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Joseph M Serletti

Publications and source records attributed to Joseph M Serletti.

18 recordsLinked to original sources
PubMed2006

Breast reconstruction with the TRAM flap: pedicled and free.

BACKGROUND: Breast cancer is a ubiquitous disease affecting one in seven women. While breast conservation techniques are available for local control of the disease for many patients, not all patients are good candidates for these techniques. Mastectomy, therefore, remains a common method of breast cancer treatment. Methods of reconstruction include implant reconstruction and autogenous reconstruction. The advantages of autogenous reconstruction include the creation of a soft, ptotic breast mound, which tends to match a native contralateral breast both in and out of bra support. Autogenous reconstructions do not tend to change with time and usually do not require periodic revision as seen in implant reconstructions. METHODS: The most common method of autogenous reconstruction is the TRAM flap, either pedicled or free. The TRAM flap employs the redundant excess lower abdominal tissue typically removed during a cosmetic abdominoplasty. This tissue is brought to the mastectomy defect as a pedicled flap, passing subcutaneously from the upper abdomen and into the defect site. The pedicled flap is based upon the superior epigastric vessels. A free TRAM is harvested with the overlying muscle and the attached inferior epigastric vessels. This flap is completely separated from the abdomen and brought to the chest defect where it is anastomosed to either the thoracodorsal or internal mammary vessels. The donor defect within the abdominal wall is repaired with an inlay mesh with both the pedicled and free techniques. RESULTS: Patient selection criteria usually help determine which technique is used. The advantage of the free flap technique is improved blood supply to the skin island. The free flap, therefore, is used in patients at higher risk for partial flap loss with the pedicled technique. Such high-risk patients include smokers, the obese, patients with significant medical comorbidities, and patients with prior abdominal surgery. Patients without these risk factors can be expected to achieve good results with either the pedicled or free flap technique. CONCLUSION: Autogenous breast reconstruction with the TRAM flap achieves long lasting satisfactory results in most patients with the creation of a soft, naturally ptotic breast mound, which typically matches well a contralateral native breast.

Anastomosis, Surgical↗
PubMed2006

Free tissue transfer: comparison of outcomes between university hospitals and community hospitals.

BACKGROUND: In university hospitals, free tissue transfer has become a standard method of reconstruction for a broad spectrum of defects. Because of its complexity, free tissue transfer has not been routinely performed in a community hospital setting. This study reports the outcomes of two equal groups of free tissue transfer performed by the same surgeons, comparing the university versus the community hospital setting. METHODS: A total of 735 free tissue transfers were performed at one university hospital and six community hospitals in our region over a 10-year study period. Outcome parameters used in this study included wound complications such as infection, dehiscence, delayed healing, hematoma, and fat necrosis. RESULTS: A total of 674 operations were performed using 735 free tissue transfers: 386 free tissue transfers were performed at the university hospital (53 percent) and 349 (47 percent) were performed at the community hospital. Categories of free tissue transfer reconstruction included breast, lower extremity, head and neck, and upper extremity reconstructions. Most of the breast reconstructions were performed in the community hospital, whereas most of the lower extremity and head and neck reconstructions were performed at the university hospital. Fifty-one major postoperative complications occurred in the university hospital (14 percent), while 31 (10 percent) occurred in the community hospital. Complication rates did not differ significantly between settings; however, there was a trend toward more wound infections in the university hospital and more cases of fat necrosis in the community hospital, most likely reflected in the differing case mix between hospital settings. CONCLUSION: Free tissue transfer is an effective and practical method of reconstruction that has been safely performed in both university and community hospital settings.

Academic Medical Centers↗
PubMed2006

Improving outcomes in bilateral breast reconstruction using autogenous tissue.

Bilateral breast reconstruction utilizing autologous free tissue transfer is a complex procedure with multiple options for donor tissue available. This study set out to compare the outcomes of patients undergoing bilateral breast reconstruction with muscle-sparing free TRAM flaps versus those undergoing bilateral reconstructions utilizing procedures which aim to minimize abdominal donor site morbidity in the form of deep inferior epigastric perforator (DIEP) or superficial inferior epigastric (SIEA) flaps. A retrospective review identified 31 patients and 62 free flaps for bilateral autologous breast reconstruction at our teaching institutions in Rochester, NY. Patients receiving procedures which aimed to minimize donor-site morbidity experienced a shorter length of hospital stay versus those patients undergoing bilateral free TRAM procedures (P = 0.0494 by t test and P = 0.0389 by parametric test). There was no significant difference in complication rates between these 2 groups. Other demographic and premorbid factors showed no difference between groups. Here, we demonstrate that bilateral autologous breast reconstruction with flaps which minimize donor site morbidity are a safe and effective option for bilateral reconstruction. Furthermore, patients who received bilateral breast reconstruction with abdominal wall sparing techniques (DIEP or SIEA flaps) had a significantly shorter length of hospital stay, with no significant difference in complication rates when compared with patients undergoing bilateral free TRAM procedures.

Adult↗
PubMed2006

Risk factors and complications in free TRAM flap breast reconstruction.

METHODS: The authors retrospectively reviewed 500 free TRAM flaps performed between 1992 and 2003. This cohort was subdivided based on smoking history, obesity, preoperative chemotherapy, preoperative radiation therapy, peripheral vascular disease, chronic obstructive pulmonary disease (COPD), and hypertension, and compared surgical complication rates. Measured complications included fat necrosis, mastectomy flap necrosis, abdominal flap necrosis, partial TRAM flap loss, wound infection, hematoma, seroma, vessel thrombosis, and abdominal hernia. Chi2 analysis and Fisher exact test were performed to determine differences between groups, and linear regression models were used to predict the risk factors of surgical complications. RESULTS: Smokers were more likely to have a higher incidence of wound infection (P = 0.01), mastectomy flap necrosis (P = 0.015), abdominal flap necrosis (P = 0.033), and fat necrosis (P = 0.01). Obese patients were more likely to have higher rates of mastectomy flap necrosis (P = 0.01) and hematoma (P = 0.01). Patients with peripheral vascular disease were more likely to have a higher incidence of wound infection (P = 0.031), and patients with preoperative radiation therapy were more likely to have a higher incidence of seroma (P = 0.043). Logistic regression showed that smoking was found to be a risk factor for fat necrosis (P = 0.006), wound infection (P = 0.002), mastectomy flap necrosis (P = 0.039), and abdominal flap necrosis (P = 0.042). Obesity was a risk factor for mastectomy flap necrosis (P = 0.002). Peripheral vascular disease was a risk factor for wound infection (P = 0.032). CONCLUSION: Awareness of risk factors and associated complications will lead to modification and individualization of surgical techniques in an attempt to limit these complications and continually improve outcomes.

Breast↗
PubMed2005

Current trends in pediatric microsurgery.

Free tissue transfer has become a routine method for the reconstruction of a variety of defects and is commonly employed in both the university and community hospital setting. Free tissue transfer has most often been reported in adult patients and is used to reconstruct defects caused by trauma, tumor, or vascular insufficiency. Several series have reported on free tissue transfer specifically in children, addressing both the similarities and differences employed in the special patient population. This article reviews common microsurgical practices used in treating pediatric patients and discusses etiologies, donor site selection issues, technical considerations including recipient site selection, and the potential for growth disturbances at both the recipient and donor sites.

Child↗
PubMed2005

Management of complex groin wounds: preferred use of the rectus femoris muscle flap.

This study reviews our experience with the rectus femoris muscle flap for complex groin wound reconstruction. Over the past 5 years, the rectus femoris has become our routine method of groin wound reconstruction. The rectus femoris is harvested through a midanterior incision extending over the distal two-thirds of the thigh. The muscle is elevated on its pedicle and transposed into the groin wound defect either directly or through an intervening skin bridge. Hospital and outpatient records were reviewed for all patients undergoing groin wound reconstruction with this technique from 1999 through 2003. Thirty-seven rectus femoris muscle flaps were performed in 33 patients. The mean patient age was 65.3 years (range, 25 to 88 years). Thirty groin wounds (81.1 percent) occurred after infrainguinal revascularization, 23 (76.7 percent) of which contained prosthetic material. Five (21.7 percent) of these wounds had their prosthetic material removed at the time of reconstruction. The remaining seven groin wounds (18.9 percent) occurred after femoral vessel cannulation for either cardiac or transplant surgery. There were no intraoperative mortalities and no anastomotic hemorrhages. There were no flap losses. Thirty-five of the 37 treated wounds healed (94.6 percent), 26 primarily (70.3 percent) and nine (24.3 percent) after delayed healing and contracture. Reoperation was performed in one patient for flap readvancement and in three patients for prosthetic graft removal after initial flap reconstruction. Two patients (6.1 percent) died during their hospitalization with persistent open groin wounds after flap reconstruction. All muscle flap donor incisions healed, with only two (5.4 percent) experiencing minimal delayed healing. There were no donor-site wound infections and no donor sites required reoperation. Thirty-three groin wounds (89.2 percent) demonstrated culture-positive microbial infection, 15 (45.5 percent) of which were polymicrobial. The 30-day mortality rate was 15.2 percent and the 6-month mortality rate increased to 27.2 percent, with multisystem organ failure as the most common cause. The rectus femoris muscle flap is an effective and reliable means of complex groin wound reconstruction. The muscle flap is dependable and the donor site is not problematic, even in the presence of peripheral vascular disease. On the basis of our clinical results, we believe that the rectus femoris muscle flap is the flap of choice for groin wound reconstruction.

Adult↗
PubMed2005

Transfusion-free pediatric burn surgery: techniques and strategies.

More than 1.3 million children sustain burns each year, resulting in 40,000 admissions and more than 3000 pediatric deaths. Pediatric burn surgery has been described as excessively bloody. Strategies to reduce intraoperative blood loss include the use of topical thrombin and epinephrine, extremity tourniquets, acute normovolemic hemodilution, and hypotensive anesthesia. This study reviews the single surgeon pediatric burn experience at a children's hospital and describes a comprehensive blood conservation protocol to achieve transfusion-free pediatric burn surgery. A retrospective chart review of consecutive pediatric burn surgeries from July 2000 to April 2002 was performed. Patient demographics, burn characteristics, treatment, blood loss, laboratory values, transfusion history, and complications were reviewed. Blood loss per percent total body surface area (TBSA) treated as well as percent total blood volume (TBV) loss divided by percent TBSA treated were calculated. A total 31 burn surgeries in 23 patients were reviewed. The average age was 7 years (range, 9 months-17 years). There were 17 extremity, 6 trunk, and 2 head/neck burns. The average TBSA burned was 15% (range, 1-55%). The protocol to reduce intraoperative blood loss consisted of the debridement of full-thickness burns with electrocautery and partial-thickness burns with dermabrasion. All debrided or harvested surgical sites were treated immediately with epinephrine solution-soaked pads. All graft harvest sites were injected with an epinephrine solution before harvesting split-thickness skin grafts. The average TBSA treated per surgery was 7% (range, 1-29%). The average blood loss per percent TBSA treated was 15 mL (range, 0.7-37 mL). The average percent TBV/percent TBSA was 0.76% (range, 0.04-3.6%). All 20 patients underwent surgical debridement, 7 patients were treated with AlloDerm and ultrathin split-thickness skin grafts, 2 with full-thickness skin grafts, and 17 with split-thickness skin grafts alone. Five children required blood transfusions. These burns averaged 32% TBSA (range, 20-55%). All 5 children receiving transfusions had anemia of thermal injury and demonstrated an average preoperative drop in hematocrit of 12% (range, 10-14%). There was a 29% complication rate, with 7 patients experiencing partial graft loss, and 1 patient who developed a postgraft contracture that required revisional surgery. There was a single mortality secondary to systemic inflammatory response syndrome and acute respiratory distress syndrome. After the proposed pediatric burn treatment protocol, intraoperative blood loss requiring transfusion can be minimized or eliminated. Large TBSA burns must be surveilled for burn wound anemia that may ultimately require blood transfusion.

Adolescent↗
PubMed2004

Free tissue transfer in patients with renal disease.

Several authors have cited renal disease as a risk factor for free flap failure. The authors performed a retrospective analysis of all patients who underwent free tissue transfer with concomitant renal disease, including acute renal failure, end-stage renal disease, chronic renal insufficiency, and functional kidney transplants, to determine what effect renal disease has on flap survival and overall reconstructive outcome. More than 1053 free flaps were examined. Renal disease was identified in 32 patients who underwent 33 free tissue transfers. Average patient age was 57 years (range, 36 to 80 years). Twelve patients (38 percent) were on chronic dialysis (end-stage renal disease), 18 patients (56 percent) had chronic renal insufficiency, and three patients (9 percent) had the diagnosis of acute renal failure at the time of surgery. Three patients in the chronic renal insufficiency group had a functioning renal transplant. Average follow-up was 16 months. Immediate postoperative complications occurred in 14 patients (42 percent of the 33 flaps). Overall perioperative mortality was 3 percent. Within the first 30 days there were two cases (6 percent) of primary flap failure; an additional four legs were lost as the result of complications related to their bypass grafts. There were no primary flap failures after 30 days; however, within the first year after surgery an additional seven limbs were lost as the result of progressive ischemia or infection, and an additional three patients died. This resulted in a 52 percent incidence of major morbidity or mortality during the first year and a 55 percent reconstructive success rate in survivors at 1 year. No significant difference was seen in postoperative morbidity or mortality when comparing the end-stage renal disease group to the chronic renal insufficiency group; however, patients with renal disease and diabetes tended to have poorer outcomes. Renal disease, especially renal disease associated with diabetes and peripheral vascular disease, can be a strong indicator of possible reconstructive failure. The surgeon and patient should be aware of the medical and surgical complications associated with this procedure at the outset.

Acute Kidney Injury↗
PubMed2004

Macromastia as an etiologic factor in bulimia nervosa: 10-year follow up after treatment with reduction mammaplasty.

Patients with psychologic diagnosis such as eating disorders have been automatically disqualified as candidates for plastic surgery. We have previously reported on a cohort of women with bulimia nervosa who presented with symptomatic macromastia. All patients reported that dysfunctional eating habits where in part the result of breast enlargement. Five patients underwent reduction mammaplasty and postoperatively reported relief of physical symptoms and improvement in psychologic well-being. Symptoms of eating disorders were completely eliminated or greatly reduced. The aim of the current study is to evaluate the degree of long-term postoperative satisfaction and recovery from eating disorders. Patients participating in the original study were contacted for long-term follow-up telephone survey. Data regarding current physical symptoms, body dissatisfaction, and eating attitudes measured by the Eating Attitude Test-26 (EAT-26) questionnaire was obtained. A statistical analysis was performed. Data was obtained from 4 patients. All patients maintained consistent recovery from their eating disorder. A statistically significant improvement in eating attitudes was found when comparing pre- and postoperative data obtained from the EAT-26. Comparing body dissatisfaction, pain, and physical symptoms, we found an overall consistent improvement in subjective scoring. Macromastia can produce a distortion of body image and become a secondary cause of eating disorders. Surgical correction of macromastia can correct physical symptoms, improve body image, and lead to permanent amelioration of associated eating disorders. This could, in part, represent a surgical treatment of a psychologic abnormality. Consequently, the presence of an eating disorder should not automatically exclude a woman from surgical consideration.

Body Image↗
PubMed2003

An outcome analysis comparing the thoracodorsal and internal mammary vessels as recipient sites for microvascular breast reconstruction: a prospective study of 100 patients.

The thoracodorsal vessels have been the standard recipient vessels for the majority of surgeons performing free transverse rectus abdominis musculocutaneous (TRAM) flap reconstructions. Recently, the internal mammary vessels have been recommended as the first-choice recipient vessels for microvascular breast reconstruction. This approach requires a shorter pedicle length, allows for central placement of flap tissue, and avoids axillary scarring. The use of the internal mammary vessels may provide for a shorter operative time and a higher-quality aesthetic reconstruction. The authors performed a prospective trial examining the differences in operative and aesthetic outcomes between each recipient site. A prospective trial of 108 consecutive free-tissue transfers was conducted in 100 patients. The first 60 TRAM flap patients were randomized so that 30 flaps were anastomosed to the internal mammary vessels and 30 were anastomosed to the thoracodorsal vessels, whereas the recipient vessels for the remaining 40 patients were left to the discretion of the surgeon. Of the 40 nonrandomized patients, 10 patients underwent reconstruction using the internal mammary vessels and 30 patients underwent reconstruction using the thoracodorsal vessels. The patients' medical history and hospital course were noted. To evaluate aesthetic outcome, a group of five blinded nonmedical observers and three blinded plastic surgeons graded the reconstructions in the 60 TRAM flap patients for symmetry and overall aesthetic result on a scale of 1 to 5. Blinded practitioners administered postoperative questionnaires to patients regarding recovery time and satisfaction with the aesthetic result. Forty-three flaps were transferred to the internal mammary vessels and 65 were transferred to the thoracodorsal vessels. No significant differences existed between groups with regard to age of preoperative risk factors. Average operative time was 6 hours in each group. Average hospital stay was 5.8 days in each group. Conversion from initial recipient vessel to a secondary recipient site occurred in 12.5 percent of internal mammary reconstructions and 7 percent of thoracodorsal reconstructions. All converted internal mammary cases occurred in left-sided reconstructions and were attributable to problems with the veins. Overall, 20 percent of left-sided internal mammary reconstructions were found to have an inadequate recipient vein. Unusable thoracodorsal vessels were found only in delayed reconstructions, at a rate of 15 percent in the delayed setting. All flaps from converted procedures survived without complications. Average follow-up was 20 months, during which time there was one flap loss in the thoracodorsal group. There were no significant differences in complication rates between groups. Average aesthetic grade was 3.6 in each group. Postoperative recovery time and overall patient satisfaction were not significantly different between groups. Either recipient site can provide for a safe and acceptable result; however, surgeons should be aware of conversion rates and plan appropriately if recipient vessels appear unusable for free-tissue transfer.

Anastomosis, Surgical↗
PubMed2003

The cleft lateral lip element: do traditional markings result in secondary deformities?

In cleft surgery, two methods have traditionally been used to mark the height of cupid's bow on the lateral lip element. One technique measures the distance from the oral commissure to the height of cupid's bow on the noncleft side, and transposes this distance onto the cleft-side lateral lip element. The second technique marks the height of cupid's bow on the cleft-side lateral lip element where the white roll disappears. The authors believe these techniques may result in deformities of residual cleft tissue in the repair. Marking the height of cupid's bow on the cleft-side lateral lip element, just before the attenuation of lip fullness, can prevent this deformity. A retrospective study yielded a series of 17 patients with secondary deformities of residual cleft tissue in their repair. The method used to mark the lateral lip element was determined by chart review. Patients then underwent secondary surgery with excision of residual cleft tissue, and repair using the initial technique. A random group of primary cleft patients, repaired using the authors' technique for marking the lateral lip element, was likewise evaluated for the presence of residual cleft tissue in the repair. Of the 17 cases of secondary deformities, 14 were unilateral and 3 were bilateral. Among the unilateral cases, seven were repaired with a triangular flap and seven by rotation advancement. The bilateral cases were repaired using the modified Millard technique. The lateral lip element was marked using cessation of the white roll in 8 patients, and the commissure to the height the of cupid's bow in 2 patients, whereas in 7 patients the method was unreported. Using the authors' technique, both "controls" repaired primarily and cases repaired secondarily resulted in no redundant cleft tissue. Average follow-up was 11 months (range, 1-41 months). The authors think that traditional markings for establishing the height of cupid's bow on the cleft lateral lip element may result in residual cleft tissue in the repair. This deformity can be prevented by marking the height of cupid's bow on the cleft lateral lip element just before the attenuation of lip fullness.

Child, Preschool↗
PubMed2003

TRAM flap breast reconstruction for patients with advanced breast disease.

Transverse rectus abdominis musculocutaneous (TRAM) breast reconstruction in patients with advanced breast cancer is controversial. Management of these patients is often complex and consists of surgical extirpation, postoperative radiation, chemotherapy, and in some cases bone marrow transplantation. Few studies have attempted to examine patient long-term survival and overall satisfaction with the surgical procedure. This study examines one center's experience with patients undergoing breast reconstruction for stage III and stage IV breast carcinoma. A retrospective review was performed of all patients undergoing TRAM reconstruction with stage III or IV breast cancer. Surviving patients and family members were contacted for follow-up. Patients were asked to grade their satisfaction with the reconstructive procedure on a 5-point scale (5 points, extremely satisfied; 1 point, extremely dissatisfied). Postoperative complications and time to return to work were also recorded. During a 10-year period (1991-2000) 21 women underwent TRAM reconstruction for advanced breast cancer. Twenty patients had stage III disease and 1 patient had stage IV disease. Mean patient age was 49 years. A total of 26 TRAM flaps were performed; 5 patients had bilateral procedures. Of the 26 TRAM flaps, 17 were immediate and 9 were delayed, and 20 were free and 6 were pedicled. Follow-up averaged 6.5 years (range, 2-10 years). Postoperative complications occurred in 7 patients and included fat necrosis (N = 3), hematoma (N = 2), cellulitis (N = 1), delayed donor site healing (N = 2), and seroma (N = 1). There were no flap losses. Patients were able to return to normal activities or work at an average of 10.6 weeks. Eleven patients developed recurrent disease. Nine patients (43%) succumbed to their disease during the follow-up period. In these patients the average interval between TRAM reconstruction and death was 3.7 years (range, 1-6.5 years). Eleven patients or surviving family members participated in the patient satisfaction survey. The average satisfaction grade was 4.6 points. All patients would repeat the TRAM reconstruction again. Patients with advanced breast cancer can be considered appropriate candidates for TRAM reconstruction. The results of this study indicate that patients with advanced breast cancer do not have an increased rate of postoperative complications, and they recover within a reasonable time from their surgical procedure despite adjuvant radiation and chemotherapy. Furthermore, the majority of patients are satisfied with their reconstructed breast and postoperative course, and would choose this reconstructive option again.

Adult↗
PubMed2002

Assessment of nerve graft donor sites used for reconstruction of traumatic digital nerve defects.

Several donor nerve graft sites commonly are used when repairing segmental defects in sensory nerves distal to the wrist. The cross-sectional area and number of fascicles of donor nerves and specific digital nerve segments were investigated to provide guidelines for selection of nerve graft harvest sites according to defects encountered. Nerve segments were harvested from 10 fresh cadavers (20 upper extremities). Five sites of nerve graft were harvested: lateral and medial antebrachial cutaneous nerves (LABCN, MABCN), posterior and anterior interosseous nerves (PIN, AIN), and sural nerves. Four sites of typical segmental nerve defects were harvested in a zone protocol: common digital nerve (zone 4), proper digital nerve (zone 3), digital nerve distal to main dorsal branch at the metacarpophalangeal joint (zone 2), and digital nerve distal to trifurcation at fingertip (zone 1). Sural nerve is the most anatomically similar nerve graft for defects in zone 4 by cross-sectional area and number of fascicles. Lateral antebrachial cutaneous nerve is most appropriate for zone 2 and 3 injuries by both criteria. Fingertip grafts for zone 1 injuries displayed cross-sectional area similarity to PIN, AIN, and MABCN. With regard to number of fascicles, zone 1 digital nerves are most similar to LABCN donors.

Brachial Plexus↗
PubMed2002

Effects of late loss of arterial inflow on free flap survival.

Greater than 80 percent of free flap thromboses have been shown to occur within the first three postoperative days, warranting immediate re-exploration and restoration of adequate vessel patency. The infrequency of thromboses beyond this period is reflected in the lack of reported cases in the literature and the absence of accepted guidelines for the treatment of such delayed complications. A single study reported free flap survival in vessel thromboses only when encountered after postoperative day (POD) 7 in a pig model. Since 1990, over 800 free tissue transfers have been done at the University of Rochester. A total of ten cases of late (defined as after POD 7) arterial inflow loss were identified and examined. A retrospective chart review recorded patient demographics, site of tissue defect, free tissue transferred, major co-morbidities, preoperative XRT, timing of arterial inflow loss, nature of inflow loss, and flap survival. The mean POD of arterial inflow loss was 53 days (range: 8 to 166). The mean age of patients was 58 years. No major co-morbidities correlated with late arterial inflow loss. Loss of inflow occurred as anastomotic rupture (5), occlusion of recipient bypass graft in lower extremity cases (3), primary donor arterial thrombosis (1), and pedicle avulsion during re-exploration for seroma (1). Five flaps survived, one sustained partial necrosis, and four were completely lost. Of the five surviving flaps, three were inset into healthy recipient sites. One was utilized on a dysvascular lower extremity, and another was used in an irradiated neck defect. Of the four failed flaps, all were placed in recipient beds compromised by radiation, ischemia, or scarring. Two exemplary case reports are presented. The timing of late loss of arterial inflow does not appear to be the primary determinant of free tissue survival. The condition and quality of the recipient site plays a large role in survival of these flaps. Ischemic, irradiated, and scarred beds are inadequate in providing late flap neovascularization, compared to healthy recipient sites. When encountering late loss of arterial inflow in flaps placed on such compromised beds, the microsurgeon should not anticipate survival based on surrounding vessel ingrowth. More aggressive salvage attempts may be warranted.

Adult↗
PubMed2002

Reconstruction of an extensive vulvectomy defect using the gluteus maximus fasciocutaneous V-Y advancement flap.

Effective management of a vulvar wound resulting from oncological ablative surgery poses a formidable task for the reconstructive surgeon. During the past two decades, numerous procedures have been described in an effort to provide stable, sensate coverage that minimizes deformity and preserves function, often in the setting of concomitant radiation. At the authors' institution, a fasciocutaneous V-Y advancement flap based on the gluteus maximus has been adopted as a common approach to this problem. They present their institutional experience with this procedure. A 10-year chart review (1991-2001) yielded a series of 20 vulvectomy patients, all of whom were reconstructed by the same surgeon using ischial fasciocutaneous V-Y flaps based on perforators from the inferior border of the gluteus maximus muscle. Patients underwent vulvectomy for recurrent or advance-stage vulvar cancer, or extensive carcinoma in situ. Squamous cell carcinoma was the most common pathology (N = 13). Fifteen patients had bilateral V-Y flaps; the remainder had unilateral procedures. Six patients underwent prior radiation therapy. Two patients had delayed reconstruction for vaginal stenosis. Flap survival was 100%. There were no major complications, early or late. Minor complications were limited to localized areas of delayed healing, all of which responded to conservative measures. Functional outcome was excellent in all patients. At an average follow-up of 44 months, there were five episodes of recurrent disease necessitating surgical intervention. Based on this series, the gluteus maximus V-Y advancement flap provides a straightforward and reliable method to recruit local tissue for stable coverage of these often difficult-to-manage wounds.

Adult↗
PubMed2002

Primary cutaneous mucormycosis: guide to surgical management.

Mucormycosis is the most acute, fulminate, and fatal of all fungal infections in humans. It presents most frequently in immunocompromised patients, but can occur in healthy patients in the presence of often-insignificant trauma. Surgical management of primary cutaneous mucormycosis is almost always required. Case reports of surgical treatment for primary cutaneous mucormycosis are reported in the literature; however, the extent of debridement required for cure is unclear and no uniform plan of treatment has been suggested. To date, no clinical guidelines exist to assist the clinician in the surgical management of this disease. This article reviews the literature, reports on two clinical cases, and submits clinical guidelines designed to assist the clinician in the surgical management of primary cutaneous mucormycosis. Because of the infrequent and potentially fatal nature of the diagnosis, a high index of suspicion and a low threshold for wound biopsy must be maintained. Wound cultures are grossly inadequate and should not be relied on for a false sense of security. It is recommended that, for the early diagnosis of cutaneous mucormycosis, chemotherapy and surgical debridement of grossly necrotic tissue be performed at the earliest possible time. The debrided wound is monitored for the resolution of surrounding erythema and induration before definitive reconstruction. In the case of delayed diagnosis and/or advanced or rapidly progressive disease, surgical debridement of all involved tissue, in addition to chemotherapy, is warranted.

Debridement↗
PubMed2002

Free-tissue transfer in patients with peripheral vascular disease: a 10-year experience.

Advances in free-tissue transfer have allowed for lower limb salvage in patients with significant peripheral vascular disease and limb-threatening soft-tissue wounds. The authors retrospectively reviewed their 10-year experience with free flaps for limb salvage in patients with peripheral vascular disease to assess postoperative complication rates and long-term functional outcome. They identified all patients undergoing free-tissue transfer with significant peripheral vascular disease and otherwise unreconstructible soft-tissue defects. Charts were reviewed for perioperative and long-term outcome. Parameters studied included perioperative morbidity and mortality, flap success, bypass graft patency, ambulatory results, and long-term limb and patient survival. Survival data were analyzed using life-table analysis, Kaplan-Meier survival analysis, and Cox testing. A total of 79 flaps were examined in 75 patients with peripheral vascular disease from July of 1990 to November of 1999. All patients would have required a major amputation had free-tissue transfer not been performed. Mean age was 60 years, average hospital stay was 32 days, and perioperative mortality was 5 percent. Within the first 30 days after operation, there were four cases of primary flap loss, and another two were lost as the result of bypass graft failure (8 percent); five of these cases resulted in amputation. There were no primary flap failures after 30 days. Follow-up ranged to 91 months (mean, 24 months). During this time, another 14 limbs were lost, most commonly because of progressive gangrene and/or infection in sites remote from the still-viable free flap. Using Kaplan-Meier survival analysis, 5-year flap survival was 77 percent, limb salvage 63 percent, and patient survival 67 percent. Sixty-six percent of patients were able to ambulate independently with the use of their reconstructed limb at least 1 year after hospital discharge, although some of these later went on to amputation. Free-tissue transfer for lower extremity reconstruction can be performed with acceptable morbidity and mortality in patients with peripheral vascular disease. Flap loss is low, and limb salvage, ambulation, and long-term survival rates in these patients are excellent.

Follow-Up Studies↗