Follow-up: orthognathic surgery. Is there a future? A national survey

BACKGROUND

The authors recently documented a significant decrease in orthognathic surgical cases performed by both plastic and oral surgeons in Ohio over a recent 5-year period. The main reason noted was related to third-party reimbursement. This is a potentially serious issue that may affect the quality of health care for patients with dentofacial deformities. Therefore, an expanded survey was conducted to determine whether this was indicative of a national trend.

METHODS

A three-page questionnaire was sent nationally to plastic surgeons and oral surgeons who were members of the American Society of Maxillofacial Surgery and the American Association of Oral and Maxillofacial Surgeons, respectively. Surveys requested information regarding changes in the number of orthognathic operations over a 5-year period (1999-2003) and reasons for these changes.

RESULTS

Of the 3273 surveys sent, 883 were returned, representing an overall response rate of 27 percent. Of the 883 returned, 771 (87.3 percent) were completed by oral surgeons and 112 (12.7 percent) were completed by plastic surgeons. The majority surveyed (70.0 percent) noted a decrease in the number of orthognathic procedures performed over a 5-year period, and 443 (77.3 percent) stated that the decrease was attributable to problems with insurance. Professional reimbursement per hour was calculated based on data collected from consecutive operations performed at the authors' institution. These data demonstrated that reimbursement per hour is significantly lower when orthognathic surgery procedures were compared with other standard plastic surgery operations.

CONCLUSIONS

Orthognathic surgery may rapidly be becoming a cosmetic procedure. This has the potential of creating a two-tier system whereby only those who can afford it will undergo orthognathic correction.

Cosmetic surgery volume and its correlation with the major US stock market indices

BACKGROUND

As a consumer-driven industry, cosmetic plastic surgery is subject to ebbs and flows as the economy changes. There have been many predictions about the short, intermediate, and long-term impact on cosmetic plastic surgery as a result of difficulties in the current economic climate, but no studies published in the literature have quantified a direct correlation.

OBJECTIVES

The authors investigate a possible correlation between cosmetic surgery volume and the economic trends of the three major US stock market indices.

METHODS

A volume analysis for the time period from January 1992 to October 2008 was performed (n = 7360 patients, n = 8205 procedures). Four cosmetic procedures-forehead lift (FL), rhytidectomy (Rh), breast augmentation (BA), and liposuction (Li)-were chosen; breast reduction (BRd), breast reconstruction (BRc), and carpal tunnel release (CTR) were selected for comparison. Case volumes for each procedure and fiscal quarter were compared to the trends of the S&P 500, Dow Jones (DOW), and NASDAQ (NASD) indices. Pearson correlation statistics were used to evaluate a relationship between the market index trends and surgical volume. P values <.05 were considered statistically significant.

RESULTS

Three of the four cosmetic surgery procedures investigated (Rh, n = 1540; Li, n = 1291; BA, n = 1959) demonstrated a direct (ie, positive) statistical correlation to all three major market indices. FL (n =312) only correlated to the NASD (P = .021) and did not reach significance with the S&P 500 (P = .077) or DOW (P = .14). BRd and BRc demonstrated a direct correlation to two of the three stock market indices, whereas CTR showed an inverse (ie, negative) correlation to two of the three indices.

CONCLUSIONS

This study, to our knowledge, is the first to suggest a direct correlation of four cosmetic and two reconstructive plastic surgery procedures to the three major US stock market indices and further emphasizes the importance of a broad-based plastic surgery practice in times of economic recession.

Anterior approach to neck rejuvenation

The anterior (submental) approach to neck rejuvenation has been described by multiple authors. The efficacy of the procedure depends on adequate release of cutaneous septae and cutaneous ligaments, which allows for skin contraction without skin resection as well as subplatysmal recontouring and platysma muscle tightening. With this procedure, the greatest improvement in appearance will be seen in the profile view. No improvement will occur above the mandibular border. The degree of profile improvement correlates best with skin quality. Because no skin is removed in this procedure, skin tightening is dependent upon skin elasticity. Therefore, those patients with poor skin quality will obtain lesser results. Patients are graded with regard to skin quality from grades I to IV, with grade I patients demonstrating ideal skin elasticity and grade IV patients demonstrating poor skin quality. The technique is described in detail, potential complications are noted, and technical limitations of the procedure are described.

Use of Calcium-Based Bone Cements in the Repair of Large, Full-Thickness Cranial Defects: A Caution

BACKGROUND

Calcium-based bone cements have increased in popularity for the correction of craniofacial contour defects. The authors' experience with them in more than 120 patients has resulted in the establishment of strict criteria for their use. Although the authors' overall complication rate with these cements has been low, certain patient groups have an unacceptably high complication rate. The authors describe their experience with the repair of large, full-thickness cranial defects using calcium-based bone cements.

METHODS

The study group comprised 16 patients who underwent correction of large, full-thickness (>25 cm2) skull defects. The surgical technique included reconstruction of the floor of the defect with rigid fixation to the surrounding native bone, interposition of the cement to ideal contour, and closure of the defect.

RESULTS

The mean patient age was 35 years (range, 1 to 69 years). The mean defect area was 66.4 cm2 (range, 30 to 150 cm2). Cases were equally divided between BoneSource and Norian CRS. The mean amount of bone cement used was 80 g. Follow-up varied between 1 and 6 years (mean, 3 years). Major complications occurred in eight of 16 patients, with one occurring as late as 6 years postoperatively. Complications occurred throughout the course of review, indicating that they were not caused by a learning curve.

CONCLUSION

Because of the unacceptably high complication rate with the use of calcium-based bone cements in large skull defects, the authors believe that their use is contraindicated and have returned to using autogenous split skull cranial bone reconstruction for these patients.

A comparison of dermabond tissue adhesive and sutures in the primary repair of the congenital cleft lip

OBJECTIVE

To compare the long-term cosmesis of Dermabond (octyl-2-cyanoacrylate) and traditional skin sutures among patients undergoing primary cleft lip +/- palate repair.

MATERIALS AND METHODS

Eleven patients underwent photographic analysis following primary cleft lip +/- palate repair, including the use of Dermabond. Eleven age-matched controls who underwent cleft lip +/- palate repair with traditional suture closure served as controls. Cosmesis was assessed by 3 blinded plastic surgeons using a visual analogue scale (VAS) and the Hollander Wound Evaluation Scale (HWES).

RESULTS

The overall mean VAS score for the patients treated with and without Dermabond was 70.0 (SD, 9.5) and 68.3 (SD, 13.4), respectively (P = 0.46). The overall mean HWES score for the patients treated with and without Dermabond was 1.7 (SD 1.7) (P = 0.92).

CONCLUSIONS

Dermabond tissue adhesive offers equivalent mature wound cosmesis as traditional suture closure in the repair of the congenital cleft lip +/- palate.

Cosmetic Procedures for the Aging Face

As the United States' population continues to age and as cosmetic procedures have become more accepted, adults from all age groups and socioeconomic brackets are seeking improvement in facial aging. Ideal correction includes improvement in the quality of skin, improvement in wrinkles, correction of soft tissue descent, removal of skin excess, and volume restoration. The physiologic rather than the chronologic age is the most important factor in determining the advisability of cosmetic surgery in elderly people. In addition to traditional cosmetic surgery procedures, the elderly population is amenable to several shortcuts, minimizing operative time and post-operative recovery. These can be performed alone or in combination with traditional procedures, improving the stigmata of facial aging and enhancing quality of life.

Bilateral Vascularized Femoral Bone Transplant

We present a new model of vascularized bone marrow transplantation-bilateral vascularized femoral bone (BVFB) isograft transplant based on abdominal aorta and inferior vena cava. A total of 7 BVFB isograft transplants were performed between Lewis (RT1) rats. In the donor, both femoral bones were harvested based on the abdominal aorta and inferior vena cava. In the recipient, the harvested isograft transplants were transferred into the inguinal region (in 3 animals) and into the abdominal cavity (in 4 animals). The mean operation time was 3 hours and 35 minutes. The mean warm ischemic time was 35 minutes. The vascular pedicles of the transplants that were transferred into the inguinal region were thrombosed at day 7 posttransplantation. The vascular pedicles of transplants into the abdominal cavity were patent and the bones were viable during the follow-up period of 63 days posttransplant. We have confirmed the feasibility of BVFB transplantation based on abdominal aorta and inferior vena cava.

Calvarial Thickness and Its Relation to Cranial Bone Harvest

BACKGROUND

The purpose of this study was to define the variability in skull thickness from location to location and from individual to individual in a large number of human skulls.

METHOD

Skull thickness was measured in multiple areas of the calvaria in 281 dry skulls from the Hamman-Todd osteological collection (Cleveland Museum of Natural History, Cleveland, Ohio). A total of 40 points were determined over the frontal, occipital, and parietal bones, with a higher number of points concentrated on the latter. Repeated measures analysis of variance models were used to assess the effects of covariates (individual variables) on skull thickness and location.

RESULT

A statistically significant pattern of increased thickness toward the posterior parietal bones was seen in all subgroups. The mean thickness of the skull across all locations was 6.32 mm (SEM, 0.07 mm) and ranged from 5.3 mm (SEM, 0.09 mm) to 7.5 mm (SEM, 0.09 mm). Age was not found to be a significant predictor of mean skull thickness. Differences between male and female skulls were greater toward the rear of the parietal bones.

CONCLUSION

The thickest area of the skull is the parasagittal posterior parietal area in male skulls and the posterior parietal area midway between the sagittal and superior temporal line in female skulls. An accurate map of the skull thickness representing the normative data of the studied population was developed. It is hoped that this topographic map will assist the surgeons in choosing the safest area of cranial bone graft harvest, thus increasing the safety of the procedure.

Reconstruction of intraosseous hemangiomas of the midface using split calvarial bone grafts

BACKGROUND

Intraosseous hemangiomas are benign lesions that usually occur in the vertebral column and the calvaria. They are rare in the midface, with only 22 zygomatic and 26 nasal bone hemangioma cases described in the literature. Methods of reconstruction of craniofacial defects after surgical removal of these tumors have been inconsistent.

METHODS

The authors report long-term follow-up in three cases of midface intraosseous hemangiomas all treated in a similar fashion: surgical excision of the tumor with a small margin of normal bone and primary reconstruction using split calvarial bone grafts.

RESULTS

Clinical, photographic, and computed tomographic assessment (cases 1 and 2) documents no recurrence and maintenance of the result with a mean 5-year follow-up. To the authors' knowledge, this represents the longest follow-up of a patient series with hemangiomas of bone treated with primary reconstruction in the plastic surgery literature (Wolfe and Berkowitz did report on a single case with 4-year follow-up without recurrence). We recommend replacing like with like. Primary bone grafting with autogenous cranial bone was used to replace areas where original bone was thin, but full-thickness bone was used in areas where original bone was thick. Full-thickness cranial bone grafts may be superior to split cranial bone with regard to long-term volume maintenance.

CONCLUSIONS

Preoperative computed tomographic scanning should lead to the appropriate diagnosis. Proper diagnosis should lead to appropriate treatment, which includes total excision and primary bone grafting of the defect to prevent soft-tissue contraction.

Orthognathic surgery: is there a future?

BACKGROUND

Despite significant clinical advances in orthognathic surgery, a perceived decrease in recent years in the number of orthognathic cases was noted at the authors' institution. Word of mouth suggested that this phenomenon was region-wide. To explore this possible dichotomy, a one-page questionnaire was designed and sent to all plastic surgeons in the American Society of Maxillofacial Surgeons and to all active practicing oral surgeons and orthodontists in the state of Ohio.

METHODS

The questionnaire was designed to estimate both the surgeons' and the orthodontists' perception of whether the number of orthognathic cases was increasing, decreasing, or remaining the same over a 5-year period (from 1996 to 2000). A second questionnaire was then sent only to plastic surgeons and oral surgeons to further evaluate reasons for this possible increase or decrease.

RESULTS

The overall response to the first survey was 39 percent (236 of 601 surveys sent); 87 responses (32 percent) were from plastic and oral surgeons, and 132 (40 percent) were from orthodontists. Seventy-five percent of responders perceived a decrease in the number of orthognathic operations. Of those, more than 80 percent claimed that reimbursement was the major reason for the reduction in the number of surgical procedures. The degree of reduction in reimbursement over this 5-year period was documented at the authors' institution, and the perceived reduction over this 5-year period was estimated by the respondents. Finally, reimbursement per hour was calculated for orthognathic cases and compared with three other standard plastic surgery procedures.

CONCLUSION

Implications of this reduction in orthognathic surgery in Ohio are discussed, and suggestions for better documentation of this health care issue are suggested.

The ???Anterior-Only??? Approach to Neck Rejuvenation: An Alternative to Face Lift Surgery

BACKGROUND

The ideal procedure for those patients with aging of the lower face and neck is a cervicofacial rhytidectomy. However, within this group is a subset of patients whose goals can be met with a lesser procedure. These patients must be interested in profile change only, with no desired change in the midface.

METHODS

Patients undergoing neck rejuvenation by means of a submental approach fall into three groups: (1) patients with obtuse cervicomental angles and good skin elasticity (who may be treated with liposuction alone); (2) patients with subplatysmal fat or mild to moderate skin and muscle laxity (these patients are best treated by anterior lipectomy and platysmaplasty); and (3) patients with marked skin excess or severe skin laxity (best treated by procedures with excised skin, i.e., traditional face lift or direct excision of neck skin and Z-plasty).

RESULTS

Thirty-three consecutive patients with mild (grade II, 16 patients), moderate (grade III, 11 patients), and severe (grade IV, six patients) cervicomental angle deformities were treated with anterior platysmaplasty and submental lipectomy. Twenty of 33 patients improved by one grade (61 percent), whereas 12 of 33 improved by two grades (36 percent).

CONCLUSIONS

Young patients with minimal subplatysmal fat can be treated by liposuction alone. Patients with subplatysmal fat and mild or moderate skin or muscle laxity will obtain consistent results with platysmaplasty and submental lipectomy. Skin excisional procedures are reserved for those patients with severe skin excess or laxity.

Prospective Analysis of the Outcome of Subpectoral Breast Augmentation: Sensory Changes, Muscle Function, and Body Image

This study is a prospective analysis of the outcome of subpectoral breast augmentation. Forty-seven patients undergoing breast augmentation were studied. They were assessed for pectoralis muscle function, breast sensation, and body image before and after subpectoral breast augmentation with saline implants. The patients were evaluated as follows: Pectoralis function was determined by measuring maximal voluntary isometric force. Sensation was evaluated by two means: vibration and pressure. The patient's body image was assessed using the Multidimensional Body-Self Relations Questionnaire. Results indicated a significant change in breast sensation at 3 months postoperatively but not at 6 months. Pectoralis muscle function did not significantly change during the study period. Body image was significantly improved at both postoperative measuring periods. The authors conclude that breast augmentation results in improved body image with negligible effect on muscle or nerve function.

A New Composite Facial and Scalp Transplantation Model in Rats

There are limited sources of autogenous tissue available for reconstruction of severe facial and scalp deformities caused by extensive tumor ablation, burns, or trauma. Allografts from cadaveric sources may serve as a reconstructive alternative. However, technical and immunological aspects of harvesting and transplanting face and scalp flaps limit the routine use of such procedures. For evaluation of the feasibility of composite-tissue reconstruction, an experimental model of composite face/scalp flap transplantation in rats was designed. Technical aspects of the model, survival rates, and the complications encountered during development of the model are presented. A total of 64 animals, in three experimental groups, were studied. In group I, the anatomical study group (n = 6), the anatomical features of the face and scalp region in rats were explored. Groups II and III were the transplantation groups. Isograft transplantations were performed between identical Lewis rats (RT11 to RT11), and allografts were transplanted, across major histocompatibility complex barriers, between Lewis-Brown Norway rats (RT1l/n) and Lewis rats (RT11). In group II (the control group, n = 8), transplantation of nonvascularized composite face/scalp isografts and allografts was performed. In group III (the transplantation group, n = 50), vascularized face/scalp isografts (n = 36) and allografts (n = 14) were transplanted. Complications included partial or total flap necrosis, death attributable to food aspiration, and poor general condition. To prevent acute and chronic allograft rejection, cyclosporine A (16 mg/kg per day) therapy was initiated 24 hours after transplantation; the dose was tapered to 2 mg/kg per day within 4 weeks and was maintained at that level thereafter. Long-term survival (>170 days) was achieved, without any signs of rejection, with low-dose (2 mg/kg per day) cyclosporine A therapy. This is the first report documenting successful composite face/scalp flap transplantation in the rat model.

Induction of tolerance in composite-tissue allografts

BACKGROUND

Transplantation of composite-tissue allograft (CTA) such as the human hand recently became a clinical reality. The high risks associated with the use of lifelong immunosuppression have been the prohibiting factor in the routine use of the CTA transplants. In this article, we present a new approach of inducing long-term, donor-specific tolerance to CTAs without recipient preconditioning and need for chronic immunosuppression.

METHODS

We have developed a clinically applicable 35-day protocol that induces donor-specific tolerance in a rat hindlimb-transplantation model across major histocompatibility complex (MHC) barrier [Lewis-Brown-Norway (LBN, RT1 -->F1) to Lewis (LEW, RT1 ) by using cyclosporine A (CsA) and a mouse monoclonal antibody against rat alphabeta-T-cell receptor (TCR) to systemically eliminate alloresponsive cells. Standard skin grafting, flow cytometry (FC), and mixed lymphocyte reaction (MLR) were used to assess efficacy of immunodepletion and confirm donor-specific tolerance and chimerism.

RESULTS

Under this protocol long-term tolerance (>720 days) was induced in all (n=5) CTA recipients across the MHC barrier without further need for immunosuppression. Tolerance was confirmed in all limb-allograft recipients by skin grafting in vivo and by MLR in vitro. The animals rejected third-party grafts, indicating immunocompetence.

CONCLUSIONS

In this CTA model, combined protocol of alphabeta-TCR monoclonal antibody and CsA resulted in induction of donor-specific tolerance across the MHC barrier without recipient conditioning. We believe that our findings will foster development of new therapeutic strategies and expand clinical applications for composite-tissue transplantation.

The role of preoperative antibiotic prophylaxis in cosmetic surgery

An estimated 2.7 million cosmetic procedures were performed in the United States in 1998, yet the role of preoperative antibiotic prophylaxis for cosmetic surgery is not clearly defined. Routine antibiotic prophylaxis for cosmetic procedures was discontinued by the senior author at the authors' institution in an effort to reduce use and cost in June of 1999. Subsequently, a cluster of four Staphylococcus aureus postoperative surgical site infections were identified. A case-control study to identify risk factors for surgical site infections in these patients was performed. All patients who underwent cosmetic surgical procedures by the senior author during June of 1999 and did not develop a surgical site infection were selected as control patients. Four case patients and 12 control patients were included in the study. The significant risk factors associated with surgical site infections were the mean duration of procedure (5 hours versus 2 hours; p = 0.02), general anesthesia (p = 0.004), and placement of a Blake drain (p = 0.004). No common source of infection was identified by review and observation of surgical technique. Pulse-field gel analysis of the S. aureus isolates from the four case patients and the nares of surgical personnel revealed no common strain. After the reinstitution of preoperative antibiotic prophylaxis with cefazolin for procedures anticipated to last 3 hours or longer, no additional surgical site infections were identified through December of 1999 (four of 29 versus none of 104; p = 0.002). It was concluded that targeted antibiotic prophylaxis for cosmetic surgery with cefazolin may be useful in reducing surgical site infections attributable to S. aureus.

Antibiotic use in aesthetic surgery: a national survey and literature review

Although much has been written regarding the use of antibiotics in surgery, no clear guidelines exist in the literature regarding the use of antibiotics in aesthetic surgery. To determine the pattern of antibiotic use in aesthetic surgery, a comprehensive survey was mailed to 6000 American Society of Plastic and Reconstructive Surgeons members and candidates. A total of 1767 completed responses were returned, which represents a response rate of 30 percent. The type, route, and duration of antibiotic administration are reported for 10 common cosmetic surgical procedures. The results of the survey confirmed that there is widespread use of antibiotics in aesthetic surgery. To provide guidelines for proper antibiotic use, the current literature was extensively reviewed. The authors found little or no correlation between reported clinical practice and the literature. It is hoped that this study will stimulate further investigation into this area of aesthetic surgery.

Computer-guided microsurgery: surgical evaluation of a telerobotic arm

A new telerobotic arm was evaluated in different microsurgical procedures. The system consisted of a robotic arm bearing a microsurgical forceps controlled by a joystick-like master unit operated by the surgeon's hand. The robotic arm functioned as an operating as well as assisting instrument. Advantages of the system were its precise functioning, which was especially important when tissue or instruments had to be held for a longer period of time, as well as its ability to replace an assisting person to some extent. Deficiencies of the system were its 10-min startup, the spatial conflict with in the operative field, and the poor rotation of the robotic tip. In some procedures, the telerobotic arm could replace the standard microsurgical instrument guided by the surgeon's second hand; in other maneuvers it could function as the surgeon's third hand with precision and void of tremor.

[A model for allogenic extremity transplantation in the rat with possible microcirculatory monitoring]

A rat model for monitoring allograft rejection of transplanted rat hindlimbs at the microcirculatory level is described. The well-established rat cremaster flap model is combined with a rat hindlimb transplantation procedure at a level proximal to the neurovascular pedicle of the cremaster muscle. The cremaster serves as a microcirculatory monitor for in vivo evaluation of graft rejection by measuring skeletal muscle perfusion. Donor animals are male Lewis Brown Norway rats and recipients are Lewis rats. The right cremaster muscle of the donor animal is dissected as a tubular island flap and preserved in a subcutaneous tunnel in the hindlimb. Afterwards, the right hindlimb including the cremaster is amputated at the mid level of the common iliac vessels and transplanted to the recipient at the level of the external iliac vessels. Over a time period of five days, the cremaster muscle of the composite transplants showed appropriate tissue quality for intravital microscopical observations. This transplantation model allows evaluation of allograft rejection in vivo at the microcirculatory level.

Relationship of obesity and specimen weight to complications in reduction mammaplasty

Obesity and specimen weight have both been associated with a higher incidence of complications for patients undergoing reduction mammaplasty. However, obesity has been arbitrarily and inconsistently defined, and the degree of obesity has not been considered in these previous studies. Because insurance companies are increasingly demanding weight loss before authorizing surgery, the relationship of obesity and breast size to complications is of great importance. Upon critical review of the literature, a number of fundamental questions remain unanswered. If complications are more frequent in the obese patient, are these complications directly proportional to the degree of obesity? Also, if the patient is required to lose weight before surgery, is weight loss effective in reducing complication rates? In an attempt to clarify these issues, 395 patients who underwent reduction mammaplasty over a 10-year period were reviewed retrospectively. Patients were arbitrarily divided into five groups in which, depending on their degree of relative obesity, they were classified as less than 5 percent, 5 to 10 percent, 10 to 15 percent, 15 to 20 percent, or greater than 20 percent above average body weight. To evaluate the relationship of specimen weight to complications, patients were also arbitrarily divided into five groups according to weight of the breast reduction specimen, which was classified as less than 300 g, 300 to 600 g, 600 to 900 g, 900 to 1200 g, and greater than 1200 g reduction per breast. Complications were then divided into local and systemic and major and minor. When bilateral reductions alone were analyzed (n = 267), there was a statistically significant increase in complication rate in the obese (p = 0.01). However, when the obese population was further subdivided according to their degree of obesity (less than 5 percent, 5 to 10 percent, 10 to 15 percent, 15 to 20 percent, and greater than 20 percent above average body weight), no further correlation was found. However, the relationship between specimen weight per breast and complications was much stronger with a direct correlation existing between increasing specimen weight and the incidence of complications. Although this study has shown that patients who are average body weight have fewer complications than obese patients after breast reduction surgery, it has not shown an increasing incidence of complication with increasing degrees of obesity. The implications of these findings and their relationship for denying patients surgery on the basis of weight alone are discussed in detail.

[Improving microcirculation of muscle flaps by tissue plasminogen activator in the rat cremaster muscle flap model]

Currently, tissue-plasminogen activator (t-PA) is the most potent and nevertheless safe fibrinolytic in clinical use. Its indications are fibrinolysis in acute myocardial infarction, ischemic stroke, deep vein thrombosis, pulmonary thromboembolism, as well as different kinds of peripheral arterial embolism. However, controlled studies on the effect of t-PA in microsurgery and free tissue transplantation are lacking. This study was designed to evaluate the effect of tissue-plasminogen activator on skeletal muscle flap perfusion after a thrombogenic stimulus. 24 male Sprague-Dawley rats were divided into four experimental groups of six animals each. In group 1, the cremaster was isolated as an end organ flap, in group 2 after cremaster isolation a semicircular inverted suture as a thrombogenic insult was performed at the ipsilateral common iliac artery. In group 3, local t-PA infusion followed the inverted suture and in group 4, vehicle was infused. After 24 hours, we measured cremaster muscle flap hemodynamics using intravital microscopy. Capillary perfusion significantly decreased after the inverted suture from 6.23 (group 1) to 1.50 (group 2) functional capillaries per visual field (medians). t-PA significantly increased capillary perfusion after the thrombogenic insult from 1.50 (group 2) and 2.50 (group 4) to 6.00 (group 3) (medians). Restoring capillary perfusion after a thrombogenic insult t-PA may increase flap survival rates.