Thumb reconstruction following a traumatic injury challenge depends on the extent of the injury. Ideally, reconstruction should restore thumb length and position and retain thumb stability, mobility, and strength, whi...Thumb reconstruction following a traumatic injury challenge depends on the extent of the injury. Ideally, reconstruction should restore thumb length and position and retain thumb stability, mobility, and strength, while preserving sensation and aesthetics. Achieving these outcomes can be especially challenging in severe cases of soft tissue and bony loss. The authors present a case of a 20-year-old right-hand dominant female involved in a motor vehicle accident who sustained severe crush injuries and burns to her right hand. Her injuries included soft tissue and bony defects extending from the thumb to the distal radius, namely avulsion of the thumb and significant loss of the distal radial and carpal column, resulting in severe wrist instability. We employed a three-segment vascularized osteocutaneous fibula flap to reconstruct the thumb and wrist to restore bony construct, carpal support, and soft tissue coverage. Thumb motion could not be achieved, but this technique offered a sensate, functional post for opposition and the appearance of an anatomic hand. Because of this surgery, the patient was enabled to graduate from college and pursue full-time employment. The authors hope that this report will add to the fund of knowledge and surgeon armamentarium for similar devastating injuries demanding thumb and wrist reconstruction.展开更多
Microvascular free flap surgery has become a successful and reliable method of reconstruction following head and neck cancer resection. The effectiveness of free flap reconstruction has increased with improved surgica...Microvascular free flap surgery has become a successful and reliable method of reconstruction following head and neck cancer resection. The effectiveness of free flap reconstruction has increased with improved surgical technique as well as technological refinement in vessel selection and flap monitoring. Few papers have studied the factors that influence success or failure rates of free flap reconstructions, particularly with an eye towards the technologic advancements that have refined the procedure in the last several decades. Here we present a comprehensive review of perioperative and intraoperative considerations that influence free flap outcomes as well methods of vessel selection and flap monitoring important during microvascular reconstruction of the head and neck.展开更多
There is long-standing debate about sensate versus non-sensate free microvascular flaps among microsurgeons. The principle of connecting not only the vascular supply, but also sensitive nerves, in free tissue transfer...There is long-standing debate about sensate versus non-sensate free microvascular flaps among microsurgeons. The principle of connecting not only the vascular supply, but also sensitive nerves, in free tissue transfer is attractive. However, increased operating time and partial spontaneous innervation led to the common decision to restrict microsurgical tissue transfer to the vascular anastomosis and to leave the nerves ＂untreated＂. Nevertheless, in special cases such as breast reconstruction or extremity reconstruction, the question about sensory nerve coaptation of the flaps remains open. We present our experience with free microvascular tissue transfer for breast and extremity reconstruction and compare the data with previous literature and conclude that most free flap surgeries do not benefit from nerve coaptation.展开更多
Single stage reconstruction of circumferential pharyngo-esophageal defects using the free jejunum flap produces excellent functional results with minimal morbidity and mortality. The most serious complication with thi...Single stage reconstruction of circumferential pharyngo-esophageal defects using the free jejunum flap produces excellent functional results with minimal morbidity and mortality. The most serious complication with this flap is vascular compromise, usually within the first 24 - 48 hours after surgery. Compromised flaps are frequently diagnosed late often making their salvage impossible, so close postoperative monitoring of tissue perfusion is critical. Rapid identification and salvage of the failing flap increases the chance of a successful outcome.展开更多
The authors present the double-paddled pectoralis major myocutaneous flap as a successful alternative for the reconstruction of complex orocervical defects following failure of prior microvascularized free flaps or fr...The authors present the double-paddled pectoralis major myocutaneous flap as a successful alternative for the reconstruction of complex orocervical defects following failure of prior microvascularized free flaps or free flap harvest is not feasible. This method was used for the reconstruction of post-ablative defect in a 36-year-old male with a T4 squamous cell carcinoma of the base of tongue with laryngeal involvement. The distal paddle was adapted to reconstruct a defect of the floor of the mouth and further sutured in two layers (muscle-basal mandible and skin paddle-oral mucosa) while the proximal skin paddle was used to close the cervical skin and the peri-tracheostomy defect.展开更多
The author reviews his pioneering work in aesthetic restoration of the severely disfigured burn face first introduced in 1995 and refined over the past two decades. The reader will be exposed to the step by step appro...The author reviews his pioneering work in aesthetic restoration of the severely disfigured burn face first introduced in 1995 and refined over the past two decades. The reader will be exposed to the step by step approach to achieving cosmetic enhancement and functional rehabilitation of advanced facial burns. The"keystone"of the autogenous reconstruction is the pre-patterned, sculpted microvascular free flap designed to fit like the"piece of a puzzle"into the aesthetic units of the face to replace disfiguring burn scars. Aggressive intraoperative"sculpting"is employed both"in situ"at the donor site and during the flap transfer to simulate the normal facial contours and planes. Comparisons of the author's approach are made to the whole spectrum of reconstructive modalities ranging from conventional grafting to expanded pre-fabricated flaps and even to CTA face transplants;advantages/disadvantages of each are discussed. The pre-patterned, sculpted microvascular (MV) free flap offers the benefit of a single-stage transfer of composite skin/soft tissue hiding the seams at the junction of facial planes. When harvested from distant donor sites, the donor deformities can easily be concealed. The MV free tissue transfer offers the substrate that can be sculpted into nuanced facial components as well as the"palette"upon which the face can be painted with creative camouflage makeup. The soft contour and texture of the autogenous patterned transfers translates into a"natural"facial appearance while preserving fluid motions of facial expression.展开更多
文摘Thumb reconstruction following a traumatic injury challenge depends on the extent of the injury. Ideally, reconstruction should restore thumb length and position and retain thumb stability, mobility, and strength, while preserving sensation and aesthetics. Achieving these outcomes can be especially challenging in severe cases of soft tissue and bony loss. The authors present a case of a 20-year-old right-hand dominant female involved in a motor vehicle accident who sustained severe crush injuries and burns to her right hand. Her injuries included soft tissue and bony defects extending from the thumb to the distal radius, namely avulsion of the thumb and significant loss of the distal radial and carpal column, resulting in severe wrist instability. We employed a three-segment vascularized osteocutaneous fibula flap to reconstruct the thumb and wrist to restore bony construct, carpal support, and soft tissue coverage. Thumb motion could not be achieved, but this technique offered a sensate, functional post for opposition and the appearance of an anatomic hand. Because of this surgery, the patient was enabled to graduate from college and pursue full-time employment. The authors hope that this report will add to the fund of knowledge and surgeon armamentarium for similar devastating injuries demanding thumb and wrist reconstruction.
文摘Microvascular free flap surgery has become a successful and reliable method of reconstruction following head and neck cancer resection. The effectiveness of free flap reconstruction has increased with improved surgical technique as well as technological refinement in vessel selection and flap monitoring. Few papers have studied the factors that influence success or failure rates of free flap reconstructions, particularly with an eye towards the technologic advancements that have refined the procedure in the last several decades. Here we present a comprehensive review of perioperative and intraoperative considerations that influence free flap outcomes as well methods of vessel selection and flap monitoring important during microvascular reconstruction of the head and neck.
文摘There is long-standing debate about sensate versus non-sensate free microvascular flaps among microsurgeons. The principle of connecting not only the vascular supply, but also sensitive nerves, in free tissue transfer is attractive. However, increased operating time and partial spontaneous innervation led to the common decision to restrict microsurgical tissue transfer to the vascular anastomosis and to leave the nerves ＂untreated＂. Nevertheless, in special cases such as breast reconstruction or extremity reconstruction, the question about sensory nerve coaptation of the flaps remains open. We present our experience with free microvascular tissue transfer for breast and extremity reconstruction and compare the data with previous literature and conclude that most free flap surgeries do not benefit from nerve coaptation.
文摘Single stage reconstruction of circumferential pharyngo-esophageal defects using the free jejunum flap produces excellent functional results with minimal morbidity and mortality. The most serious complication with this flap is vascular compromise, usually within the first 24 - 48 hours after surgery. Compromised flaps are frequently diagnosed late often making their salvage impossible, so close postoperative monitoring of tissue perfusion is critical. Rapid identification and salvage of the failing flap increases the chance of a successful outcome.
文摘The authors present the double-paddled pectoralis major myocutaneous flap as a successful alternative for the reconstruction of complex orocervical defects following failure of prior microvascularized free flaps or free flap harvest is not feasible. This method was used for the reconstruction of post-ablative defect in a 36-year-old male with a T4 squamous cell carcinoma of the base of tongue with laryngeal involvement. The distal paddle was adapted to reconstruct a defect of the floor of the mouth and further sutured in two layers (muscle-basal mandible and skin paddle-oral mucosa) while the proximal skin paddle was used to close the cervical skin and the peri-tracheostomy defect.
文摘The author reviews his pioneering work in aesthetic restoration of the severely disfigured burn face first introduced in 1995 and refined over the past two decades. The reader will be exposed to the step by step approach to achieving cosmetic enhancement and functional rehabilitation of advanced facial burns. The"keystone"of the autogenous reconstruction is the pre-patterned, sculpted microvascular free flap designed to fit like the"piece of a puzzle"into the aesthetic units of the face to replace disfiguring burn scars. Aggressive intraoperative"sculpting"is employed both"in situ"at the donor site and during the flap transfer to simulate the normal facial contours and planes. Comparisons of the author's approach are made to the whole spectrum of reconstructive modalities ranging from conventional grafting to expanded pre-fabricated flaps and even to CTA face transplants;advantages/disadvantages of each are discussed. The pre-patterned, sculpted microvascular (MV) free flap offers the benefit of a single-stage transfer of composite skin/soft tissue hiding the seams at the junction of facial planes. When harvested from distant donor sites, the donor deformities can easily be concealed. The MV free tissue transfer offers the substrate that can be sculpted into nuanced facial components as well as the"palette"upon which the face can be painted with creative camouflage makeup. The soft contour and texture of the autogenous patterned transfers translates into a"natural"facial appearance while preserving fluid motions of facial expression.
