American Journal of Physiology-Regulatory, Integrative and Comparative Physiology, 1998
We investigated the functional importance and signal transduction pathways of endothelin (ET)-B r... more We investigated the functional importance and signal transduction pathways of endothelin (ET)-B receptors in mediating ET-1-induced vasoconstriction in pig skin. Skin vasoconstriction was studied by monitoring the perfusion pressure of isolated perfused pig skin flaps (6 × 16 cm) at a constant flow rate. Intra-arterial infusion of the ETA/Breceptor agonist ET-1, the ETBreceptor agonists sarafotoxin 6C (S6c) and BQ-3020, or the thromboxane A2mimetic U-46619 ( n = 4 or 5) caused a concentration-dependent skin vasoconstriction. The vasoconstrictor potency of ET-1 (EC503.1 × 10−9M) was lower ( P < 0.05) than that of S6c (EC501.8 × 10−9M) and similar to that of BQ-3020 (EC502.6 × 10−9M). The vasoconstrictor potency of ET-1, S6c, and BQ-3020 was at least 300-fold higher than that of U-46619 (EC500.9 × 10−6M). The skin vasoconstrictor effect of ET-1 (10−9–10−8M) was partially inhibited by 10−5M BQ-123, an ETAreceptor antagonist. Further inhibition was achieved with the combination of 10...
Ischemia-reperfusion (I/R) injury causes skeletal muscle infarction and ischemic preconditioning ... more Ischemia-reperfusion (I/R) injury causes skeletal muscle infarction and ischemic preconditioning (IPC) augments ischemic tolerance in animal models. To date, this has not been demonstrated in human skeletal muscle. This study aimed to develop an in vitro model to investigate the efficacy of simulated IPC in human skeletal muscle. Human skeletal muscle strips were equilibrated in oxygenated Krebs-Henseleit-HEPES buffer (37°C). Aerobic and reperfusion phases were simulated by normoxic incubation and reoxygenation, respectively. Ischemia was simulated by hypoxic incubation. Energy store, cell viability, and cellular injury were assessed using ATP, 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyl-2 H-tetrazolium bromide (MTT), and lactate dehydrogenase (LDH) assays, respectively. Morphological integrity was assessed using electron microscopy. Studies were designed to test stability of the preparation ( n = 5–11) under normoxic incubation over 24 h; the effect of 1, 2, 3, 4, or 6 h hypoxia foll...
ABSTRACTWhatever is excisable, is reconstructable! "You excise, we will reconstruct" ar... more ABSTRACTWhatever is excisable, is reconstructable! "You excise, we will reconstruct" are the confident words of reconstructive surgeons today. Reconstruction with multiple flaps has become routine. Radial artery (FRAF), Antero lateral thigh (ALT) and Fibula osteo cutaneous flap (FFOCF) are three most popular free flaps which can reconstruct any defect with excellent asthetics and performance. Radial Artery provides thin, pliable innervated skin; ALT large amount of skin & bulk; and FFOCF strong 22 to 25 centimetres of bone and reliable skin paddle. Free flap survival has gone to 98% in most of the renouned institutes and is an established escalator in management of defects.
The various elements used in assessing the lymphedema patient are presented. These include the Hi... more The various elements used in assessing the lymphedema patient are presented. These include the History and Physical examination and the various measurements that include limb circumference, limb volume, and bio-impedence spectroscopy. In addition, the different imaging techniques used to assess the lymphatic system are discussed. Finally, a treatment algorithm is presented for the treatment of the lymphedema patient.
American Journal of Physiology-Heart and Circulatory Physiology, 1999
The aim of this project was to investigate the role of ETAand ETBreceptors in the mediation of en... more The aim of this project was to investigate the role of ETAand ETBreceptors in the mediation of endothelin (ET)-1-induced vasoconstriction in human skin. This information should provide important insights into the design of pharmacological intervention against skin vasospasm induced by ET-1 in peripheral vascular disease or surgical trauma. Vasoconstriction in response to intra-arterial drug infusion in isolated perfused human skin flaps (8 × 18 cm) derived from dermolipectomy specimens was assessed by studying changes in skin perfusion and perfusion pressure under constant flow rate in each drug treatment ( n = 4). It was observed that ET-1 (10−10to 10−8M) and norepinephrine (NE, 10−8to 10−5M) caused skin vasoconstriction in a concentration-dependent manner, with the vasoconstrictor potency of ET-1 ∼200-fold higher than NE. The ETA-receptor antagonist BQ-123 but not the ETB-receptor antagonist BQ-788 blocked the vasoconstrictor effect of ET-1. This observation was confirmed by study...
Vasospasm is one of the main causes of skin ischemic necrosis in cutaneous and musculocutaneous f... more Vasospasm is one of the main causes of skin ischemic necrosis in cutaneous and musculocutaneous flap surgery, but the pathogenic mechanism is unclear. We planned to test the hypothesis derived from clinical impression that veins are more susceptible to vasospasm than arteries in flap surgery and, once established, that venous vasospasm is difficult to resolve and more detrimental than arterial vasospasm. To this end, we investigated the differences in sensitivity to vasoconstrictors and vasodilators between the human musculocutaneous perforator (MCP) artery and vein by measuring the isometric tension of arterial and venous rings suspended in organ chambers. Vascular contraction was expressed as a percentage of the tension induced by 50 mM KCl. Relaxation was expressed as a percentage of contraction induced by a submaximal concentration (3 × 10−9M) of endothelin-1 (ET-1). We observed that the vasoconstrictor potency of norepinephrine was significantly higher in the MCP vein than in t...
American Journal of Physiology-Regulatory, Integrative and Comparative Physiology, 2000
Protein kinase C (PKC) inhibitors, chelerythrine (Chel, 0.6 mg) and polymyxin B (Poly B, 1.0 mg),... more Protein kinase C (PKC) inhibitors, chelerythrine (Chel, 0.6 mg) and polymyxin B (Poly B, 1.0 mg), and PKC activators, phorbol 12-myristate 13-acetate (PMA, 0.05 mg) and 1-oleoyl-2-acetyl glycerol (OAG, 0.1 mg), were used as probes to investigate the role of PKC in mediation of ischemic preconditioning (IPC) of noncontracting pig latissimus dorsi (LD) muscles against infarction in vivo. These drugs were delivered to each LD muscle flap (8 × 12 cm) by 10 min of local intra-arterial infusion. It was observed that LD muscle flaps sustained 43 ± 5% infarction when subjected to 4 h of global ischemia and 24 h of reperfusion. IPC with three cycles of 10 min ischemia-reperfusion reduced muscle infarction to 25 ± 3% ( P < 0.05). This anti-infarction effect of IPC was blocked by Chel (42 ± 7%) and Poly B (37 ± 2%) and mimicked by PMA (19 ± 10%) and OAG (14 ± 5%) treatments ( P < 0.05), given 10 min before 4 h of ischemia. In addition, the ATP-sensitive K+ (KATP) channel antagonist sodiu...
American Journal of Physiology-Regulatory, Integrative and Comparative Physiology, 2001
Our objective was to test the hypothesis that acute exposure of human skin vasculature to nicotin... more Our objective was to test the hypothesis that acute exposure of human skin vasculature to nicotine may have deleterious effects on endothelial function. Vasoconstriction and vasorelaxation in isolated perfused human skin flaps (∼8 × 18 cm) derived from dermolipectomy specimens were assessed by studying changes in skin perfusion pressure measured by a pressure transducer, and skin perfusion was assessed by a dermofluorometry technique ( n = 4 or 5). It was observed that nicotine (10−7M) amplified ( P < 0.05) the norepinephrine (NE)-induced concentration-dependent (10−7-10−5M) increase in skin vasoconstriction compared with the control. This amplification effect of nicotine in NE-induced skin vasoconstriction was not blocked by the nicotine-receptor antagonist hexamethonium (10−6M) or the cyclooxygenase inhibitor indomethacin (10−5M). It was also observed that ACh and nitroglycerin (NTG) elicited a concentration-dependent (10−8-10−5M) vasorelaxation in skin flaps preconstricted wit...
Immediate implant-based techniques are common practice in post-mastectomy breast reconstruction. ... more Immediate implant-based techniques are common practice in post-mastectomy breast reconstruction. Previous studies have shown an increased complication rate in the setting of immediate versus delayed, MD reconstruction. We aimed to quantify any additional risk in complications when implant-based immediate breast reconstruction (IBR) is performed versus mastectomy alone. We retrospectively reviewed all IBR cases and all mastectomies without reconstruction from 2007 to 2011. Patient characteristics, operative details, and complication rates were reviewed and analyzed. IBR was performed in 315 consecutive women; mastectomy alone was performed in 401 women. Patients undergoing mastectomy alone were more often older, diabetic, and more frequently underwent neoadjuvant chemotherapy or radiation. Overall complications were higher in the IBR group, most commonly reoperation and delayed wound healing. In a multivariate analysis, IBR, increasing age, body mass index, history of radiation thera...
Background Nipple-areolar reconstruction completes postmastectomy breast reconstruction. Many tec... more Background Nipple-areolar reconstruction completes postmastectomy breast reconstruction. Many techniques for nipple reconstruction have been described, and each has their advocates and critics. One of the frequent failings of most designs is loss of nipple projection with time. Objectives To determine the effect of including autologous costal cartilage on patient satisfaction with their nipple reconstruction. Methods Sixty-eight patients were identified who had undergone fishtail flap nipple reconstruction following autologous free flap breast reconstruction between 1990 and 2004. Qualitative questionnaires, using Likert scales, were sent to each patient to specifically assess their satisfaction with their nipple reconstruction. Results Of 26 respondents (mean ± SEM follow-up period 3.7±3.6 years), 13 had undergone nipple reconstruction incorporating costal cartilage banked at the time of initial breast reconstruction, and the other 13 had no cartilage in their nipple reconstruction...
Inadequate tissue perfusion is a key contributor to early complications following reconstructive ... more Inadequate tissue perfusion is a key contributor to early complications following reconstructive procedures. Accurate and reliable intraoperative evaluation of tissue perfusion is critical to reduce complications and improve clinical outcomes. Clinical judgment is the most commonly used method for evaluating blood supply, but when used alone, is not always completely reliable. A variety of other methodologies have been evaluated, including Doppler devices, tissue oximetry, and fluorescein, among others. However, none have achieved widespread acceptance. Recently, intraoperative laser angiography using indocyanine green was introduced to reconstructive surgery. This vascular imaging technology provides real-time assessment of tissue perfusion that correlates with clinical outcomes and can be used to guide surgical decision making. Although this technology has been used for decades in other areas, surgeons may not be aware of its utility for perfusion assessment in reconstructive surg...
The anterolateral thigh flap was described by Song et al. in 1984. Although more usually used as ... more The anterolateral thigh flap was described by Song et al. in 1984. Although more usually used as a free flap, it also has remarkable versatility as a pedicled flap. There are, however, no well-established guidelines that exist to define the extent of defects that can be reconstructed using this flap. In this article, the authors evaluate their experience with consecutive cases of the pedicled anterolateral thigh flap in complex abdominal and pelvic reconstruction. A retrospective review of medical records and photographic archives was performed looking at 28 proximally pedicled anterolateral thigh flaps in 27 patients. The authors identified the arcs of rotation achieved, the types of defects reconstructed, points of surgical technique that enhanced their results, and some pitfalls of this flap. Useful points of surgical technique identified included suprafascial flap harvesting, extended harvesting of fascia, utilization of fascia to protect the pedicle, harvesting as a composite flap with the vastus lateralis, prudent preservation of large perforators that transgress the lateral aspect of the rectus femoris, synergistic use with a sartorius &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot;switch,&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot; complete flap deepithelialization to fill dead space, and simple conversion to a free flap when pedicle length is inadequate. Pitfalls identified included the increased risk of pedicle avulsion in the morbidly obese, the risk of atherosclerotic plaque embolization in an atheromatous pedicle, and the potential inadequacy of thigh fascia for reconstituting abdominal wall integrity. This versatile flap has a wide arc of rotation. Multiple surgical modifications can be employed to tailor the flap to individual patient needs.
Ablative surgery in the head and neck often results in defects that require free flap reconstruct... more Ablative surgery in the head and neck often results in defects that require free flap reconstruction. With improved ablation/reconstructive and adjuvant techniques, improved survival has led to an increase in the number of patients undergoing multiple free flap reconstruction. We retrospectively analyzed a single institution&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s 10-year experience (August 1993 to August 2003) in free flap reconstruction for malignant tumors of the head and neck. Five hundred eighty-two flaps in 534 patients were identified with full details regarding ablation and reconstruction with a minimum of 6-month follow-up. Of these 584 flaps, 506 were for primary reconstruction, 50 for secondary reconstruction, 12 for tertiary reconstruction, and 8 patients underwent two flaps simultaneously for extensive defects. Overall flap success was 550/584 (94%). For primary free flap surgery, success was 481/506 (95%), compared with 44/50 (88%) for a second free flap reconstruction and 9/12 (75%) for a third free flap reconstruction ( P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.05). Eight extensive defects were reconstructed with 16 flaps, all of which were successful. More than one free flap may be required for reconstruction of head and neck defects, although success decreases as the number of reconstructive procedures increases.
We report the case of a 59-year-old woman who developed an arteriovenous fistula in her right but... more We report the case of a 59-year-old woman who developed an arteriovenous fistula in her right buttock following a right inferior gluteal artery perforator flap for breast reconstruction.
American Journal of Physiology-Regulatory, Integrative and Comparative Physiology, 1998
We investigated the functional importance and signal transduction pathways of endothelin (ET)-B r... more We investigated the functional importance and signal transduction pathways of endothelin (ET)-B receptors in mediating ET-1-induced vasoconstriction in pig skin. Skin vasoconstriction was studied by monitoring the perfusion pressure of isolated perfused pig skin flaps (6 × 16 cm) at a constant flow rate. Intra-arterial infusion of the ETA/Breceptor agonist ET-1, the ETBreceptor agonists sarafotoxin 6C (S6c) and BQ-3020, or the thromboxane A2mimetic U-46619 ( n = 4 or 5) caused a concentration-dependent skin vasoconstriction. The vasoconstrictor potency of ET-1 (EC503.1 × 10−9M) was lower ( P < 0.05) than that of S6c (EC501.8 × 10−9M) and similar to that of BQ-3020 (EC502.6 × 10−9M). The vasoconstrictor potency of ET-1, S6c, and BQ-3020 was at least 300-fold higher than that of U-46619 (EC500.9 × 10−6M). The skin vasoconstrictor effect of ET-1 (10−9–10−8M) was partially inhibited by 10−5M BQ-123, an ETAreceptor antagonist. Further inhibition was achieved with the combination of 10...
Ischemia-reperfusion (I/R) injury causes skeletal muscle infarction and ischemic preconditioning ... more Ischemia-reperfusion (I/R) injury causes skeletal muscle infarction and ischemic preconditioning (IPC) augments ischemic tolerance in animal models. To date, this has not been demonstrated in human skeletal muscle. This study aimed to develop an in vitro model to investigate the efficacy of simulated IPC in human skeletal muscle. Human skeletal muscle strips were equilibrated in oxygenated Krebs-Henseleit-HEPES buffer (37°C). Aerobic and reperfusion phases were simulated by normoxic incubation and reoxygenation, respectively. Ischemia was simulated by hypoxic incubation. Energy store, cell viability, and cellular injury were assessed using ATP, 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyl-2 H-tetrazolium bromide (MTT), and lactate dehydrogenase (LDH) assays, respectively. Morphological integrity was assessed using electron microscopy. Studies were designed to test stability of the preparation ( n = 5–11) under normoxic incubation over 24 h; the effect of 1, 2, 3, 4, or 6 h hypoxia foll...
ABSTRACTWhatever is excisable, is reconstructable! "You excise, we will reconstruct" ar... more ABSTRACTWhatever is excisable, is reconstructable! "You excise, we will reconstruct" are the confident words of reconstructive surgeons today. Reconstruction with multiple flaps has become routine. Radial artery (FRAF), Antero lateral thigh (ALT) and Fibula osteo cutaneous flap (FFOCF) are three most popular free flaps which can reconstruct any defect with excellent asthetics and performance. Radial Artery provides thin, pliable innervated skin; ALT large amount of skin & bulk; and FFOCF strong 22 to 25 centimetres of bone and reliable skin paddle. Free flap survival has gone to 98% in most of the renouned institutes and is an established escalator in management of defects.
The various elements used in assessing the lymphedema patient are presented. These include the Hi... more The various elements used in assessing the lymphedema patient are presented. These include the History and Physical examination and the various measurements that include limb circumference, limb volume, and bio-impedence spectroscopy. In addition, the different imaging techniques used to assess the lymphatic system are discussed. Finally, a treatment algorithm is presented for the treatment of the lymphedema patient.
American Journal of Physiology-Heart and Circulatory Physiology, 1999
The aim of this project was to investigate the role of ETAand ETBreceptors in the mediation of en... more The aim of this project was to investigate the role of ETAand ETBreceptors in the mediation of endothelin (ET)-1-induced vasoconstriction in human skin. This information should provide important insights into the design of pharmacological intervention against skin vasospasm induced by ET-1 in peripheral vascular disease or surgical trauma. Vasoconstriction in response to intra-arterial drug infusion in isolated perfused human skin flaps (8 × 18 cm) derived from dermolipectomy specimens was assessed by studying changes in skin perfusion and perfusion pressure under constant flow rate in each drug treatment ( n = 4). It was observed that ET-1 (10−10to 10−8M) and norepinephrine (NE, 10−8to 10−5M) caused skin vasoconstriction in a concentration-dependent manner, with the vasoconstrictor potency of ET-1 ∼200-fold higher than NE. The ETA-receptor antagonist BQ-123 but not the ETB-receptor antagonist BQ-788 blocked the vasoconstrictor effect of ET-1. This observation was confirmed by study...
Vasospasm is one of the main causes of skin ischemic necrosis in cutaneous and musculocutaneous f... more Vasospasm is one of the main causes of skin ischemic necrosis in cutaneous and musculocutaneous flap surgery, but the pathogenic mechanism is unclear. We planned to test the hypothesis derived from clinical impression that veins are more susceptible to vasospasm than arteries in flap surgery and, once established, that venous vasospasm is difficult to resolve and more detrimental than arterial vasospasm. To this end, we investigated the differences in sensitivity to vasoconstrictors and vasodilators between the human musculocutaneous perforator (MCP) artery and vein by measuring the isometric tension of arterial and venous rings suspended in organ chambers. Vascular contraction was expressed as a percentage of the tension induced by 50 mM KCl. Relaxation was expressed as a percentage of contraction induced by a submaximal concentration (3 × 10−9M) of endothelin-1 (ET-1). We observed that the vasoconstrictor potency of norepinephrine was significantly higher in the MCP vein than in t...
American Journal of Physiology-Regulatory, Integrative and Comparative Physiology, 2000
Protein kinase C (PKC) inhibitors, chelerythrine (Chel, 0.6 mg) and polymyxin B (Poly B, 1.0 mg),... more Protein kinase C (PKC) inhibitors, chelerythrine (Chel, 0.6 mg) and polymyxin B (Poly B, 1.0 mg), and PKC activators, phorbol 12-myristate 13-acetate (PMA, 0.05 mg) and 1-oleoyl-2-acetyl glycerol (OAG, 0.1 mg), were used as probes to investigate the role of PKC in mediation of ischemic preconditioning (IPC) of noncontracting pig latissimus dorsi (LD) muscles against infarction in vivo. These drugs were delivered to each LD muscle flap (8 × 12 cm) by 10 min of local intra-arterial infusion. It was observed that LD muscle flaps sustained 43 ± 5% infarction when subjected to 4 h of global ischemia and 24 h of reperfusion. IPC with three cycles of 10 min ischemia-reperfusion reduced muscle infarction to 25 ± 3% ( P < 0.05). This anti-infarction effect of IPC was blocked by Chel (42 ± 7%) and Poly B (37 ± 2%) and mimicked by PMA (19 ± 10%) and OAG (14 ± 5%) treatments ( P < 0.05), given 10 min before 4 h of ischemia. In addition, the ATP-sensitive K+ (KATP) channel antagonist sodiu...
American Journal of Physiology-Regulatory, Integrative and Comparative Physiology, 2001
Our objective was to test the hypothesis that acute exposure of human skin vasculature to nicotin... more Our objective was to test the hypothesis that acute exposure of human skin vasculature to nicotine may have deleterious effects on endothelial function. Vasoconstriction and vasorelaxation in isolated perfused human skin flaps (∼8 × 18 cm) derived from dermolipectomy specimens were assessed by studying changes in skin perfusion pressure measured by a pressure transducer, and skin perfusion was assessed by a dermofluorometry technique ( n = 4 or 5). It was observed that nicotine (10−7M) amplified ( P < 0.05) the norepinephrine (NE)-induced concentration-dependent (10−7-10−5M) increase in skin vasoconstriction compared with the control. This amplification effect of nicotine in NE-induced skin vasoconstriction was not blocked by the nicotine-receptor antagonist hexamethonium (10−6M) or the cyclooxygenase inhibitor indomethacin (10−5M). It was also observed that ACh and nitroglycerin (NTG) elicited a concentration-dependent (10−8-10−5M) vasorelaxation in skin flaps preconstricted wit...
Immediate implant-based techniques are common practice in post-mastectomy breast reconstruction. ... more Immediate implant-based techniques are common practice in post-mastectomy breast reconstruction. Previous studies have shown an increased complication rate in the setting of immediate versus delayed, MD reconstruction. We aimed to quantify any additional risk in complications when implant-based immediate breast reconstruction (IBR) is performed versus mastectomy alone. We retrospectively reviewed all IBR cases and all mastectomies without reconstruction from 2007 to 2011. Patient characteristics, operative details, and complication rates were reviewed and analyzed. IBR was performed in 315 consecutive women; mastectomy alone was performed in 401 women. Patients undergoing mastectomy alone were more often older, diabetic, and more frequently underwent neoadjuvant chemotherapy or radiation. Overall complications were higher in the IBR group, most commonly reoperation and delayed wound healing. In a multivariate analysis, IBR, increasing age, body mass index, history of radiation thera...
Background Nipple-areolar reconstruction completes postmastectomy breast reconstruction. Many tec... more Background Nipple-areolar reconstruction completes postmastectomy breast reconstruction. Many techniques for nipple reconstruction have been described, and each has their advocates and critics. One of the frequent failings of most designs is loss of nipple projection with time. Objectives To determine the effect of including autologous costal cartilage on patient satisfaction with their nipple reconstruction. Methods Sixty-eight patients were identified who had undergone fishtail flap nipple reconstruction following autologous free flap breast reconstruction between 1990 and 2004. Qualitative questionnaires, using Likert scales, were sent to each patient to specifically assess their satisfaction with their nipple reconstruction. Results Of 26 respondents (mean ± SEM follow-up period 3.7±3.6 years), 13 had undergone nipple reconstruction incorporating costal cartilage banked at the time of initial breast reconstruction, and the other 13 had no cartilage in their nipple reconstruction...
Inadequate tissue perfusion is a key contributor to early complications following reconstructive ... more Inadequate tissue perfusion is a key contributor to early complications following reconstructive procedures. Accurate and reliable intraoperative evaluation of tissue perfusion is critical to reduce complications and improve clinical outcomes. Clinical judgment is the most commonly used method for evaluating blood supply, but when used alone, is not always completely reliable. A variety of other methodologies have been evaluated, including Doppler devices, tissue oximetry, and fluorescein, among others. However, none have achieved widespread acceptance. Recently, intraoperative laser angiography using indocyanine green was introduced to reconstructive surgery. This vascular imaging technology provides real-time assessment of tissue perfusion that correlates with clinical outcomes and can be used to guide surgical decision making. Although this technology has been used for decades in other areas, surgeons may not be aware of its utility for perfusion assessment in reconstructive surg...
The anterolateral thigh flap was described by Song et al. in 1984. Although more usually used as ... more The anterolateral thigh flap was described by Song et al. in 1984. Although more usually used as a free flap, it also has remarkable versatility as a pedicled flap. There are, however, no well-established guidelines that exist to define the extent of defects that can be reconstructed using this flap. In this article, the authors evaluate their experience with consecutive cases of the pedicled anterolateral thigh flap in complex abdominal and pelvic reconstruction. A retrospective review of medical records and photographic archives was performed looking at 28 proximally pedicled anterolateral thigh flaps in 27 patients. The authors identified the arcs of rotation achieved, the types of defects reconstructed, points of surgical technique that enhanced their results, and some pitfalls of this flap. Useful points of surgical technique identified included suprafascial flap harvesting, extended harvesting of fascia, utilization of fascia to protect the pedicle, harvesting as a composite flap with the vastus lateralis, prudent preservation of large perforators that transgress the lateral aspect of the rectus femoris, synergistic use with a sartorius &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot;switch,&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot; complete flap deepithelialization to fill dead space, and simple conversion to a free flap when pedicle length is inadequate. Pitfalls identified included the increased risk of pedicle avulsion in the morbidly obese, the risk of atherosclerotic plaque embolization in an atheromatous pedicle, and the potential inadequacy of thigh fascia for reconstituting abdominal wall integrity. This versatile flap has a wide arc of rotation. Multiple surgical modifications can be employed to tailor the flap to individual patient needs.
Ablative surgery in the head and neck often results in defects that require free flap reconstruct... more Ablative surgery in the head and neck often results in defects that require free flap reconstruction. With improved ablation/reconstructive and adjuvant techniques, improved survival has led to an increase in the number of patients undergoing multiple free flap reconstruction. We retrospectively analyzed a single institution&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s 10-year experience (August 1993 to August 2003) in free flap reconstruction for malignant tumors of the head and neck. Five hundred eighty-two flaps in 534 patients were identified with full details regarding ablation and reconstruction with a minimum of 6-month follow-up. Of these 584 flaps, 506 were for primary reconstruction, 50 for secondary reconstruction, 12 for tertiary reconstruction, and 8 patients underwent two flaps simultaneously for extensive defects. Overall flap success was 550/584 (94%). For primary free flap surgery, success was 481/506 (95%), compared with 44/50 (88%) for a second free flap reconstruction and 9/12 (75%) for a third free flap reconstruction ( P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.05). Eight extensive defects were reconstructed with 16 flaps, all of which were successful. More than one free flap may be required for reconstruction of head and neck defects, although success decreases as the number of reconstructive procedures increases.
We report the case of a 59-year-old woman who developed an arteriovenous fistula in her right but... more We report the case of a 59-year-old woman who developed an arteriovenous fistula in her right buttock following a right inferior gluteal artery perforator flap for breast reconstruction.
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