Faculty Bibliography

BACKGROUND: Recent clinical trials involving patients with acute coronary syndromes have demonstrated significant reduction in the progression of coronary artery thrombosis using a regimen of aspirin, heparin, and the glycoprotein IIb/IIIa inhibitor tirofiban. Acute coronary syndromes and free tissue transfer are similar pathophysiologically in that they both involve endothelial injury, thrombosis, and ischemia. In this study, the authors investigate tirofiban, combined with aspirin and heparin, for the prevention of microsurgical anastomotic thrombosis in a thrombogenic rat model. METHODS: Using a randomized, controlled, double-blind experimental design, 80 thrombogenic anastomoses were performed on rat femoral arteries (n = 40) and veins (n = 40). Preoperatively, each rat received one of four treatment regimens: aspirin and heparin (regimen 1), aspirin and heparin plus tirofiban (regimen 2), tirofiban alone (regimen 3), or isotonic saline (control) (regimen 4). Vessels were assessed for patency at 5, 15, 30, and 120 minutes after reperfusion and then harvested for microscopic analysis. RESULTS: At 120 minutes after reperfusion, regimen 1 had an arterial and venous patency rate of 80 percent and 70 percent, respectively, whereas the vessel patency rate for regimen 2 was 100 percent. The difference between regimens 1 and 2 was not statistically significant. Regimens 3 and 4 had vessel patency rates of 40 percent or less. The aspirin/heparin and aspirin/heparin/tirofiban groups both demonstrated significantly improved vessel patency and significantly less thrombotic occlusion compared with controls. CONCLUSIONS: Combination therapy with aspirin, heparin, and tirofiban significantly increases arterial and venous patency and decreases anastomotic thrombus formation in thrombogenic anastomoses in rats. The role of glycoprotein IIb/IIIa inhibitors in microsurgery warrants further investigation.

BACKGROUND: Large, complex, posttraumatic and recurrent abdominal hernias present a reconstructive challenge. Multiple techniques have been described to restore the integrity of the abdominal wall, although the indications and applications can be difficult to navigate. The authors propose an algorithm that facilitates the assessment and treatment of secondary large ventral defects. METHODS: The algorithm described involves a systematic approach to abdominal wall reconstruction and was applied to 23 consecutive patients at the R Adams Cowley Shock Trauma Center. Data collected from the chart review included age, body mass index, mechanism of injury, placement of skin graft and use of resorbable mesh before definitive reconstruction, size of defect, number of tissue expanders placed, length of follow-up, and complications. RESULTS: There were six female patients and 17 male patients, with an average age of 36 years. The average follow-up was 7 months. Seventeen patients had posttraumatic laparotomies, five patients had aggressive abdominal wall debridement following necrotizing fasciitis, and one patient developed a large abdominal wall hernia following complications from gastric bypass surgery. All patients underwent delayed abdominal wall reconstruction, with an average time to initial reconstruction of 19.5 months. Sixteen patients had no postoperative complications. Seven patients had complications, including one with an enterocutaneous fistula, one with a partial small bowel obstruction, two with seromas, one with a superficial wound infection, and two with recurrent abdominal wall laxity. CONCLUSIONS: The reconstructive ladder for large, complex abdominal hernias is poorly defined. The proposed algorithm provides a systematic staged approach that incorporates available techniques used for delayed reconstruction of the abdominal wall.

We present two cases of infected frontal sinus fractures requiring simultaneous obliteration of the frontal sinus and reconstruction of the horizontal buttress. In both cases, a free fibula flap was used for obliteration and bony reconstruction in a single stage. We believe that this is a novel technique for treatment of infected frontal sinus fractures obviating the need for secondary staged procedures.

BACKGROUND: Identification of a single donor site capable of providing all the components of the soft tissue envelope and the ability to selectively harvest a subset of these components is a central requirement for the microvascular reconstruction of the trauma patient. The anterolateral thigh (ALT) flap's long pedicle and adaptability in supporting a variety of tissues (muscle, fascia, soft tissue) make it a valuable tool for microsurgical reconstruction in these challenging patients. We investigated the utility of the ALT as a donor for microvascular tissue reconstruction in a Level I trauma center. METHODS: We conducted a retrospective chart review on all trauma patients treated by the plastic surgery service at the R Adams Cowley Shock Trauma Center who required microsurgical free flap coverage from July 2002 to March 2005. Fifty-eight patients underwent reconstruction of traumatic deformities with 62 microvascular free flaps from the ALT region. RESULTS: Of the 58 patients, 42 were male and 16 were female with an average age of 39 years. Recipient site locations for the 62 flaps were lower extremity, upper extremity, trunk, and head and neck. Analysis of flap anatomy revealed that 43 were fasciocutaneous, 14 were myocutaneous, 2 were adipofascial, and 3 were myofascial (vastus lateralis muscle). Six flaps were based on septocutaneous perforators, whereas the remainder contained myocutaneous perforators. Nine thigh donor sites required a split thickness skin graft, and 53 were closed primarily. The size of the flaps ranged from 36 cm2 to 600 cm2. CONCLUSIONS: The ALT is a predictable donor site that facilitates a 2-team approach. ALT displays minimal donor site morbidity and in most cases provided sufficient tissue to cover the entire traumatic defect. Our results suggest the ALT is a reliable tissue source and an ideal donor site for the management of complex traumatic wounds in the United States.

A 66-year-old man with silent sinus syndrome, resulting in progressive enophthalmos and subclinical chronic maxillary sinusitis, presented after several failed attempts at reconstruction with conventional methods. A free fibula osteoseptocutaneous flap was used to recreate the orbital floor, obliterate the maxillary sinus, and augment the periorbital contour deformity in a single stage. This is a novel approach for the treatment of Silent Sinus Syndrome in a single stage.

BACKGROUND: Trauma patients with high-energy injuries often present with severe tissue damage that extends beyond the immediate zone of injury and requires recruitment of vascularized tissues from distant sites. The objective of this study was to evaluate the utility of the anterolateral thigh (ALT) flap for reconstruction of the traumatically injured lower extremity. METHODS: Prospective data were collected on all patients who underwent lower extremity reconstruction with an ALT flap during a 3.5-year period at a primary adult resource center (PARC). Demographics captured included age, gender, Injury Severity Score, mechanism of injury, and size of defect and complications. RESULTS: Fifty-six patients underwent a total of 59 ALT flap harvests during the study period. The majority of patients were male (75%) and sustained blunt injury (95%). The mean age was 37 +/- 14 years with a mean Injury Severity Score of 17.9 +/- 8. The mean flap size was 20.7 x 8.4 cm, with 64% harvested from the injured limb. Total flap success rate was 91.5%, with four total (6.7%) and one partial flap failure (1.7%). CONCLUSION: The ALT flap is a useful tool for trauma reconstruction in lower extremity salvage. We have shown that the ALT flap can be performed successfully in the traumatically injured patient even when harvested from the ipsilateral lower extremity.

The plastic surgeon's usual involvement in patients with hepatitis C is most frequently limited to an inner city population with hand and forearm abscesses from intravenous drug use or to incidences of needle-stick injury in the operating room when the patient is hepatitis C positive. Hand surgeons and peripheral nerve surgeons often treat patients with underlying neuropathies who have superimposed overlying nerve compressions such as carpal tunnel syndrome. We have applied this experience to a patient with underlying peripheral neuropathy associated with Hepatitis C and clinical evidence of overlying lower extremity nerve compressions. We believe that she is the first successful surgical treatment of peripheral nerve compressions in a patient with hepatitis C-associated neuropathy, documented by noninvasive neurosensory testing.