Biomedical subjects
Publications and source records attributed to D Serafin.
Skin closure with stainless steel staples can be done economically, simply, quickly, and accurately. Stapling is indicated in a wide range of surgical procedures. Scarring is minimal and patient acceptance is excellent.
A retrospective assessment of 50 vascularized composite tissue transfers was carried out with 48 patients. Factors responsible for improved tissue survival included (1) the evaluation and proper selection of recipient vasculature, (2) the increased dependence on the vacularized latissimus dorsi musculocutaneous flap, and (3) the frequent use, wherever possible, of an end-to-side arterial anastomisis. Specific indications for reconstruction of the lower extremity with vascularized composite tissue include (1) avulsive injuries to the distal tibia and foot, (2) the failure of conventional methods, (3) the treatment of extensive chronic osteomyelitis, (4) deficiency of both soft tissue cover and skeletal support, (5) the restoration of form and contour with minimal secondary deformity of the donor site, and (6) extensive loss of soft tissue only. Reconstruction of the lower extremity with vascularized tissue is a reliable method with acceptable patient and tissue morbidity statistics that should be considered when specific indications are present.
Three approaches to provide rib-periosteal or osteocutaneous composite tissue in maxillary or mandibular reconstruction are presented. All methods appear to be useful in replacing viable osteocytes and improving vascularity of maxillary or mandibular defects. Disadvantages include the bulk of the transplanted tissue, volume deficiency of bone, and the unreliability in viability of the associated cutaneous tissue, especially with the posterior and posterolateral approach. Significant patient morbidity and pulmonary complications in our series should indicate caution when considering these methods of reconstruction. At present, rib-periosteal transplantation is most often indicated to replace segmental defects of mandibular continuity when the recipient bed is avascular but the quantity of cutaneous cover is adequate. In those patients with deficient soft tissue and a small segmental mandibular loss, reconstruction with musculocutaneous flaps and nonvascularized bone grafts is indicated. With extensive deficiencies of both soft tissue cover and mandibular or maxillary continuity, an iliac osteocutaneous flap based on the deep circumflex iliac vessels may be the most effective. Lower patient morbidity statistics should be anticipated.
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A technique utilizing the inferiorly based dermal pedicle nipple-areolar flap is described. The advantages of this technique are:(1) predictable breast shape based on preoperative markings; (2) direct visibility of all areas for ease of resection and hemostasis; (3) retention of normal nipple duct connections; (4) no impairment of subjective sensation; and (5) adequate blood supply. This technique has particular application in younger women, in whom nipple sensation is quite important. The interruption of the intercostal nerve branches is usually limited because of the thickness and width of the inferior pedicles. Utilizing our modifications of the technique originally described, this versatile flap can now be used routinely in reduction mammaplasties requiring the removal of either small amounts (200 gm) or quite large amounts (2,500 gm) of tissue with consistently satisfactory aesthetic results and excellent patient satisfaction.
No technique will serve the needs of all patients requiring a reduction mammaplasty and mastopexy. However, the modified, inferiorly-based dermal flap technique appears to us to offer the most advantages and the greatest latitude for a predictable breast reduction in most of these patients.
We present a patient who bled into the pocket around a breast implant 2 1/2 years after an augmentation mammaplasty. She had received inflatible silicone prostheses, each containing 40 mg of triamcinolone acetonide. Our belief is that this large dosage of corticosteroid was responsible for the late erosion of the medium-sized artery, which caused the hemorrhage. Exploration and evacuation of the hematoma was followed by an uneventful postoperative course.
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Since 1974, 69 patients with extensive defects have undergone reconstruction by microsurgical composite tissue transplantation. Using this method, donor composite tissue is isolated on its blood supply, removed to a distant recipient site, and the continuity of blood flow re-established by microvascular anastomoses. In this series, 56 patients (81%) were completely successful. There have been eight (12%) failures, primarily in the extremities. There have been five (7%) partial successes, (i.e., a microvascular flap in which a portion was lost requiring a secondary procedure such as a split thickness graft). In those patients with a severely injured lower extremity, the failure rate was the greatest. Most of these were arterial (six of seven). These failures occurred early in the series and were thought to be related to a severely damaged recipient vasculature. This problem has been circumvented by an autogenous interpositional vein graft, permitting more mobility of flap placement. In the upper extremity, all but one case were successful. Early motion was permitted, preventing joint capsular contractures and loss of function. Twenty-three cases in the head and neck region were successful (one partial success). This included two composite rib grafts to the mandible. Prolonged delays in reconstruction following extirpation of a malignancy were avoided. A rapid return to society following complete reconstruction was ensured. Nine patients presented for reconstruction of the breast and thorax following radical mastectomy. All were successfully reconstructed with this new technique except one patient. Its many advantages include immediate reconstruction without delayed procedures and no secondary deformity of the donor site. Healthy, well vascularized tissue can now be transferred to a previously irradiated area with no tissue loss. This new method offers many advantages to older methods of reconstruction. Length of hospital stay and immobilization are reduced. The total number of operative procedures required in achieving the desired result is also less, thus decreasing the cost of hospital care.
The use of a free flap to bring in well-vascularized cover for a breast reconstruction (following radical mastectomy) is presented. Eleven of 12 such transfers were successful. (One free groin glap failed, and that reconstruction was abandoned.) Patients for breast reconstruction who have a marked deficiency of healthy, well-vascularized skin and subcutaneous tissue in the area are suitable candidates for this operative procedure. When a free groin flap is transferred, the donor defect is minimal.
Of thirty-five cases of microsurgical composite tissue transplantation, twenty-five (71 per cent) were completely successful, four (11 per cent), were partially successful, and six (17 per cent) failed. If a microvascular flap should fail, older but more lengthy methods of reconstruction may be employed with a reasonable chance for success. The advantages of the donor groin flap are discussed. Operative technic and management are outlined.
A composite free flap based on intercostal vessels may be used to reconstruct in one stage defects around the mandible in which skin, soft tissue and bone are missing. A delay procedure is recommended one week prior to transfer.
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The use of free flaps to repair defects of the leg or foot is a viable alternative to cross-leg flaps because (1) the total time of immobilization and hospitalization is less, (2) the total number of general anesthetics is less, and (3) the morbidity and cost are less. Increased experience will enhance the survival statistics for free flaps, making their use the method of choice for the reconstruction of defects in the distal part of the lower extremity.
We present 14 free flap transfers, 9 of which were completely successful (74 percent), two of which were partial successes (14 percent), and 3 of which were failures (22 percent). All the 5 cases involving free flaps to the head and neck region were successful. In the 9 cases involving free flap transfer to an extremity, 4 were completely successful (44 percent), two were partially successful (22 percent), and 3 were failures (34 percent). Many factors determine the success or failure of free flap transfer, but two that seem most significant are (1) the technical expertise and experience of the surgeon, and (2) the quality of the vasculaturein the recipient bed.
A patient is presented who presumably had multiple drugs injected intra-arterially in the right hand. Clinical signs and angiographic evidence of severe vascular insufficiency were well demonstrated. Therapy with fibrinolysin, reserpine, and heparin was followed by a return of normal circulation.