Faculty Bibliography

Perforator flaps allow the transfer of the patient's own skin and fat in a reliable manner with minimal donor site morbidity. For breast reconstruction, the abdomen typically is our primary choice as a donor site. The deep inferior epigastric perforator (DIEP) flap remains our first choice as an abdominal perforator flap and has become a mainstay for the repair of mastectomy defects. It allows the transfer of the same tissue from the abdomen to the chest for breast reconstruction as the TRAM flap without sacrifice of the rectus muscle or fascia. We discuss our current techniques and specific issues related to the surgery. We present the results of 1095 cases of free tissue transfers from the abdomen for reconstruction of the breast

BACKGROUND: Several alternatives exist for breast cancer reconstruction with perforator flaps. For those patients in whom the buttock is the best choice as a source for autologous tissue, the IGAP and SGAP flaps are an excellent option. These flaps allow the reliable transfer of skin and soft tissue from the buttock without the associated donor site morbidity of a muscle flap. INDICATIONS: Most women requiring tissue transfer to the chest from the buttock for breast reconstruction or other reasons are candidates for IGAP or SGAP flaps. Do to an improved donor site contour and scar, we now prefer to use the IGAP to the SGAP flap. Absolute contraindications specific to perforator flap breast reconstruction in our practice include history of previous liposuction of the donor site or active smoking (within 1 month prior to surgery). ANATOMY AND TECHNIQUE: IGAP and SGAP flaps are based on perforators from either the superior or inferior gluteal artery. These perforators are carefully dissected free from the surrounding gluteus maximus muscle, which is spread in the direction of the muscle fibres and safely preserved. The vascular pedicle is anastomosed to recipient vessels in the chest and the donor site closed primarily. CONCLUSIONS: IGAP and SGAP flaps allow the safe and reliable transfer of tissue from the buttock for breast reconstruction as an alternative to soft tissue transfer from an abdominal donor site or even as a first choice in selected patients

BACKGROUND: Perforator flaps allow the transfer of the patient's own skin and fat in a reliable manner with minimal donor-site morbidity. The deep inferior epigastric artery (DIEP) and superficial inferior epigastric artery (SIEA) flaps transfer the same tissue from the abdomen to the chest for breast reconstruction as the TRAM flap without sacrificing the rectus muscle or fascia. Gluteal artery perforator (GAP) flaps allow transfer of tissue from the buttock, also with minimal donor-site morbidity. INDICATIONS: Most women requiring tissue transfer to the chest for breast reconstruction or other reasons are candidates for perforator flaps. Absolute contraindications to perforator flap breast reconstruction include history of previous liposuction of the donor site or active smoking (within 1 month prior to surgery). ANATOMY AND TECHNIQUE: The DIEP flap is supplied by intramuscular perforators from the deep inferior epigastric artery and vein. The SIEA flap is based on the SIEA and vein, which arise from the common femoral artery and saphenous bulb. GAP flaps are based on perforators from either the superior or inferior gluteal artery. During flap harvest, these perforators are meticulously dissected free from the surrounding muscle which is spread in the direction of the muscle fibers and preserved intact. The pedicle is anastomosed to recipient vessels in the chest and the donor site is closed without the use of mesh or other materials. CONCLUSIONS: Perforator flaps allow the safe and reliable transfer of abdominal tissue for breast reconstruction

BACKGROUND: The reported incidence of hematoma following male rhytidectomy ranges from 7.9 to 12.9 percent. In 1976, it was demonstrated that postoperative hypertension is a key etiologic factor in hematoma formation and postoperative use of Thorazine was recommended to control blood pressure. This study analyzes the incidence of hematoma after male rhytidectomy at one institution after a strict and aggressive perioperative blood pressure control regimen was initiated. METHODS: From 1982 to 2002, 985 patients with a mean age of 61 years (range, 49 to 72 years) underwent rhytidectomy. Thirty-six patients required surgical evacuation of expanding hematoma after rhytidectomy. Operative procedures were performed by more than 100 different plastic surgery attending surgeons, residents, and fellows. RESULTS: The overall incidence of hematoma during this study period was 4.24 percent. Age, medical history, medications, type of anesthesia, rhytidectomy technique and combination of procedures, and length of operation were not independent risk factors for determining who was more likely to develop a hematoma. Thirty-three percent of the patients requiring surgical evacuation had systolic blood pressure greater than 150 mmHg and diastolic blood pressure greater than 90 mmHg preoperatively, intraoperatively, and postoperatively. Over a 30-year period, the incidence of hematoma requiring surgical evacuation has decreased from 8.7 percent to 3.97 percent after initiation of a strict perioperative blood pressure control regimen. CONCLUSION: Despite the lower incidence of hematoma following male rhytidectomy today as compared with 30 years ago, the incidence in men (3.97 percent) remains higher than that in women (1 to 3 percent).

Radiation therapy (RT) is considered by some to be a contraindication to nipple-areola reconstruction (NAR) particularly in patients with breast implant reconstruction. In this retrospective chart review, all patients who underwent breast reconstruction with tissue expanders and implants from 1997-2003 were reviewed. A subset of patients with a history of radiation therapy (pre- or postoperative) was identified. Postoperative complications, surgical technique, and the time course of reconstructive procedures were analyzed. Thirteen percent of patients with a history of RT had NAR compared with 36% of similarly reconstructed patients without a history of RT. Reconstruction was accomplished using a variety of local flaps, with an overall complication rate of 25%. Nipple-areola reconstruction after chest-wall irradiation in patients reconstructed with breast implants should be performed in carefully selected patients. Acceptable surgical candidates demonstrate resolution of acute radiation changes, no evidence of late radiation changes, and appropriate thickness of the mastectomy skin flaps.

Apert syndrome, first described in 1906, is one of the most severe of the craniosynostosis syndromes and is further characterized by midface hypoplasia, syndactyly, and other visceral abnormalities. Affected individuals generally require lifelong management by a multidisciplinary team of health care specialists. Apert syndrome results almost exclusively from one or the other of two point mutations in fibroblast growth factor receptor 2. Tremendous scientific advances have been made recently in understanding the molecular basis for Apert syndrome through clinical genetic, biochemical, and structural approaches. In this review, the authors provide the clinician with a basic overview of these findings and their therapeutic implications

BACKGROUND: Silicone, in the form of injectable liquid and prosthetic blocks, has been used to correct facial contour defects. However, silicone also has been associated with many complications including malposition, dyschromia, dysesthesia, contractures, infection, and fistula. Complications related to injectable-liquid and prosthetic-block silicone use in treatment of facial deformities pose a challenging surgical dilemma. METHODS: Over a 15-year period, microvascular free flap technique has been used successfully as a surgical tool to correct severe soft-tissue complications of the face resulting from silicone treatment of facial contour deformities. Surgical treatment guidelines, methods, and results for treating this difficult problem with free tissue transfer are presented. RESULTS: In 23 patients, 24 free tissue transfers (22 inframammary extended circumflex scapular free flaps and two superficial inferior epigastric free flaps) were performed. Flap survival was 100 percent. Both hematoma and skin necrosis were encountered in three of 24 cases (12.5 percent). Revisional surgery combined with aesthetic surgical procedures was required in 20 of 24 cases (83 percent). CONCLUSIONS: We recommend the following surgical treatment guidelines for this unique subset of patients: silicone excision with immediate microvascular free flap reconstructive procedure when the skin and soft tissue are mildly to moderately affected, or silicone excision with delayed reconstructive procedure when the skin and soft tissue are severely affected. Free tissue transfer is a useful surgical tool for salvaging severe facial skin and soft-tissue deformities caused by previous silicone treatment