Microvascular free tissue reconstruction after total laryngectomy

Summary Twelve latissimus dorsi flaps, five radial forearm flaps, one scapular flap, two combined latissimus dorsi and scapular flaps, six jejunal and seven gastroomental flaps were used to reconstruct defects following surgical treatment of laryngeal and hypopharyngeal cancer in 33 patients. Reconstruction provided a mucosal lining in 7 patients, external coverage in 11 patients, and both a mucosal lining and external coverage in 15 patients. There were two flap failures in this series. The average operating time was eight hours. There was a single postoperative death due to pneumonia. Local wound complication was noted in nine patients. Twenty-eight patients had adequate swallowing after operation. The lower morbidity and mortality in these patients with very advanced disease make these methods acceptable means for restoration of the function of the alimentary tract in the neck.     

Microvascular soft tissue reconstruction after complicated talocrural arthroplasty

Seven patients were referred to our unit during a 17-month period because of soft tissue problems 2–4 weeks after a talocrural arthroplasty (TCA). The infection was superficial in one and deep in six cases. In all patients the area was revised and a microvascular flap reconstruction was performed. In four cases the prosthesis was left in place and in two TC fusions were done. The flap was selected according to size and shape of the defect. Four partial latissimus dorsi flaps (LD), two gracilis free flaps, and one radial forearm flap (RF) were used. Four of the seven TCAs could be salvaged and no amputations were needed.     

Achilles tendon reconstruction after electrical injury with a neurotized cross-leg fillet flap

The authors present a case where a cross-leg fillet flap from an amputated limb allowed reconstruction of the contralateral disrupted Achilles tendon and provided neurotized soft tissue. Achilles tendon reconstruction of the left leg was achieved by utilizing vascularized extensor tendons from the dorsum of the right foot based on the dorsalis pedis circulation. Neurotization was accomplished end to side between a cutaneous nerve from the dorsum of the foot and the recipient sural nerve. Healing was complete and without complication. Cross-leg flaps including tendon and nerve may be used to reconstruct complex lower-extremity injuries, even when free flaps are not feasible.     

Renal reconstruction after injury

During an 11-year period 1,363 patients presented to our institution with renal trauma. Renal exploration was performed in 127 patients (133 renal units). Most patients had multiple organ injuries, as indicated by a mean blood loss of 4,160 ml. and a mean injury severity score of 25.8. Absolute indications for exploration were bleeding and pulsatile perirenal hematoma and relative indications included urinary extravasation, nonviable renal tissue and incomplete staging. Renal surgery was required in 2.4% of the blunt injuries, 45% of the stab wounds and 76% of the gunshot wounds. Salvage was successful in 88.7% of the kidneys explored and total nephrectomy was required in 11.3%. The success rate was based on early vascular control and reconstructive techniques of "renorrhaphy," partial nephrectomy, vascular repair and coverage with omental pedicle flaps. Complications occurred in 9.9% of the cases but none resulted in renal loss. When indicated, renal exploration after trauma is safe and in a high percentage of cases reconstruction will be successful.     

Normoblastemia after thermal injury

The peripheral blood smears of 214 thermally injured patients studied during a thirty month period revealed a 20 per cent incidence of normoblastemia (51 patients). Nucleated red blood cells were most common in patients with the largest burns. The absolute number of normoblasts was not related to the hematocrit and was not correlated with other determinants of erythropoietic function.     

Microvascular reconstruction of nasal defects

Microvascular reconstruction of nasal defects is a complex procedure and must consider 3 nasal components: skin, osteocartilaginous framework, and intranasal lining. These layers can be reconstructed with various flaps and grafts. The commonly used flaps are the first dorsal metacarpal flap, dorsalis pedis flap, auricular helical rim flap, and radial forearm and prelaminated flaps. These flaps can be composed of skin and cartilage or skin and bone. The decision is based on the patient's needs taking into consideration the extent of the defect and presence or absence of nasal septum and columella.     

Microvascular reconstruction of the hand

For the patient with a demonstrated occlusion in either the major arterial supply of the hand or in the distal digital circulation, modern microsurgery offers an opportunity for reconstruction with restoration of normal flow and sensibility. Observation should not be the mainstay of therapy for digital or upper extremity ischemic symptoms. The surgeon may select from a myriad of sophisticated invasive and noninvasive tests that permit definitive identification of microvascular pathology. Until further improvement in pharmacologic treatment occurs, microsurgery offers the greatest opportunity for correction of these conditions.     

Microvascular approaches to nasal reconstruction

In summary, the use of free tissue transfers for nasal reconstruction offers a wide variety of tissues that provide cutaneous coverage, underlying support, and nasal lining. Obtaining the final aesthetic result frequently requires defatting and other touch-up procedures, which usually can be done under local anesthesia on an outpatient basis.     

Microvascular free flap breast reconstruction

As in other areas of reconstruction, microvascular free flaps have earned a definite role in certain breast reconstructions difficult to accomplish with conventional techniques. With improvements in techniques and survival rates, the advantages of such reconstructions have become increasingly more attractive to the patient and the surgeon.     

Microvascular reconstruction of the mandible

Five microvascular reconstructions of the mandible were performed in the past 2 years. One dorsalis pedis osteocutaneous flap was used to reconstruct the alveolar ridge and four groin osteocutaneous flaps were used for various defects of the mandible. Free microvascular bone grafts were found useful in previously irradiated fields, in anterior arch reconstruction, and in patients with massive soft tissue and bone loss.     

Microvascular flaps in head and neck reconstruction

Twenty-six patients with head and neck tumors were submitted to 27 microvascular reconstructive procedures. In 15, the mandible was reconstructed using the rib (4), iliac crest (7), and scapula (4). Nine patients underwent craniofacial reconstructions with the latissimus dorsi (5), rectus abdominis (2), greater omentum (2), and scapular (1) flaps. Two patients received a jejunum (1) and a stomach plus greater omentum (1) flaps for pharyngoesophageal reconstruction. Three illustrative cases, one from each group, are presented in detail. Good results were obtained in 22 patients (85%), with both functional and morphological rehabilitation. There were five flap losses (two in the same patient) due to thrombosis of the microvascular anastomoses. There was no operative mortality, and the average operative time was 11 hours. The good results observed in these very advanced cases show that there is a place for these complex procedures in the treatment of selected cases of head and neck tumors.