Large animal models are essential to research in facial paralysis, face transplant, craniofacial surgery, and ophthalmology. Pigs are a well-studied species with high similarity to human anatomy and physiology for these research areas. However, in contrast to cats and dogs protecting the cornea and eye is difficult in swine due to the inability to use an Elizabethan collar (E-collar) and the complexity of placing and maintaining a temporary tarsorrhaphy for corneal protection due to the strength of the pig levator muscle. This study presents an effective method to provide corneal and eye protection in the domestic swine for at least 50 d. Furthermore, protection of the eye and face is achieved through the innovative use of a modified ophthalmologic face shield. The findings from this study will advance large animal research in these fields, enabling innovation in surgery and tissue engineering in areas of both craniofacial and ophthalmologic research.
Purpose: End-stage renal disease patients are increasing at around 5% annually. Success rates of free-tissue transfer have been reported between 95 and 99%. Comorbidities, such as uremia, diabetes mellitus and atherosclerotic disease, can increase the level of complexity. We describe the outcomes of ESRD patients under dialysis who underwent free tissue transfer for head/neck reconstruction. Methods: Based on the Taiwan national insurance database, two-cohorts were analyzed: ESRD group on dialysis and a non-ESRD control group. Postoperative complications within 90-days and mortality within 30-days of the date of surgery were recorded. For coexisting comorbidities, we determine the presence of diabetes mellitus (DM) and peripheral vascular disease (PVD). Results: Between1998-2010, 85 cases with ESRD on dialysis and 841 controls without ESRD were analyzed. Majority of patients were aged ≦65 years (82.5%) and 92.9% were men. The major subdivision of head/neck cancer was neoplasm of other and unspecified parts of the mouth followed by neoplasm of tongue, the gum, hypopharynx and floor of mouth. ESRD patients tended to have higher rates of DM and PVD (p<0.001). They also were significantly associated with an increased risk of stroke (adjusted OR=4.28, 95% CI=1.30–14.1) and a significantly increased risk of 30-day mortality (adjusted OR=4.58, 95% CI=1.18–17.8). However, there was no significant difference regarding flap failure among groups (adjusted OR=0.74, 95% CI=0.27–2.05). Conclusion: Despite greater pre-operative risk factors, renal failure does not appear to effect free flap survival following head and neck reconstruction. Optimizing patient’s medical condition is critical to the success of this reconstructive effort.
This report elucidates the continued and relatively rare problem of congenital symmastia and its surgical repair without concomitant bilateral breast reduction. This case highlights the use of suction-assisted lipectomy techniques to address the excess fat in the presternal web and a periareolar approach for access to the intermammary space. The periareolar incision allows for the use of a concealed approach and the avoidance of a central scar that could result in hypertrophy or keloid formation, especially in this patient who is more prone to hypertrophic scarring. Furthermore, plication of the central web dermis to the sternal periosteum in a more superior position serves to not only correct the symmastia but also redrape the excess skin and restore the blunted inframammary folds.
PURPOSE: The availability of an objective outcome measure for facial reconstructive surgery remains elusive. Evaluations submitted by external raters or by patient self-report may be influenced by expert knowledge, emotional antecedent, or implicit attitude. These types of subjective ratings, or objective measures such as anthropometric analysis, may unreliably convey how one is perceived by others. We are interested in observers’ instantaneous, reflexive responses to the human face, and how those instinctive responses relate to subjective judgment of a given face. We explored the visual markers that lead to differential perception of patients before and after facial reanimation surgery. By examining the early stages of visual processing that occur, we intended to measure changes in the focus of impression formation, thereby helping surgeons and their patients prioritize areas for reconstruction. METHODS: Pre and post operation (>3 months) photographs from 10 patients with unilateral facial nerve palsy who underwent cross facial nerve graft and free gracillis muscle transfer were obtained. Twenty lookzone regions were mapped onto each facial image, reflecting aesthetic units of the face. 40 observers examined each image while an infrared eye-tracking camera continuously recorded their eye movements. The observers were then asked to rate the image for character attributes (attractiveness, trustworthiness, sociability, healthy, and capability, 1–7 scale). Factorial ANOVA and student t-test analysis was performed to determine significance of differences between groups. RESULTS: (i) The surgical intervention was found to decrease the observers’ attention to the upper lip on the unaffected (non palsy) side, thus equalizing attention to both sides of the lips. (ii) The surgical intervention was found to significantly increase the character ratings for all five attributes compared to pre op controls: (sociable 3.2 to 3.6, trustworthy 3.42 to 3.61, attractive 2.96 to 3.2, health 3.37 to 3.54, p<0.05. (iii) For those pre-operative images of facial palsy, observers’ attention was overwhelming drawn to the area of disproportion. (iv) Our eye tracking methodology clearly reflects a trend towards normalization of gaze attention following surgical intervention. This finding was associated with the improvement in character assessment of the images in the post-op cohort of images. CONCLUSION: We provide data illustrating a novel and objective technique to evaluate the effect of reconstructive intervention for facial palsy. This information may be used to inform patients about how these areas of facial difference/aging are perceived, and the potential effect that surgical intervention may have on others’ perception of them. This work may assist patients and their surgeons to more meaningfully focus their surgical decision-making priorities.
Surgical management of lymphedema of the lower extremity is indicated in select patients when conservative measures have failed. The excisional approach has traditionally consisted of a staged excision procedure or total excision of diseased tissue. Based on an improved knowledge of vascular anatomy and understanding of perforator flap surgery, radical reduction of lymphedema with preservation of perforators (RRPP) applies an excisional approach and microsurgical principles to the radical reduction of lymphedema.Fifteen patients underwent RRPP during the period of June 1993 to February 2002 and were included in this study. Medial and lateral skin flaps were raised through incisions on the anterior and posterior leg, preserving a 4-cm skin bridge in the central portion of the incisions. The skin flaps were reduced to 5 mm in thickness, except in the vicinity of the lateral and medial septae, which contain perforators from the posterior tibial and peroneal arteries.At an average follow-up period of 13 months, a statistically significant reduction in lymphedema was achieved (P < 0.05). The average percentage in reduction above the knee was 51%, below the knee 66%, at the ankle 44%, and at the level of the foot 41%. The average overall lymphedema reduction for the patients was 52%. There were no cases of wound breakdown or skin flap necrosis. Complications consisted of cellulitis in 3 patients and seroma and hematoma in 1 patient.Based on angiosome principles and application of perforator principles to the surgical reduction of lymphedema, effective, long-lasting, and cosmetically appealing results are achieved in a single-stage procedure.
Taipei, Taiwan From the Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital. Received for publication February 3, 2003; revised May 30, 2003. Hung-Chi Chen, M.D. Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, 9 Alley 23, Lane 76, Ho-Ping East Road, Taipei, Taiwan [email protected]
PURPOSE: The implantable Cook Swartz Doppler is a commonly used, reliable technique for free flap monitoring. The device is removed once microvascular monitoring is no longer necessary. Occasionally there is difficulty retrieving the device and the use of further tension is avoided due to concerns about disrupting the anastomosis. In these cases, the metallic filament is cut at the skin level and a portion is retained in the soft tissues. Magnetic resonance imaging (MRI) is often strongly indicated in the postoperative followup of these patients who may be treated for malignancy or osteomyelitis, and the presence of retained probes raises some level of concern for MRI safety. Outcomes of retained probes, as well as safety when using MRI have not been studied. We present a series of retained Cook Swartz devices examining outcomes, clinical MRI safety and image quality. METHODS: A retrospective chart review was conducted of patients who underwent microvascular free tissue transfer and placement of an implantable Cook Swartz Doppler probe from July 2007 to August 2018. Routine postoperative imaging was reviewed for all patients to identify incidental findings of a retained probe. Demographics, post-operative complications, and follow up period were reviewed. Any subsequent MRIs performed on patients who we positively identified to have a retained probe were reviewed by a radiologist to detect any degradation of image quality. RESULTS: A total of 323 patients underwent microsurgery followed by Cook Swartz monitoring. Eighteen (5.6%) patients were identified with an incidental radiographic finding of a retained probe and were included in this study. The retained device was detected on various imaging modalities on average 21 months (1–65) following surgery. Mean age was 49 years (25–67) with mean follow-up of 34.4 months (2–122). The indications for free tissue transfer were esophageal reconstruction (n=5), breast reconstruction (n=5) extremity reconstruction (n=5), and facial reconstruction (n=3). Removal of the device was attempted on average 36 days (5–165) following surgery. Device-related complications occurred in only 1 patient who underwent lower extremity reconstruction when the filament caused a draining sinus that resolved after surgical device removal. One other asymptomatic patient underwent elective device removal due to concerns with potential imaging quality for cancer follow-up. A total of 32 MRIs were performed in 8 patients with retained devices, including 6 patients who underwent MRIs of the surgical site. On independent review of these MRI images and the medical record, there were no complications related to the scans, and we found no significant degradation of image quality. CONCLUSION: Retained Cook Swartz Doppler probes were not associated with substantial negative clinic outcomes after free tissue transfer for extremity, breast and esophageal reconstruction. Retained filaments did not affect MRI image quality of the surgical site at follow-up. Additionally, no patient who underwent MRI with a retained probe experienced any MRI-related complications due to heating or motion. If MRI is to be considered in situations with a known retained probe, we recommend that patients should be awake and communicative for the study due to the potential heating effects.
The purpose of this study was to report the motor functional outcomes and sensory recovery of patients who had undergone total or subtotal glossectomy for oral squamous cell carcinomas reconstructed with chimeric anterolateral thigh (ALT) flaps.Six patients, 4 men and 2 women, with a mean age of 49.5 years (range, 36-73 years) were included in the study. All patients were treated with chimeric ALT, including the vastus lateralis muscle with its motor nerve and skin paddle with its innervating nerve. All patients were administered functional tests involving sensory recovery, intelligibility, and swallowing. Flap sensibility was evaluated using light touch sensation with the Semmes-Weinstein monofilament test, 2-point discrimination according to the Weber sensitive test, warm and cold temperature sensations, and pain sensation. Intelligibility was scored by a speech therapist on a scale from 1 to 5. Swallowing was assessed by electromyography, deglutition scores (on a scale of 1 to 8), and modified barium swallow. Donor-site morbidities were recorded.Mean follow-up was 26.6 months (6 months-5 years). The flaps were successful in all 6 patients. The donor site was closed primarily and no complications were seen in the follow-up period. Normal extension of the knee joint and no evidence of lateral patella instability occurred. Speech intelligibility was good (4) in 3 patients and acceptable (3) in 3. Deglutition scores were 6 in 2 patients, 5 in 2, and 4 in 2. Modified barium swallow revealed that 4 patients experienced bolus transit, but 2 required a liquid swallow to promote bolus transit. Electromyographic recordings showed innervations of the vastus lateralis muscle with active generation of motor unit potentials in 4 patients when trying to elevate the tongue. This was not performed in 1 patient, and 1 other had macroscopic muscle contractions. All sensory tests were satisfactory in all parameters.The results of this reconstructive option were satisfactory in terms of motor function and sensitive assessment of the neotongue. This technique is strongly recommended for patients with total or subtotal glossectomy.
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