Faculty Bibliography

The feasibility of prefabricating free flaps by inducing, through the process of staged reconstruction, an arteriovenous bundle and its surrounding fascia to perfuse a selected block of tissue was investigated experimentally and clinically. Sixteen rat knee joints were wrapped with their ipsilateral superficial inferior epigastric (SIE) fascia. In 8 joints, the composite flaps were resected en bloc and were immediately replaced orthotopically pedicled upon the superficial inferior epigastric vessels. In the remaining joints, the resection and orthotopic transfer were performed 2 weeks later. Only the joints in the latter group, which benefited from the staging period, were found to be perfused. The long finger proximal interphalangeal joint of a child was reconstructed by the staged microvascular transfer of his second toe proximal interphalangeal joint. At the first stage, a temporalis fascia flap was wrapped around the toe proximal interphalangeal joint and revascularized to the dorsalis pedis vessels. Six weeks later, the joint and its temporalis fascia envelope were dissected, and the "prefabricated" joint flap was transferred to the hand and revascularized to the wrist vessels. Bony union progressed uneventfully with excellent recovery of the range of motion. We conclude that regardless of the indigenous vascular anatomy, an unlimited array of composite free flaps can be constructed and transferred based on induced large vascular pedicles.

Forty-two male Sprague-Dawley rats were utilised to determine whether the angiogenic property of basic fibroblast growth factor (bFGF) could be applied to improve the survival of the ischaemic portion of a random skin flap and to accelerate the process of staged flap transfer. In the ischaemic flap model, bFGF enhanced the development of vascular connections between the bed and the flap and prevented marginally perfused areas from undergoing necrosis. No effect was observed in the staged reconstruction model using the same dosage of bFGF. A speculative explanation is given for the differential effect of BFGF in these two models. The application of angiogenic factors may improve the survival of the random portion of skin flaps. Further investigations are needed to determine whether exogenously applied angiogenic factors can have a beneficial effect in staged flap reconstructions.

Twenty-two cases of traumatic below-knee amputation stumps with inadequate soft-tissue coverage salvaged with microvascular free flaps were reviewed retrospectively. All patients would have required an above-knee amputation for prosthesis fitting had microvascular free flaps not bee utilized. A total of 24 flaps were used in 22 patients; parascapular 11 (46%), foot filet six (25%), latissimus dorsi four (17%), lateral thigh, tensor fascia lata, and groin one (4%). Free flaps were performed immediately after injury in five (21%) cases, within the first week in two (8%), between 1 and 3 months in 12 (50%), and after 3 months in five (21%). Fifty per cent of the patients had significant other injuries. The patients had a total of 107 operations (mean, 4.9) related to their injury: 33 (mean, 1.5) of those operations were after the free flap, 27 (25%) of which were either performed because of a complication of the free flap or for revision of the free flap. Complications included partial necrosis in five (21%), neuroma in three (13%), hematoma in two (8%), donor site complication in two (8%), thrombosis requiring reoperation in one (4%), and flap failure in one (4%). Patient followup ranged from 12 to 116 months. All patients maintained a functional below-knee prosthetic level. The mean time to ambulation was 5.75 months, and was not significantly affected by flap complications. Most patients employed before their injury were employed after their injury. Despite a protracted course in these severe injured trauma patients, a functional below-knee amputation level was preserved in all cases utilizing microvascular free flaps

A technique of wound closure following tethered cord correction is presented that significantly reduces the incidence of cerebrospinal fluid collections in the subcutaneous space. In over 60 cases, the described method of fascia and skin closure has lessened wound problems to a minimal level. Patient hospitalization time has also been greatly diminished

A multitude of factors influence the palpebral aperture: the surrounding bony orbital anatomy, the internal orbital volume, the integrity of the eyelids, and their muscular and tarsoligamentous support system. Furthermore, it is influenced by the relative amount of associated periorbital skin, fat, and soft tissues. Unique individual combinations of the above eyelid and orbital anatomic influences cause the variations in the palpebral apertures

The fidelity of visualizing craniofacial features using two modern three-dimensional (3D) imaging algorithms - one employing surface and the other volume rendering - are compared. Each rendering technique was evaluated for its ability to display closed cranial sutures, loss of thin bone through partial volume averaging, and the presence of artifacts. Linear measurements of the orbits, foramina, and mounting holes were taken on the 3D renderings and compared with direct measurements. Both techniques visualized the closed cranial sutures, orbits, mandibles, and teeth. The errors in linear measurement averaged less than 1.5 mm (root mean square) and were not statistically different between the two techniques. Errors are attributable to uncertainty in locating edges due to partial transparency (volume rendering) and sub- optimal lighting. Both rendering techniques suffer from step pattern and thin bone artifacts. We conclude that an algorithm for surface construction can provide detailed and accurate representation of the craniofacial anatomy

This report proposes that reflex sympathetic dystrophy be defined as a pain syndrome in which the pain is accompanied by loss of function and evidence of autonomic dysfunction. In the clinical setting, this diagnosis is usually associated with other anatomic and psychological diagnoses and may be associated with a variety of systemic illnesses and medicolegal factors. All components should be assessed before a treatment plan is established. Priorities should go to emergency care, acute injuries, and systemic illness, psychiatric problems, and chronic anatomic problems, in that order. Early, accurate diagnosis improves prognosis