technique, however, consumptive coagulopathy, fibrinolysis, and platelet dysfunction occur.(ABSTRACT TRUNCATED AT 250 WORDS)     

Bilateral brachial plexus palsy after a right-side modified radical mastectomy with immediate TRAM flap reconstruction

A 65-year-old women developed bilateral brachial plexus palsy after unilateral modified radical mastectomy with TRAM flap reconstruction. The patient recovered spontaneously. The failure of appropriate intra-operative positioning to prevent the injury is discussed.     

Cancer recurrence involving a TRAM flap and abdominal donor site following mastectomy and immediate breast reconstruction: a case report

Local tumor recurrence after mastectomy with immediate reconstruction is rare. Most reported recurrences involve invasive or in situ ductal carcinoma and occur at the skin or subcutaneous tissues near the mastectomy site. We report a case of a patient with malignant phyllodes tumor that recurred after mastectomy with immediate pedicle transverse rectus abdominis myocutaneous flap reconstruction. The recurrent disease involved the mastectomy bed, transverse rectus abdominis myocutaneous flap, abdominal donor site, and precostal tunnel.     

Reconstruction of breast after super-radical mastectomy with a pedicled latissimus dorsi flap and a free TRAM flap

Reconstruction of the breast after super-radical mastectomy is difficult because not only a breast mound but also the subclavicular and anterior axillary regions must be reconstructed simultaneously. If a defect is extremely large a single flap cannot fulfil these two purposes. For this goal we use two flaps, an ipsilateral pedicled latissimus dorsi musculocutaneous flap and a free TRAM flap pedicled on the inferior epigastric vessels. A latissimus dorsi flap along with a silicone gel prosthesis is used to reconstruct a breast mound and the free TRAM flap is transferred to augment the subclavicular and anterior axillary regions. We have used this technique successfully in three cases.     

The "aesthetic subunit" principle in late TRAM flap breast reconstruction

The "aesthetic subunit" principle is well established in facial reconstruction. This principle dictates that the margins of regional reconstructions correspond to existing visual boundaries. This will minimize the visual perception of "abnormal." The subunit principle also applies to secondary TRAM flap breast reconstructions in which the available chest wall skin is of poor quality. In these situations, it might be aesthetically advantageous to replace poor quality chest wall skin with a TRAM flap skin paddle that ends at the inframammary fold.     

Effect of hyperthermic preconditioning on the survival of ischemia-reperfused skin flaps: a new skin-flap model in the mouse

To investigate whether hyperthermic preconditioning can actually protect skin flaps against ischemia/reperfusion injury, the authors first developed a new skin-flap model in 15 mice, a dorsal bipedicle island skin-flap model. Then, another 75 mice were separated into five groups. Mice in Groups 1 to 4 received the same hyperthermic preconditioning, but had different recovery times of 6 hr, 24 hr, 48 hr, and 72 hr, respectively. Mice in Group 5 served as control. Island skin flaps were elevated in all groups, and then were subjected to 8 hr of ischemia and subsequent reperfusion. Flap survival was statistically significantly higher than in controls in animals in Groups 1 and 3, with recovery times of 6 hr and 48 hr, respectively. Mice in Groups 2 and 4 had recovery times of 24 hr and 72 hr, respectively. Hyperthermic preconditioning could thus protect skin flaps against ischemia/reperfusion injury, and there were two optimal periods for such a protective effect.     

The increase in TRAM flap survival after delay does not diminish long term

The delay phenomenon is sometimes relied on to increase survival of the transverse rectus abdominis musculocutaneous (TRAM) flap in high-risk patients. TRAM reconstruction has then been performed traditionally 1 to 2 weeks after the delay procedure. The optimum time course from this surgical delay to flap elevation, as it relates to survival, has not been well studied--specifically whether the potential benefit of delay lessens at any particular time after the delay procedure. The authors examined the effects of varying time periods (up to 7 months) after delay, via division of the dominant bilateral superior epigastric vessels, on the viability of the TRAM flap in a rat model. TRAM flap survival improved significantly (p < 0.01) at all time points in delayed groups compared with a nondelayed control group. The benefit of delay in this model was maintained at all times, even long term. In conclusion, it may be possible to extend the delay period safely beyond the customary 1 to 2 weeks without compromising survival of the TRAM flap, which may prove to be more convenient.     

Delayed cricoid reconstruction by use of a free graft of autogenous "patient banked" cartilage

Avulsed cartilage may be "banked" or preserved by subcutaneous implantation in the traumatized patient for delayed reconstruction of the defect when immediate reconstruction is contraindicated. The perichondrium of the avulsed cartilage should be preserved if possible. In the reconstructive procedure the cartilage graft must be surrounded by vascularized flaps developed from adjacent neck tissue. These vascularized flaps increase the local vascular supply for revascularization of the free graft. In addition, they allow complete separation of the free graft from the airway to minimize the possibility of secondary infection arising from the airway. Mucosal coverage of the defect does not appear to be necessary as long as well-vascularized soft tissue is available for complete coverage of the defect. The use of this technique may be considered for patients with avulsion of portions of the laryngeal cartilages when immediate reconstruction is contraindicated or when the viability of adjacent soft tissue necessary for reconstruction is uncertain. The success of this procedure may be related to the adequacy of the closure or separation of the airway from the free cartilage graft, and the ability to provide coverage of the graft with vascular tissue to allow graft revascularization. This new technique follows the traditional principles vital for successful management of laryngotracheal injuries. This procedure provides an additional method of therapy for those patients with an avulsion injury of the laryngeal cartilage. Additional surgical procedures must be performed utilizing the indications and principles presented here before this method is universally accepted for the management of severe laryngotracheal injury.     

The use of a lateral skin-flap perineoplasty in congenital anorectal malformations

A lateral skin-flap perineoplasty has been used in 15 patients born with an absent anal canal. The aim behind the introduction of this modification was the prevention of mucosal prolapse. On early assessment, this has been achieved in 11 of the cases. This represents a 50% improvement on our previous results.     

The augmented TRAM flap: a technique for the large-breasted patients

The transverse rectus abdominis myocutaneous (TRAM) flap is the most common method of autogenous breast reconstruction. In high-risk patients, a reliable and bulky flap is needed to achieve breast symmetry and a mound together with durable satisfactory projection. The purpose of this study is to look into the use of contralateral zones of the pedicled TRAM flap to improve flap survival and to reduce the incidence of fat necrosis in order to achieve good cosmetic results. Seven obese large-breasted patients of cup size C and above who underwent primary breast reconstruction by the same surgeon are presented. In each case, all the four zones of the TRAM flap were used to achieve symmetry of the reconstruction. Patients had mastectomy with or without axillary clearance. The pedicled TRAM flap was elevated and the other side was raised as a perforator flap for microvascular augmentation. The perforator vascular pedicle was anastomosed to the thoracodorsal vessels in all cases. The anterior rectus sheath was repaired with a mesh in all cases. All the flaps were coned to achieve a good projection. All flaps survived with no complications or loss. All patients were satisfied with the outcome. One of our patients developed an abdominal bulge that was treated conservatively. Microvascular augmentation improved survival of zones III and IV of the TRAM flap, exemplified by flap survival and no incidence of fat necrosis. It is a good reconstructive tool to achieve breast volume, symmetry, and projection. In addition, it reduces the need of secondary breast surgery for the contralateral breast in the future.     

Delayed mastectomy after outpatient breast biopsy: Long-term survival study

Forty-one patients who had outpatient biopsy and delayed mastectomy (most within 3 days) were subjected to long-term survival study. The ten year and longer survival studies revealed no deleterious effects from this procedure. The improved statistics were believed due to operation on lesions considered clinically benign, the short period of delay, and a low incidence of axillary metastasis.     

The modified extended mastectomy using the trap-door method as a staging operation

The choice of operation for breast cancer must be directed towards giving the best chance of local control of the disease. Extended radical mastectomy may be beneficial for patients with internal mammary lymph node metastases, although it has remained controversial. The anterior chest defect created by extended radical mastectomy should be avoided in patients with no metastasis in the internal mammary lymph nodes. This paper, proposes a new technique of modified extended mastectomy using the trap-door method as a staging operation and an intermediate operation between modified radical mastectomy and extended radical mastectomy. In this operation, the axillary dissection could be performed by reflecting the pectoralis major muscle and the internal mammary lymph nodes could be dissected by reflecting the parasternal chest wall in trap-door fashion. In cases in which the metastasis is histologically found in the internal mammary content, extended radical mastectomy by sternal splitting is preferred.