Faculty Bibliography

Cancelled elective surgical cases result in wasted operating room time and additional hospital expense. We prospectively reviewed 1063 scheduled cases that resulted in 184 (17%) cancellations. For outpatient surgery, urology had significantly more, and orthopedic and pediatric surgery significantly fewer cancellations. For inpatient surgery, plastic surgery had significantly more and orthopedic surgery and obstetrics and gynecology significantly fewer cancellations. Lack of medical clearance and outpatient "no shows" accounted for the majority of avoidable cancellations. Case cancellations can be decreased by improved preoperative patient evaluation, improved communication between physician and patient, and modified schedule design.

The ideal material for reconstruction of a breast is fat and skin. Most current methods of autogenous reconstruction use myocutaneous flaps. We investigated the feasibility of transfer of skin and fat from the lower abdomen without muscle sacrifice. The flap is based on one, two, or three perforators of the deep inferior epigastric vessels. The study will demonstrate both experimentally and clinically this original technique for breast reconstruction. Fifteen breasts have been successfully reconstructed with this technique. This technique has all of the advantages of the free transverse rectus abdominis myocutaneous flap with decreased possibility of ventral hernia or muscle weakness.

During the past 4 years, our trauma and reconstructive service has treated a number of patients with lower extremity trauma involving the loss of both soft tissue and significant segments of tibia. While there are many methods for reconstruction of such defects, we became interested in providing a one-stage reconstruction of both the soft tissues and the missing bone segments. Since our standard flap for lower extremity reconstruction is a latissimus dorsi flap, we became interested in transferring a portion of the lateral border of the scapula along with the latissimus muscle. We dissected 34 cadaver scapulas in order to verify the reliability of the blood supply to the lateral border of the scapula based on the thoracodorsal artery. We then performed 12 "latissimus/bone flaps" from 1988 to 1992. Prior to flap transfer, control of the wound was obtained with surgical debridement and aggressive wound management. The flap usually was performed 5 to 7 days after initial contact with the patient. The muscle was skin grafted. All patients reported are ambulating, with x-ray evidence of bony incorporation of the transferred bone segment into the tibia. We feel that inclusion of the lateral scapula bone with the latissimus dorsi is a useful adjunct in the management of lower extremity trauma.

Bilateral mastectomies are relatively frequent. Free flaps from the abdomen, buttock, and lateral thigh can be used for simultaneous or staged reconstructions. The more extensive surgery is well rewarded by the permanent and gratifying results achieved. For patients unsuitable for implants or who have had failed implant reconstructions, such autologous tissue reconstructions are important alternatives.

In order to determine whether pancreatic islets could be neovascularized by a fasciovascular flap (FVP), islet transplant studies were conducted in Lewis rats. Islets from two donors were isolated by collagenase digestion and discontinuous gradient centrifugation on Ficoll. These islets were injected in syngeneic recipients either into random groin SC fat as a control, or into a flap composed of fascia and fat elevated from the groin based on the superficial inferior epigastric vessels. After two wk, islet viability was assessed by histological analysis. The degree of neovascularization of the islet tissue was evaluated with India ink injection through the vascular pedicle. Whereas control islets degenerated and did not show clear signs of neovascularization, FVP-islets showed rich neovascularization and viability as a large sheet of islet clusters. These results have demonstrated that the FVP-flap is a novel recipient site which can support a large quantity of islet tissue. This model constitutes a unique neo-endocrine pancreas flap, which can be subsequently transplanted at will to transfer the established neo-endocrine pancreas to a desired site using microvascular surgical technique.

OBJECTIVE: To compare the amount of scatter produced by titanium plates versus Vitallium (Howmedica, Rutherford, NJ) plates. Software was also evaluated to determine its effectiveness in removing the scatter and clarifying the underlying anatomy. MATERIALS AND METHODS: Miniplating and microplating systems composed of Vitallium or titanium were placed on the nasal and frontal bones of three adult pig heads. A computerized axial tomography (CAT) scan was then performed and a three-dimensional CAT scan was reconstructed using MediCad software (MediCad Inc, Cedar Knolls, NJ). The amount of scatter for each plating system was quantitated using the MediCad software measuring tool. The scatter was removed and the three-dimensional CAT scan was reconstructed to assess the clarification of the underlying anatomy. RESULTS: No scatter was found with either the miniplating or the microplating system composed of titanium. The Vitallium plates did show significant amount of scatter with the mini, micro, and micromesh system. Removal of the scatter resulted in slight improvement in the anatomic detail. CONCLUSION: Titanium plating systems do not cause any radiation scatter. The MediCad software system allows removal of the scatter found with the Vitallium plates, which helps clarify the underlying anatomy.

Contemporary head and neck hard tissue reconstruction incorporates bone transfers in the treatment of osseous discontinuity defects subsequent to congenital malformation, traumatic injury, ablative oncologic surgery, and failures of physiologic osteosynthesis. Bone grafts may also be applied in contour augmentation and in strengthening and stabilization roles in congenital and acquired aesthetic as well as posttraumatic deformities. The osseous healing process is dynamic and unique. An understanding of the physiology of these processes allows the reconstructive surgeon to choose techniques and donor sites appropriate to specific requirements, to maximize transplanted bone volume, to achieve consistent and reliable results, and to modulate the osseous healing process in a favorable direction

This retrospective study evaluates 11 infections requiring hospital readmission following 6166 consecutive face lifts (0.18 percent). Seven patients had surgical drainage of an abscess, and four patients were treated for severe cellulitis, Staphylococcus was the predominant organism in all abscess cultures. Of three patients admitted 3 weeks after surgery, two cultured gram-negative organisms in addition to Staphylococcus. This suggests that all patients should be treated initially with Staphylococcus coverage. If a patient is readmitted more than 1 week postoperatively, gram-negative coverage should be considered, pending culture results. There was no consistent finding regarding past medical history, the use of perioperative antibiotics, surgical equipment used, complexity of the surgical dissection, drains, or hematoma formation. No patients demonstrated systemic signs or grossly abnormal laboratory results on readmission. Eight patients had no sequelae from the infection. Three patients developed scarring that was considered minor by the affected patients. These data support the conclusion that major infections following a face lift are rare occurrences. Standard medical and surgical care, given in a timely fashion, usually results in a satisfactory outcome with minimal morbidity

The microvascular surgical anastomosis remains one of the most technically sensitive aspects of free-tissue transfers. To facilitate these often time-consuming, difficult anastomoses, various anastomotic coupling systems have been introduced. The 3M microvascular anastomotic coupling device, a polyethylene ring-pin device, was found to be highly successful in numerous animal studies. It has been available for use in human subjects for the last 4 years, but clinical experience remains sparse. Our clinical experience with the 3M coupler is reported in 100 free-tissue transfers. The average anastomotic time was 4 minutes. Mean follow-up was 8.6 months, and flap survival was 100 percent. The overall success rate for 3M (MACD) coupler use in microvascular anastomoses is 98.4 percent (121 of 123). Nine abandoned anastomoses were converted to sutured anastomoses intraoperatively. The over-all failure rate for 3M coupler anastomoses is 1.6 percent (2 of 123). We conclude that the 3M device is best suited for minimally discrepant, soft, pliable venous microvascular anastomoses and is unsuitable for end-to-side anastomoses in clinical situations. When carefully and selectively employed by a trained microvascular surgeon, the 3M coupler can be a safe, fast, and reliable adjunct for free-tissue transfers