Using the iliac crest free flap.
Explore the source record for details and available documents.
Humans↗
Biomedical subjects
D Buchbinder
Publications and source records attributed to D Buchbinder.
The internal oblique-iliac crest osseomyocutaneous free flap in oromandibular reconstruction. Report of 20 cases.
Microvascular free tissue transfer techniques using composite flaps are the most reliable method for the combined bone and soft-tissue reconstitution of oromandibular defects. Functional oromandibular reconstruction requires that maximum tongue mobility be achieved along with dental prosthetic rehabilitation. The internal oblique-iliac crest osseomyocutaneous microvascular free flap was used in 20 patients for oromandibular reconstruction. The internal oblique muscle, based on the ascending branches of the deep circumflex iliac artery and vein, was used to resurface mucosal defects of the oral cavity and pharynx. The iliac bone, because of its length, width, and natural contour, is the best source of vascularized bone for mandibular reconstruction. The improved soft-tissue component of this composite flap markedly improved the functional results. Reconstruction failed in one patient. Eleven patients underwent dental rehabilitation with either a tissue-borne or osseointegrated implant-borne denture. Follow-up of longer than one year showed minimal donor site morbidity.
Adult↗
Geometry of the vascular pedicle in free tissue transfers to the head and neck.
Traditionally, the most important parameters for success in free tissue transfer have been expertise in performing small vessel anastomoses, meticulous donor site dissection, and careful recipient vessel preparation. It has been our experience, in free flap transfers for head and neck reconstruction, that a very crucial, often unrecognized, parameter is the geometry of the vascular pedicle. This term encompasses the three-dimensional positioning of the nutrient vascular pedicle as well as vessel tension and redundancy. The ideal axis for the lie of the vascular pedicle in the neck is in the longitudinal direction. This configuration helps to eliminate the kinking of the pedicle that is observed with side-to-side movements of the head. The primary objectives in recipient vessel selection are to use a healthy artery and vein and to perform the anastomoses in a location that provides easy access for the surgeon and assistant. Recipient vessel selection is also a major determining factor in the achievement of the desired pedicle geometry. We believe that the transverse cervical artery and the external jugular vein are the best recipient vessels for free tissue transfer. The reasons for this selection, as well as technical details to improve pedicle geometry, are discussed in depth. Representative cases that demonstrate pitfalls in vascular pedicle geometry are presented.
Adult↗
Free flap design in head and neck reconstruction to achieve an external segment for monitoring.
Postoperative monitoring of the perfusion of a free flap used in head and neck reconstruction is vitally important in achieving a favorable outcome. There are a wide range of methods that have been advocated to assist in this surveillance. However, at this time, there is no one technique that is universally efficacious in detecting early arterial and venous occlusion. In our experience, the most reliable means of monitoring has been the clinical assessment of flap color, capillary refill, tissue turgor, and bleeding. To assess these parameters, a portion of the flap must be accessible for observation. When the defect is buried, as is often the case in head and neck reconstruction, flap design is critical to achieve a reliable external segment for monitoring. The methods for exteriorizing a well-vascularized portion of tissue in the most commonly used flaps are described.
Gastric Mucosa↗
Reduced intimal injury to canine arteries with controlled application of vessel loops.
Arterial intimal damage caused by elastic vessel loops was quantitated to determine (1) if they produce intimal injury, (2) if the injury is proportional to the force applied, and (3) if the injury is less than that produced by vascular clamps. Vessel loops were wrapped around 30 canine artery segments (5 mm in diameter) and a gram scale was connected to each to measure the force applied. The minimal occlusive force (MOF) and 150, 200, and 250 g force were applied for 30 min. For comparison, a Fogarty vascular clamp was applied at MOF for 30 min. Arteries were then reperfused for 30 min. Half was immediately harvested (group I); the remaining half was harvested at 2 weeks (group II). Scanning electron micrographs were made of each artery's intimal surface and graded from 0 (no injury) to 5 (severe intimal fracture). Mean injury grades were calculated. The MOF for vessel loops was 99 g. In group I, arteries subjected to less than 200 g force had a mean injury grade of 1.0 +/- 0.4; while those exposed to 200-250 g force had an injury grade of 3.5 +/- 0.7. The severity of injury was linearly correlated with the force applied (r = 0.72, P less than 0.009). In group II, the injury grade of 0.4 +/- 0.5 in arteries at MOF was significantly less than the injury grade of 2.8 +/- 0.5 in those at 200-250 g force, (P less than 0.0005). Injury grades of 3.7 and 3 were seen in groups I and II, respectively, when Fogarty clamps were applied. We conclude that vessel loops applied at MOF produce minimal injury. At greater occlusive forces, the injury is proportional to the force applied approaching that of a Fogarty clamp. Intimal injuries may be minimized when vessel loops are applied at MOF.
Animals↗
Functional mandibular reconstruction of patients with oral cancer.
For the patient with oral cancer who has undergone quadrant resection, mandibular reconstruction provides normalization of the lower facial contour, regained architectural support, and reestablishment of occlusal relationships. Reconstruction with vascularized bone offers the most rapid rehabilitation. Replacement of dentition provides improved deglutition, mastication, and speech. In eligible patients the use of osteointegrated implants can provide rigid stabilization for dental prostheses. In previous studies these implants were placed in a secondary procedure. In the present study microvascular mandibular reconstruction was combined with primary placement of osteointegrated implants in the treatment of seven patients. Preliminary results indicate that the combination of procedures can provide more rapid and effective rehabilitation for the patient with cancer. Issues for further study are also identified.
Adult↗
The in situ bypass above the knee.
The anatomical location of the saphenous vein in the distal thigh allows for construction of an in situ bypass to the above-knee popliteal artery. The authors have performed over 1400 in situ bypasses in the past 10 years. Forty-three of these have been to the above-knee popliteal artery. Thirty-three bypasses were performed for limb threatening ischemia, seven for disabling claudication and three for microemboli. Mean patient age was 67 years, 51% were males, 44% had diabetes mellitus, and 93% smoked. Grafts were followed from one to 108 months. The cumulative patency rate at two years was 90% and at four years 77%. Patency rates compare favorably to those of femoral-to-above-knee popliteal bypasses constructed using reversed saphenous vein or polytetrafluoroethylene. The authors found that the in situ femoral-to-above-knee popliteal bypass is a technically easy procedure requiring short operative times and has a low morbidity rate. In those select patients in whom a femoral-to-above-knee bypass is the procedure of choice the in situ bypass should be considered.
Adult↗
The internal oblique-iliac crest osseomyocutaneous microvascular free flap in head and neck reconstruction.
The iliac crest osseocutaneous free flap, based on the deep circumflex iliac artery and vein, was a landmark contribution to head and neck reconstruction. Two major problems associated with this flap are the lack of flexibility in placement of the skin paddle with relation to the bone graft, and the excessive thickness of the skin paddle when used in the oral cavity. The scapular osseocutaneous flap has achieved recent popularity for mandibular reconstruction based, in part, on its thin skin paddle that is easily positioned in three dimensions with relation to the bone graft. However, the segment of bone that can be harvested from the iliac crest is superior to that of the lateral border of the scapula because of its increased length, thickness, and natural contour. In 1984 the internal oblique free muscle flap based on the ascending branch of the deep circumflex iliac artery was described for use in reconstruction of the extremities only. The authors introduce the application of the internal oblique-iliac crest osseomyocutaneous free flap for mandibular reconstruction. The mobility of the internal oblique muscle with relation to the iliac bone graft has permitted its use for inner mucosal defects or outer cutaneous defects when covered with a skin graft. Following denervation atrophy, the muscle component becomes a thin, pliable piece of tissue that easily conforms to three-dimensional defects of the head and neck. This increased flexibility, the established benefits of the iliac bone, and the ease of intraoperative positioning for a two-team approach make this composite flap an outstanding tool for mandibular reconstruction. Two representative cases and a detailed description of flap harvesting, insetting, and donor-site closure are presented.
Carcinoma, Squamous Cell↗
Primary placement of osseointegrated implants in microvascular mandibular reconstruction.
The goal of mandibular reconstruction is to rehabilitate the patient by restoring occlusal relationships, lower facial contour, oral continence, and a denture-bearing surface. One of the major advantages of the use of vascularized bone over all other methods of mandibular reconstruction is its ability to achieve dental rehabilitation rapidly. The use of osseointegrated dental implants is a valuable adjunct in oral rehabilitation. It provides the most rigid form of stabilization to withstand the forces of mastication. In situations in which soft tissue reconstruction or the height of the alveolar ridge is not sufficient for a tissue-borne denture, implants offer the most suitable alternative. Mandibular reconstruction with free tissue transfer techniques is ideally suited for the placement of implants. These can be inserted at the time of mandibular reconstruction. Four months after surgery, when the integration process has occurred, the implants are unroofed, loaded, and ready for prosthetic placement. We will present several representative patients who underwent mandibular reconstruction with microvascular free bone transfer who have been successfully rehabilitated by osseointegrated implants. The process of osseointegration, different types of dental implants, and issues regarding radiation and implants are discussed. This is the first report of dental rehabilitation by primary placement of dental implants in patients undergoing microvascular mandibular reconstruction.
Adenocarcinoma, Bronchiolo-Alveolar↗
Origin of deep vein thrombi in an ambulatory population.
Eighty symptomatic ambulatory outpatients with acute deep vein thrombosis were evaluated with ascending contrast venography and ultrasonic imaging to determine the origin and distribution of thrombosis and to analyze clinical risk factors. Isolated calf vein thrombosis was present in 42.5 percent of the limbs, combined calf and proximal deep vein thrombosis in 47.5 percent, and isolated proximal thrombosis in 10 percent of the limbs. Discontinuity of thrombus was present in 55 percent, whereas 45 percent exhibited a continuous column of thrombus. The results of this study indicate that in the ambulatory outpatient population, acute deep vein thrombosis begins segmentally in the calf and proximal vessels and frequently coalesces into a continuous column of thrombus over several days. We believe that all cases of acute deep vein thrombosis should be treated and patients with evidence of previous acute deep vein thrombosis should be closely monitored for possible recurrences.
Adult↗
The use of split-thickness skin as an autogenous arterial conduit.
Eight mongrel dogs were anesthetized using general anesthesia, and graft consisting of split-thickness skin obtained from their abdomen was devised and inserted in each of their infrarenal aortas. Six of the grafts were reinforced with meshed polytetrafluoroethylene (PTFE) as an outer layer to prevent potential aneurysmal dilatation of the skin graft. None of the dogs received aspirin at any time. The dogs were sacrificed at one, four, and six weeks. The grafts were examined with light microscopy and three of them were analyzed with scanning electron microscope. All grafts remained patent and none formed aneurysmal dilatations. None of the dogs developed infections or aortoenteric fistulas. Of the three grafts that showed thrombus-free areas, all were oriented with the epidermis facing the lumen. The three grafts where the epidermis formed the external surface did not degenerate in any area. Endothelium-like cells continuous with the host vessel were present on all grafts at 4 and 6 weeks by light or scanning electron microscopy. Preliminary data from this study indicated that split-thickness skin may be a suitable arterial conduit. Even if it does not prove to have long-term patency rates, it may be a suitable temporary conduit until infections resolve and synthetic prostheses can be reinserted.
Animals↗
Progress in the diagnosis of deep venous thrombosis: the efficacy of real-time B-mode ultrasonic imaging.
Seventy-six limbs with clinically suspected acute deep venous thrombosis (DVT) were evaluated by means of ultrasonic imaging (UI) to define the ability of this technique to detect acute and chronic venous obstruction and to determine the origin and distribution of venous thrombi. UI was compared with ascending contrast phlebography in 46 limbs and was found to be 100% accurate in detecting both acute and chronic venous thrombosis. Overall, acute DVT was present in 63 of 76 limbs (83%) studied. Acute DVT was found in 24% and recurrent acute DVT in 76%. Our results indicate that although the calf veins are the most common site of involvement (89%), thrombi may frequently arise simultaneously in multiple anatomic sites. All limbs with recurrent acute DVT had evidence of previous calf thrombi but only 13% had previous proximal disease. This suggests that asymptomatic calf DVT is common and the prevalence of recurrent acute DVT is significantly greater than previously believed. We found UI is a practical, accurate, non-invasive method for investigating the pathogenesis of venous disease.
Acute Disease↗
In situ tibial reconstruction. State-of-the-art or passing fancy.
To further evaluate the efficacy of in situ saphenous vein bypass, the authors have reviewed their experience with in situ bypass. Between October 1981 and December 1985, 120 in situ saphenous vein bypass were performed; 81 were to infrapopliteal vessels. All procedures were performed for limb salvage. The mean patient age was 74 years, and 74% were men, 57% had diabetes mellitus, 92% were smokers, and 72% had hypertension and/or coronary artery disease. All patients were evaluated by preoperative noninvasive testing and biplanar angiography. All procedures were performed by the valve incision technique. The vein utilization rate was 91%. Grafts were routinely placed into isolated tibial segments and foot vessels without evidence of a patent pedal arch. Follow-up information was obtained at 3-month intervals. Patency and limb salvage data were calculated by life-table analysis. The cumulative patency rates were 98% at 1 month, 88% at 12 months, and 82% at 50 months. These data demonstrate that the in situ bypass maintains an excellent patency rate and provides durable limb salvage.
Aged↗
The association of central retinal artery occlusion and extracranial carotid artery disease.
To determine the incidence of associated carotid artery disease and the effect of carotid endarterectomy on subsequent neurologic sequelae, a retrospective study of 66 patients with central retinal artery occlusion (CRAO) was undertaken. Ipsilateral extracranial carotid artery disease was present in 23 of 33 patients (70%) who had carotid arteriography. Sixteen patients had carotid endarterectomy following their CRAO (Group I) and 50 did not (Group II). Seven of the 40 patients available for follow-up in Group II had a subsequent stroke (mean follow-up: 54 months). Of the seven Group II patients shown to have associated carotid disease (Group IIs), three (43%) had a subsequent stroke during follow-up (mean: 28.3 months) compared to zero in Group I (p = 0.033; mean follow-up: 18.7 months). Because of the strong association between CRAO and ipsilateral carotid artery disease and because of the significantly higher incidence of subsequent ipsilateral stroke in CRAO patients with carotid disease who did not undergo endarterectomy, thorough evaluation of the carotid arteries followed by carotid endarterectomy, if indicated, is warranted in CRAO patients who have no other obvious etiology for the occlusion.
Actuarial Analysis↗
Venous thrombosis: the clinical problem.
Although the exact cause of DVT is not known, venous thrombosis and its sequelae remain important clinical problems. Pulmonary embolism is a significant cause of morbidity and mortality in the hospitalized population, and the postthrombotic syndrome affects a large portion of the general population. While specific screening tests are not readily available to detect those patients who are likely to develop DVT, certain clinical risk factors have been identified that predispose to thrombosis. These groups include patients undergoing a wide variety of surgical procedures, patients with cardiac disease or cancer, pregnant or postpartum women, and individuals with previous history of DVT. The diagnosis of thrombosis is based on clinical findings and must be confirmed with appropriate laboratory tests. While contrast venography remains the gold standard, noninvasive tests have become increasingly more accurate. The recent use of real-time B-mode ultrasonic imaging and duplex sonography for the diagnoses of DVT has been shown to be efficacious. The postthrombotic syndrome with its associated chronic pain and ulcerations remains a significant clinical problem. The general diagnosis of this condition is readily made on clinical grounds in the advanced state. However, exact knowledge of the location and cause of the venous pathology can only be obtained using objective diagnostic tests. Older noninvasive and invasive tests may diagnose the presence of venous obstruction, valvular incompetence, and also may document venous hypertension.(ABSTRACT TRUNCATED AT 250 WORDS)
Humans↗
Use of ultrasonic venography in the evaluation of venous valve function.
Forty healthy limbs and 31 limbs with suspected deep venous insufficiency were imaged with real-time B-mode ultrasound to determine valve location, anatomic characteristics, and function. Valve function was evaluated by comparison with Doppler ultrasonographic techniques, and the data clearly indicated that ultrasonic venography accurately localized and determined the extent of deep venous reflux. Ascending contrast venography was performed in 15 postphlebitic limbs for assessment of valve location. The results indicate that ultrasonic venography is a more accurate method for visualization of valves in this group of patients. Therefore, ultrasonographic imaging is a valuable technique for evaluating limbs with chronic venous insufficiency.
Humans↗
Popliteal-to-tibial in situ saphenous vein bypass for limb salvage in diabetic patients.
This study has summarized our results with popliteal-tibial in situ saphenous vein bypass in 26 patients, 25 of whom were diabetic, over a 2 year period. Both above- and below-knee popliteal inflow sites were used for bypass of limb-threatening ischemia. Distal calf or pedal outflow sites were required in all but two patients who had sequential bypass performed to tibial sites. Postoperative ankle-brackial indices were calculated. Eleven patients had transcutaneous mapping surrounding the pedal skin envelope injuries. The mean lowest and highest transcutaneous oxygen values have been reported as a guide to successful healing.
Adult↗
Rhabdomyolysis in a patient with a mandibular fracture.
Explore the source record for details and available documents.
Acute Kidney Injury↗