Composite auricular chondrocutaneous grafting is a well-established technique for reconstructing ... more Composite auricular chondrocutaneous grafting is a well-established technique for reconstructing alar defects. It can provide excellent results because it matches nasal tissue well in terms of color, texture, and contour. However, the size of composite graft that can be transferred is limited by its lack of blood supply. The authors reviewed their experience with the free vascularized preauricular and helical rim flaps for use in the reconstruction of large, full-thickness, nasal subunit defects. The vascularized preauricular and helical rim flap is based on the superficial temporal vessels. Depending on the nature and size of the nasal defect, the crus helicis, helical rim, preauricular skin, superficial temporal fascia, and temporal bone can be harvested. In addition, a posterior auricular flap is designed to reconstruct the donor site. The authors performed a retrospective review of 63 clinical cases. All 63 patients had full-thickness nasal defects that were reconstructed using ...
Aims: This meta-analysis sought to establish if early excision and grafting is better or equivale... more Aims: This meta-analysis sought to establish if early excision and grafting is better or equivalent to the conservative treatment of burns in both children and adults with minor or major burns. The outcomes of interest are mortality, wound healing time, duration of sepsis, operating hours, complications of surgery, length of hospital stay, blood transfusion requirements and long term morbidity like
The primary goal of limb salvage is to restore or maintain function. To achieve this goal, proper... more The primary goal of limb salvage is to restore or maintain function. To achieve this goal, proper patient selection, timely reconstruction, and choosing the procedure best suited for the patient are paramount. The decision to salvage a limb should be individualized for each patient, taking into consideration not only the extremity wound but also the associated injuries, age, and socioeconomic status of the patient. Aggressive débridement and skeletal stabilization, followed by early reconstruction, are the current standard of practice and give better results than the more traditional approach of repeated débridements and delayed flap cover. Free tissue transfer remains the best choice for large defects, but local fasciocutaneous flaps are a reasonable alternative for smaller defects and cases in which free flaps are deemed not suitable.
The aim of this study was to establish the long-term biomechanical and histological properties of... more The aim of this study was to establish the long-term biomechanical and histological properties of 2-octylcyanoacrylate-assisted microvascular anastomosis over conventional suture-only anastomosis in the laboratory rat model. The biomechanical and histological properties of three groups of vessels were compared: 1) vessels with 2-octylcyanoacrylate-assisted anastomoses (study group); 2) vessels with suture-only anastomoses (control group); and 3) normal unoperated vessels (sham group). In total, 144 adult rats were used, and these were studied at 1 week, 1 month, 3 months, and 6 months postanastomosis. At 6 months, the tensile strength of study vessels was significantly higher than control vessels. The stiffness of study and control vessels was similar at all time intervals. Histologically, there was no evidence that 2- octylcyanoacrylate caused toxicity to vessel walls, and there was less perivasacular foreign-body giant-cell reaction in the study group compared to the control group. Long-term follow-up showed that microvascular anastomosis with 2-octylcyanoacrylate in rat femoral arteries had superior tensile strength and similar stiffness to vessels anastomosed with sutures only, without adverse effects to surrounding tissues.
The timing of microsurgical free flap reconstruction for traumatic lower limb injury has been de... more The timing of microsurgical free flap reconstruction for traumatic lower limb injury has been described as being optimal if conducted within the early period following injury, as higher rates of infection and flap loss were reported in the subsequent time period. However, for various reasons, reconstruction of these defects may be delayed. The aim of this article is to show that adequate debridement, negative pressure wound dressing, and sound reconstructive principles has led to increased free flap success rates regardless of the period between injury and reconstruction. A 10-year retrospective single-center analysis of 50 traumatic lower limb cases from 2002 to 2012 was conducted. All patients had microsurgical free flap reconstruction after a period of negative pressure wound therapy (NPWT). Patient factors and reconstructive methods were analyzed and outcomes were compared. Mean interval between admission and free flap coverage was 17.5 days, and patients underwent NPWT for an average of 12 days (range, 1-35). Approximately 8% of patients had postoperative infections. Overall free flap success rate was 96%. Approximately 90% of patients were able to return to their premorbid footwear, with 96% able to mobilize independently approaching the end of their follow-up period. Our study shows that traumatic lower limb reconstruction in the delayed period is no longer associated with high rates of flap failure. Improvements in microsurgery and the advent of NPWT have made timing no longer crucial in free flap coverage of traumatic lower limb injuries.
Journal of Plastic, Reconstructive & Aesthetic Surgery, 2012
Complex and extensive lower limb defects remain difficult reconstructive problems. Conventional f... more Complex and extensive lower limb defects remain difficult reconstructive problems. Conventional flaps may not be large enough or lack the versatility that allows precise tissue positioning to optimally cover the wound. The anterolateral thigh-vastus lateralis conjoint flap provides a superior reconstructive solution for these difficult wounds. From Jan 2010 to June 2011, seven patients were reconstructed with the anterolateral thigh-vastus lateralis conjoint flap. Three cases were traumatic degloving injury of the lower limb, three were open fractures of the tibia with extensive soft-tissue loss and one was a large soft-tissue defect as a result of necrotising fasciitis. The skin island and muscle component were raised with independent pedicles to allow complete freedom in the inset of each flap based on a common pedicle. The descending and oblique branches of the lateral circumflex femoral artery were used as the pedicle of the conjoint flap in four and three cases, respectively. The mean size of the skin flap was 355 cm(2) (range: 312-420 cm(2)) and the volume of the muscle flap was 210 cm(3) (range: 42-360 cm(3)). All flaps survived completely and no infective complications were noted in our patients. The skin and muscle component were widely separated to expand the area of coverage. In cases where specific areas of the wound were severely traumatised with significant tissue loss, the muscle component can be precisely positioned to obliterate the dead space and to optimise soft-tissue coverage of the wound. The anterolateral thigh-vastus lateralis conjoint flap is superior to conventional flaps available for coverage of extensive defects of the lower limb. It can cover far greater area as well as providing the versatility needed to optimise soft-tissue coverage.
This meta-analysis sought to establish if early excision and grafting is better or equivalent to ... more This meta-analysis sought to establish if early excision and grafting is better or equivalent to the conservative treatment of burns in both children and adults with minor or major burns. The outcomes of interest are mortality, wound healing time, duration of sepsis, operating hours, complications of surgery, length of hospital stay, blood transfusion requirements and long term morbidity like joint contractures and hypertrophic scarring. We searched MEDLINE (1966-July 2004), EMBASE (1980-August 2004) and the Cochrane Central Register of Controlled Trials (CENTRAL) with the keywords 'early excision' and 'burns'. This yielded 441 articles of which 15 were randomized controlled trials. Only six trials met the inclusion criteria. There was a significant reduction in mortality with early excision of burns when compared with traditional treatment only in patients without inhalational injury (RR 0.36, 95% CI 0.20 to 0.65). The blood transfusion requirement is significantly higher in the early excision group but the length of hospital stay was significantly shorter (WMD -8.89, 95% CI -14.28 to -3.50). There was no conclusive evidence on the difference between the two groups in terms of duration of sepsis, wound healing time and skin graft take. Early excision of burns is beneficial in reducing mortality (in patients without inhalational injury), length of hospital stay. The only drawback is the greater volume of blood loss.
This article details an algorithm we used for selection of recipient vessels in free tissue trans... more This article details an algorithm we used for selection of recipient vessels in free tissue transfer to the head and neck. Eighty-eight consecutive free flaps to the head and neck were performed in 85 patients. The superior thyroid was the commonest recipient artery used (61%). The facial artery, used in 14% of our cases, is the choice vessel in instances where neck dissection is not performed. In these cases, we have to access the neck separately for recipient vessels and it can be exposed easily via a short (3-cm) incision. The superficial temporal artery (11%) is our choice vessel for patients with previous neck dissection or radiotherapy as it is well outside the previous operative or irradiated field. Other vessels such as the transverse cervical and end-to-side anastomosis to the carotid artery were also used when appropriate. Recipient vein selection depends primarily on the selected artery. Corresponding veins and large branches of the internal jugular vein (IJV) in the vicinity of the selected artery are preferred. When these are exhausted, the external jugular vein and end-to-side anastomosis to the IJV are considered. We found this algorithm to be reliable in identifying the appropriate vessels in all cases.
Composite auricular chondrocutaneous grafting is a well-established technique for reconstructing ... more Composite auricular chondrocutaneous grafting is a well-established technique for reconstructing alar defects. It can provide excellent results because it matches nasal tissue well in terms of color, texture, and contour. However, the size of composite graft that can be transferred is limited by its lack of blood supply. The authors reviewed their experience with the free vascularized preauricular and helical rim flaps for use in the reconstruction of large, full-thickness, nasal subunit defects. The vascularized preauricular and helical rim flap is based on the superficial temporal vessels. Depending on the nature and size of the nasal defect, the crus helicis, helical rim, preauricular skin, superficial temporal fascia, and temporal bone can be harvested. In addition, a posterior auricular flap is designed to reconstruct the donor site. The authors performed a retrospective review of 63 clinical cases. All 63 patients had full-thickness nasal defects that were reconstructed using ...
Aims: This meta-analysis sought to establish if early excision and grafting is better or equivale... more Aims: This meta-analysis sought to establish if early excision and grafting is better or equivalent to the conservative treatment of burns in both children and adults with minor or major burns. The outcomes of interest are mortality, wound healing time, duration of sepsis, operating hours, complications of surgery, length of hospital stay, blood transfusion requirements and long term morbidity like
The primary goal of limb salvage is to restore or maintain function. To achieve this goal, proper... more The primary goal of limb salvage is to restore or maintain function. To achieve this goal, proper patient selection, timely reconstruction, and choosing the procedure best suited for the patient are paramount. The decision to salvage a limb should be individualized for each patient, taking into consideration not only the extremity wound but also the associated injuries, age, and socioeconomic status of the patient. Aggressive débridement and skeletal stabilization, followed by early reconstruction, are the current standard of practice and give better results than the more traditional approach of repeated débridements and delayed flap cover. Free tissue transfer remains the best choice for large defects, but local fasciocutaneous flaps are a reasonable alternative for smaller defects and cases in which free flaps are deemed not suitable.
The aim of this study was to establish the long-term biomechanical and histological properties of... more The aim of this study was to establish the long-term biomechanical and histological properties of 2-octylcyanoacrylate-assisted microvascular anastomosis over conventional suture-only anastomosis in the laboratory rat model. The biomechanical and histological properties of three groups of vessels were compared: 1) vessels with 2-octylcyanoacrylate-assisted anastomoses (study group); 2) vessels with suture-only anastomoses (control group); and 3) normal unoperated vessels (sham group). In total, 144 adult rats were used, and these were studied at 1 week, 1 month, 3 months, and 6 months postanastomosis. At 6 months, the tensile strength of study vessels was significantly higher than control vessels. The stiffness of study and control vessels was similar at all time intervals. Histologically, there was no evidence that 2- octylcyanoacrylate caused toxicity to vessel walls, and there was less perivasacular foreign-body giant-cell reaction in the study group compared to the control group. Long-term follow-up showed that microvascular anastomosis with 2-octylcyanoacrylate in rat femoral arteries had superior tensile strength and similar stiffness to vessels anastomosed with sutures only, without adverse effects to surrounding tissues.
The timing of microsurgical free flap reconstruction for traumatic lower limb injury has been de... more The timing of microsurgical free flap reconstruction for traumatic lower limb injury has been described as being optimal if conducted within the early period following injury, as higher rates of infection and flap loss were reported in the subsequent time period. However, for various reasons, reconstruction of these defects may be delayed. The aim of this article is to show that adequate debridement, negative pressure wound dressing, and sound reconstructive principles has led to increased free flap success rates regardless of the period between injury and reconstruction. A 10-year retrospective single-center analysis of 50 traumatic lower limb cases from 2002 to 2012 was conducted. All patients had microsurgical free flap reconstruction after a period of negative pressure wound therapy (NPWT). Patient factors and reconstructive methods were analyzed and outcomes were compared. Mean interval between admission and free flap coverage was 17.5 days, and patients underwent NPWT for an average of 12 days (range, 1-35). Approximately 8% of patients had postoperative infections. Overall free flap success rate was 96%. Approximately 90% of patients were able to return to their premorbid footwear, with 96% able to mobilize independently approaching the end of their follow-up period. Our study shows that traumatic lower limb reconstruction in the delayed period is no longer associated with high rates of flap failure. Improvements in microsurgery and the advent of NPWT have made timing no longer crucial in free flap coverage of traumatic lower limb injuries.
Journal of Plastic, Reconstructive & Aesthetic Surgery, 2012
Complex and extensive lower limb defects remain difficult reconstructive problems. Conventional f... more Complex and extensive lower limb defects remain difficult reconstructive problems. Conventional flaps may not be large enough or lack the versatility that allows precise tissue positioning to optimally cover the wound. The anterolateral thigh-vastus lateralis conjoint flap provides a superior reconstructive solution for these difficult wounds. From Jan 2010 to June 2011, seven patients were reconstructed with the anterolateral thigh-vastus lateralis conjoint flap. Three cases were traumatic degloving injury of the lower limb, three were open fractures of the tibia with extensive soft-tissue loss and one was a large soft-tissue defect as a result of necrotising fasciitis. The skin island and muscle component were raised with independent pedicles to allow complete freedom in the inset of each flap based on a common pedicle. The descending and oblique branches of the lateral circumflex femoral artery were used as the pedicle of the conjoint flap in four and three cases, respectively. The mean size of the skin flap was 355 cm(2) (range: 312-420 cm(2)) and the volume of the muscle flap was 210 cm(3) (range: 42-360 cm(3)). All flaps survived completely and no infective complications were noted in our patients. The skin and muscle component were widely separated to expand the area of coverage. In cases where specific areas of the wound were severely traumatised with significant tissue loss, the muscle component can be precisely positioned to obliterate the dead space and to optimise soft-tissue coverage of the wound. The anterolateral thigh-vastus lateralis conjoint flap is superior to conventional flaps available for coverage of extensive defects of the lower limb. It can cover far greater area as well as providing the versatility needed to optimise soft-tissue coverage.
This meta-analysis sought to establish if early excision and grafting is better or equivalent to ... more This meta-analysis sought to establish if early excision and grafting is better or equivalent to the conservative treatment of burns in both children and adults with minor or major burns. The outcomes of interest are mortality, wound healing time, duration of sepsis, operating hours, complications of surgery, length of hospital stay, blood transfusion requirements and long term morbidity like joint contractures and hypertrophic scarring. We searched MEDLINE (1966-July 2004), EMBASE (1980-August 2004) and the Cochrane Central Register of Controlled Trials (CENTRAL) with the keywords 'early excision' and 'burns'. This yielded 441 articles of which 15 were randomized controlled trials. Only six trials met the inclusion criteria. There was a significant reduction in mortality with early excision of burns when compared with traditional treatment only in patients without inhalational injury (RR 0.36, 95% CI 0.20 to 0.65). The blood transfusion requirement is significantly higher in the early excision group but the length of hospital stay was significantly shorter (WMD -8.89, 95% CI -14.28 to -3.50). There was no conclusive evidence on the difference between the two groups in terms of duration of sepsis, wound healing time and skin graft take. Early excision of burns is beneficial in reducing mortality (in patients without inhalational injury), length of hospital stay. The only drawback is the greater volume of blood loss.
This article details an algorithm we used for selection of recipient vessels in free tissue trans... more This article details an algorithm we used for selection of recipient vessels in free tissue transfer to the head and neck. Eighty-eight consecutive free flaps to the head and neck were performed in 85 patients. The superior thyroid was the commonest recipient artery used (61%). The facial artery, used in 14% of our cases, is the choice vessel in instances where neck dissection is not performed. In these cases, we have to access the neck separately for recipient vessels and it can be exposed easily via a short (3-cm) incision. The superficial temporal artery (11%) is our choice vessel for patients with previous neck dissection or radiotherapy as it is well outside the previous operative or irradiated field. Other vessels such as the transverse cervical and end-to-side anastomosis to the carotid artery were also used when appropriate. Recipient vein selection depends primarily on the selected artery. Corresponding veins and large branches of the internal jugular vein (IJV) in the vicinity of the selected artery are preferred. When these are exhausted, the external jugular vein and end-to-side anastomosis to the IJV are considered. We found this algorithm to be reliable in identifying the appropriate vessels in all cases.
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