Structural fat grafting: more than a permanent filler

Grafted fat has many attributes of an ideal filler, but the results, like those of any procedure, are technique dependent. Fat grafting remains shrouded in the stigma of variable results experienced by most plastic surgeons when they first graft fat. However, many who originally reported failure eventually report success after altering their methods of harvesting, refinement, and placement. Many surgeons have refined their techniques to obtain long-term survival and volume replacement with grafted fat. They have observed that transplanted fat not only adjusts facial and body proportion but also improves surrounding tissues into which the fat is placed. They have noted not only the improvement in the quality of aging skin and scars but also a remarkable improvement in conditions such as radiation damage, chronic ulceration, breast capsular contracture, and damaged vocal cords. The mechanism of fat graft survival is not clear, and the role of adipose-derived stem cells and preadipocytes in fat survival remains to be determined. Early research has indicated the possible involvement of more undifferentiated cells in some of the observed effects of fat grafting on surrounding tissues. Of particular interest is the research that has pointed to the use of stem cells to repair and even to become bone, cartilage, muscle, blood vessels, nerves, and skin. Further studies are essential to understand grafted fat tissue.

Results of Chest Wall Resection and Reconstruction With and Without Rigid Prosthesis

BACKGROUND

Chest wall resections are associated with significant morbidity, with respiratory failure in as many as 27% of patients. We hypothesized that our selective use of a rigid prosthesis for reconstruction reduces respiratory complications.

METHODS

The records of all patients undergoing chest wall resection and reconstruction were reviewed. Patient demographics, use of preoperative therapy, the location and size of the chest wall defect, performance of lung resection if any, the type of prosthesis, and postoperative complications were recorded. Predictor of complications were identified by chi2 and logistic regression analyses.

RESULTS

From January 1, 1995, to July 1, 2003, 262 patients (median age, 60 years) underwent chest wall resection for tumor in 251 (96%), radiation necrosis in 7 (2.7%); and infection in 4 patients (1.3%). The median defect size was 80 cm2 (range, 2.7 to 1,200 cm2) and the median number of ribs resected was 3 (range, 1 to 8). Major lung resection was performed in 85 patients (34%). Prosthetic reconstruction was rigid (polypropylene mesh/methylmethacrylate composite) in 112 (42.7%), nonrigid (polytetrafluoroethylene or polypropylene mesh) in 97 (37%), and none in 53 patients. Postoperatively, 10 patients died (3.8%), 4 of whom had pneumonectomy plus chest wall resection. Respiratory failure occurred in 8 patients (3.1%). By multivariate analysis, the size of the chest wall defect was the most significant predictor of complications.

CONCLUSIONS

Our incidence of respiratory failure is lower than previously reported and may relate to our use of rigid repair for defects likely to cause a flail segment. Pneumonectomy plus chest wall resection should be performed only in highly selected patients.

Perforator-based flaps for low posterior midline defects

A new type of flap is described based on unnamed perforators located near the midline of the lower back region. Such flaps combine the superior blood supply of the myocutaneous flap with the lack of donor-site morbidity of a skin flap. Five clinical cases are presented, showing how such perforators can augment skin flaps or create custom-designed island flaps. The dissection of the flap is described, and further possibilities for its use are suggested.

Surgical problems in the excision and repair of radiated tissue

Surgical procedures for tissues damaged by radiation are fraught with the possibility of multiple and serious complications. A knowledge of the altered pathophysiology of such tissues (chiefly diminished blood supply, fibrosis, and direct cellular reparative potential) is necessary for the surgeon to make a proper judgment. Recognition of the pathognomic signs in the skin is important. The possibility of malignant change must be kept in mind. Surgical treatment must include the excision of radiated tissues back to good blood supply, and then proper and adequate coverage by the simplest and best means. If the surrounding local tissues are so altered that they are unsuitable for coverage, structures from a distance must be used. Prior planning of the coverage before the excision pays dividends by preventing disastrous complications.

The Internal Mammary Artery Perforator Flap

The anatomic basis for the internal artery mammary perforator (IMAP) flap is described in this cadaveric study, together with a clinical case report. The IMAP flap is based on a single or double perforator of the internal mammary artery that is included in the pedicle for added length. It provides a very useful source of local tissue with skin of good texture and color for head and neck reconstruction and, being muscle free, is thin. With preservation of the anterior cutaneous branch of the intercostal nerve, the flap has the potential to be sensate. A large area can be covered, particularly if bilateral flaps are raised. The donor site can be closed directly. In selected patients, it offers an excellent option for use in head and neck reconstruction and should be considered as an alternative to the deltopectoral and pectoralis major flaps.

Simple approach to the radiated scalp wound using INTEGRA skin substitute

The chronic irradiated scalp wound remains one of the most difficult reconstructions for the plastic surgeon. With its inherent radiodermatitis and poor healing potential, chronic ulcers down to bone will result if coverage cannot be achieved. Reconstructive procedures as simple as a skin graft have a high complication rate in the irradiated wound and often fail. Local tissue transfer also has a high failure and complication rate because of the decreased vascularity of the wound bed and radiation damage to the surrounding scalp tissue, limiting its manipulation. The authors report two cases using a simple method with INTEGRA bilaminate skin substitute (Integra Life Sciences, Plainsboro, NJ) for repair of difficult wounds of the radiated scalp. Case one involves a patient with nonhealing radiation ulcers that had failed local wound care, hyperbaric oxygen, and split-thickness skin grafting. Case two involves a patient with extensive squamous cell cancer of the scalp that recurred despite total scalp radiation, requiring resection of more than 50% of the total surface area of the scalp. Both these patients were successfully treated using INTEGRA artificial skin substitute (Integra Life Sciences). This simple method using INTEGRA (Integra Life Sciences) resulted in complete healing of the radiated scalp wound and an acceptable, functional, and cosmetic outcome with minimal morbidity to the patients.

Reconstruction of extensive scalp defects with rectus free flaps

This review represents the largest reported series involving reconstruction of complex scalp and calvarial defects with rectus abdominis free flaps. Sixteen patients presented with extensive (up to 300 cm2) scalp and calvarial defects requiring free tissue transfer for closure. All of the 11 patients who underwent a rectus abdominis free flap had a technically successful microvascular transfer. The defects encountered involved a wide spectrum of complexities including extensive multilaminar defects with exposed brain and dura, irradiated fields, and infection. In our institutions, the rectus abdominis muscle has evolved as a uniquely superior donor choice for restoring extensive scalp defects for several reasons: (1) accessibility, which eliminates intraoperative patient repositioning and allows for a simultaneous two-team approach; (2) minimal donor-site morbidity; (3) vascular reliability; and (4) the ability to supply abundant, easily contoured tissue.

Chronic radiodermatitis following percutaneous coronary interventions: a report of two cases

We describe two patients in whom chronic radiodermatitis with therapy-resistant ulceration of the right scapular region developed, following percutaneous coronary intervention with fluoroscopic imaging. Contrary to most reported cases in the literature, which involve numerous cardiac catheterization procedures, in both patients described here the total radiation dose was given during two successive procedures, involving difficult and prolonged coronary intervention with stent implantation. In both cases, local treatment of the ulcerative lesions was insufficient, necessitating excision of the radiodermatitis area and replacement with a skin graft, with good therapeutic result. The incidence of radiodermatitis after percutaneous coronary interventions is rising with the increasing number and complexity of these procedures. The main risk factor is a long duration of fluoroscopy using the same incidence. The skin lesions encompass a wide spectrum, ranging from erythema, telangiectasia, atrophy, hyperpigmentation and hypopigmentation to necrosis, chronic ulceration and squamous cell carcinoma. The lesions can appear from 15 days to 10 years after the procedure. To prevent radiation-induced injury, the radiation dose has to be limited and monitored. Also, careful inspection of the skin at the site of exposure is necessary and the radiographic beam has to be restricted to the smallest field size. A good clinical follow-up at regular intervals is important after long and complicated procedures.

[Cutaneous radiation syndrome: clinical features, diagnosis and therapy]

Accidental exposure to ionizing radiation may occur during such catastrophic events as the Chernobyl accident in 1986 or over days to weeks as in Goiania in 1987 and in the military camp during the training of soldiers in Lilo/Georgia in 1997, as well as in medical institutions. The cutaneous symptoms after radiation exposure are based on a combination of inflammatory processes and alteration of cellular proliferation as a result of a specific pattern of transcriptionally activated proinflammatory cytokines and growth factors. They follow a time course consisting of prodromal erythema, latency period, acute stage, chronic stage and late stage. The entire complex is referred to as cutaneous radiation syndrome. The time course depends on several factors such as the radiation dose, radiation quality, individual radiation sensitivity, the extent of contamination and absorption and amount of skin exposed. For the diagnosis of the cutaneous radiation syndrome the following procedures are used: 7.5 MHz to 20 MHz-B-scan sonography, thermography, capillary microscopy, profilometry, nuclear magnetic resonance imaging, bone scintigraphy and histology. Based on the results of experimental and clinical research, today treatment may include topical or systemic corticosteroids, gamma-interferon, pentoxifylline, vitamin E and superoxide dismutase. The treatment depends on the stage of the cutaneous radiation syndrome. Due to the complexity of the clinical manifestations of radiation disease, most patients require interdisciplinary treatment in specialized centres. Dermatologists are essential partners in the life-long follow-up and therapy of such patients.

Surgical treatment of actinic brachial plexus lesions: free microvascular transfer of the greater omentum

Actinic brachial plexus lesions after mastectomy have been treated in 67 cases. Thirty-nine cases have been operated on, 31 of which by means of a free microvascular transfer of the greater omentum. Indications and contraindications of the procedure are discussed, as well as the types of anatomic-pathologic lesions that have been found, and the surgical technique that has been modified and improved over time is presented. Results indicate that free microvascular greater omentum transfer following neurolysis is currently the best method for relief of pain.

Flow-through anterolateral thigh flap for a free osteocutaneous fibula flap in secondary composite mandible reconstruction

Head and neck reconstruction after tumour ablation and radiotherapy often requires complex surgery. The need for free composite tissue transfer and the poor quality of the recipient site increase the level of difficulty substantially. We report a case in which the mandible, floor of the mouth and skin of the neck needed to be reconstructed in a heavily irradiated field. A single osteocutaneous fibula flap was insufficient to reconstruct the defect, and a free anterolateral thigh (ALT) flap was also used for external neck skin resurfacing. As the recipient vessels in the ipsilateral neck had been heavily irradiated the free ALT flap was used as an interposition conduit for the free osteocutaneous fibula flap enabling it to reach the healthy recipient vessels in the contralateral neck without needing vein grafts.

Tissue expansion-assisted prefabrication of the forehead flap for nasal reconstruction

A new technique for nasal reconstruction is described. This method--expansion-assisted flap prefabrication--is essentially a simultaneous application of pretransfer grafting and tissue-expansion procedures for creating custom-made forehead flaps to meet varying requirements of nasal reconstruction. We have applied this new technique on seven patients, with full-thickness nasal defects during a 3-year period. Results from these patients are presented with a review of different use of flap prefabrication principles in nasal reconstruction.

Chest wall reconstruction for radionecrosis after breast carcinoma therapy

This study aimed at evaluating various reconstructive procedures for chest wall radionecrosis after breast carcinoma therapy. Four different techniques were performed between 1973 and 1992 in 120 patients: latissimus dorsi musculocutaneous flap (LDF; n = 81); transposed omentum and split-thickness skin graft (TGO; n = 20); fasciocutaneous flap (FCF; n = 10), and transverse rectus abdominis musculocutaneous flap (TRAM; n = 9). Initial dose of irradiation ranged from 60 to 110 Gy. The average interval between initial treatment and reconstruction was 11 years. Local recurrence was suspected in 26 patients and was histologically proven after removal in 36 (30%). Surgical procedure results were analyzed by mean hospital stay (8 days for LDF vs. 52 days for TGO), early (13% LDF vs. 60% TGO) and late (7% LDF vs. 35% FCF) complications, second surgery (15% LDF vs. 53% FCF), and functional and cosmetic outcomes. In our experience, the LDF was the first-line flap. The TRAM was used to cover very large defects and when breast reconstruction was needed. When these flaps were impossible or dangerous, we performed a TGO. These three procedures have replaced FCF indications.

[Therapeutic effect of human mesenchymal stem cells in skin after radiation damage]

Over 50% of all cancer patients presently receive radiotherapy at one stage in their treatment course. Inevitably skin is one of the most frequently damaged tissue due to its localization and constant turn-over. Our present goal is to reduce radiation-induced complications in human skin through stem cell therapy, particulary in human epidermis. Mesenchymal Stem Cells (MSCs) have been shown to be multipotent cells able to engraft in many tissues after injury. Herein, we isolated human MSCs and tested their capability to improve skin wound healing after irradiation. This potential was assessed in NOD/SCID mice which received 30 Gy locally on the thigh. This dose caused within 3 weeks local epidermis necrosis which was repaired within 13 weeks. MSCs were intravenously injected in irradiated mice 24 hours after exposure. Clinical scoring throughout 6 weeks gave indications that human MSCs reduced the extent of damage and accelerated the wound healing process. We show by quantitative qPCR and histological studies the presence of human MSCs derived cells into the scar. Human MSCs homed to the damaged skin and participated to the wound healing process. These results open prospects for cellular therapy by MSCs in irradiated epithelial tissues and could be extended to the whole general field of cutaneous cicatrization, particularly after burns.

Reconstruction of extensive defects of the parotid region: experience with the pectoralis major and free latissimus dorsi flaps

Large defects of the parotid region resulting from excision of malignant tumours, or necrotic tissue due to radiotherapy, should not always be closed with local tissue, for several reasons. Occasionally, myocutaneous flaps are indicated, giving better results. We describe the problems of such tissue defects and our experience over a 10-year period using 2 different flap reconstruction techniques. A total of 28 cases, 25 with malignant tumours of the parotid or the external ear, 2 with extensive radionecrosis of the parotid region and 1 with a burn, were evaluated. The defects were restored with a pectoralis major flap in 21 cases and with a free latissimus dorsi flap in 7 cases. The follow-up ranged from 18 to 60 months. The flaps were successful in achieving stable wound healing, restoration of tissue volume and in helping patients to return to normal life activities. There were complications in 28.5% of the cases. There were 2 early deaths due to encephalitis. Two pectoralis major flaps (9.5%) failed partially. All latissimus dorsi flaps survived. The pectoralis major proved to be useful, especially in older and medically compromised patients, whereas the latissimus dorsi fared well in younger female patients and in cases of a hemifacial resection defect. Numerous technical points in both methods are emphasized.

Chronic radiodermatitis injury after cardiac catheterization

The authors present two patients in whom chronic radiodermatitis developed after repeated cardiac catheterization and coronary angioplasty procedures, with no indication of malignancy. In one patient, after other therapeutic methods were unsuccessful in alleviating his symptoms, the authors excised the lesion with wide surgical margins and skin grafted the area. The mere purpose was to free the patient from the unrelenting pain and discomfort. In this case, the authors achieved complete success in wound healing but only partial success in pain relief.

Radiation necrosis overlying the ankle joint after injection with yttrium-90

A 35-year-old woman with rheumatoid arthritis presented with radiation necrosis and an open wound overlying her ankle joint, 8 months after injection with yttrium-90 to facilitate radiosynovectomy. This problem was successfully treated by surgical excision of the area of radiation damage and closure with a fasciocutaneous flap.

Preliminary investigative studies with PDT in dermatologic and plastic surgery

PDT has been shown to be of value in inoperable basal and squamous skin cancers and in cutaneous metastases. Azone, a new investigative vehicle for HpD, is of value more for intralesional injections than for topical applications in tumors, except perhaps for superficial mucous membrane lesions. The more flexible gold head vapor is of definite value in the PDT program. For test models for PDT studies in dermatology and plastic surgery with HpD and other fluorochromes, single thickened resistant plaques of psoriasis and the common baso squamous acanthoma (seborrheic warty growth) have been used. In all these studies, adequate controls are necessary.

Late sequelae of superficial irradiation

Superficial irradiation results in well recognized late sequelae including not only sclerosis and atrophy of skin and subcutaneous tissue, but also the development of benign and malignant tumors of skin and adjacent structures. The long latency between irradiation and its late effects allowed the early uncontrolled use of radiation treatment for benign conditions. The subsequent recognition of the causal relationship between tumors and previous irradiation has restricted its use to more appropriate purposes, although it is possible that it is still overused in some areas of dermatologic practice. Clinicians need to be aware of the time interval between irradiation and the development of its late sequelae, and the incidence of these sequelae. Appropriate irradiation exposure history should be a part of the evaluation of every patient.

A new extended external oblique musculocutaneous flap for reconstruction of large chest-wall defects

A new extended external oblique musculocutaneous flap utilized in the reconstruction of chest-wall defects is described. The flap is drawn as a V-Y rotation flap on the ipsilateral abdominal wall. It is laterally based, and its pedicle coincides with the five lowest costal insertions of the external oblique. The flap extends above the transiliac line, from the posterior axillary line to the linea alba, and includes the dynamic territory of the external oblique muscle. Vascular supply is provided by the musculocutaneous perforating arteries of the intercostal vessels and their subcutaneous branches. The flap is raised medially and includes the anterior sheath of the rectus. Undermining continues between the external and the internal oblique muscles as far as the posterior axillary line. The donor site on the abdominal wall is reinforced by the plication of the internal oblique sheath. This flap was used in 13 patients with major anterior chest-wall excisional defects. The mean chest-wall defect was about 390 cm2. Marginal necrosis with distal skin loss was observed in one patient. All other flaps healed without complications. The extended external oblique musculocutaneous flap differs from other external oblique flaps already described in several aspects that allow it to obtain better functional and aesthetic results.