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Biomedical subjects

Samir Mardini

Publications and source records attributed to Samir Mardini.

48 records · Page 3Linked to original sources
PubMed2004

Strategies for a successful corrective Asian blepharoplasty after previously failed revisions.

Asian blepharoplasty, although a common procedure, has a relatively high rate of complications. Subtle imperfections and more serious iatrogenic complications often require immediate attention by the aesthetic surgeon. After attempted correction of the deformities, residual problems or new ones can arise. Blepharoptosis, supratarsal depression, an excessively high or low crease, a short or discontinuous crease, multiple creases, and asymmetric creases are the most commonly encountered complications that require special attention in this group, which has already undergone more than one surgical procedure. Between January of 1996 and December of 2002, 168 Asian blepharoplasty revisions were performed by one surgeon (S. H.-T. Chen); of these, 36 patients (21 percent) had previously undergone failed revisions. This subgroup of patients consisted of six with blepharoptosis, six with asymmetrical eyelid creases, three with supratarsal depressions, three with high creases, two with short creases, and 16 with combinations of these deformities. The results were graded as excellent, good, fair, or poor, based on the symmetry of the eyelids, palpebral fissures, crease heights, lengths, shapes, eyelid fullness, and overall aesthetics of the final outcome. A survey was performed of patient and surgeon satisfaction and factored into the grading system. With an average follow-up period of 16 months (6 to 60 months), 22 patients (61 percent) were found to have excellent results, 10 (28 percent) had good results, two (5.6 percent) had fair results, and two (5.6 percent) had poor results. Corrective procedures after failed revision Asian blepharoplasty require special strategic considerations because of the presence of extensive scarring and inadequate skin, muscle, and preaponeurotic fat and because of the occasional presence of dehiscence of the levator aponeurosis. By using careful preoperative evaluation, accurate measurements, precise preoperative planning, intraoperative fat repositioning or grafting, skin excision or redraping, and proper placement of anchoring sutures, successful outcomes can be achieved. The authors evaluate the outcomes and detail the surgical procedures that were used to achieve successful outcomes in this particularly challenging group of patients.

Asian People↗
PubMed2004

Comparison of the radial forearm flap and the thinned anterolateral thigh cutaneous flap for reconstruction of tongue defects: an evaluation of donor-site morbidity.

The radial forearm flap is commonly used for reconstruction of tongue defects following tumor extirpation. This flap is easy to harvest and offers thin tissue with large-caliber vessels. However, its use leaves behind a conspicuous aesthetic deformity in the forearm and requires the sacrifice of a major artery of that limb, the radial artery. The anterolateral thigh cutaneous flap has found clinical applications in the reconstruction of soft-tissue defects requiring thin tissue. More recently, in a thinned form, the anterolateral thigh flap has been used for reconstructing defects of the tongue with functional results equivalent to that of the radial forearm flap. For the reconstruction of tongue defects, these two flaps could provide similar soft-tissue coverage, but they seem to result in different donor-site appearances. The donor site is closed primarily, leaving only a linear scar that is inconspicuous with normal clothing, and no functional deficit is left behind in the thigh. Thus, for the supply of flaps for tongue defects, a comparison between the radial forearm flap and the anterolateral thigh flap donor sites is provided in this study. Between December of 2000 and August of 2002, 41 patients who underwent reconstruction of defects of the tongue using either a radial forearm flap or an anterolateral thigh flap were evaluated. The focus was on the evaluation of the functional and aesthetic outcome of the donor site after harvesting these flaps for the purpose of reconstructing either total or partial tongue defects. Finally, a comparison was performed between the donor sites of the two flaps. The disadvantages of the radial forearm flap include the conspicuous unattractive scar in the forearm region, pain, numbness, and the sacrifice of a major artery of the limb. In some patients, the donor-site scar of the forearm acted as a social stigma, preventing these patients from leading a normal life. In contrast, the anterolateral thigh cutaneous flap, after thinning, achieved the same results in reconstructing defects of the tongue without the associated donor-site morbidity. Most importantly, the donor site in the thigh could be closed primarily in almost all patients without any functional deficit. The thinned anterolateral thigh cutaneous flap is a viable substitute for the radial forearm flap when reconstructing defects of the tongue. The results achieved are similar to those of the radial forearm flap, and the donor-site morbidity is significantly decreased.

Adult↗
PubMed2004

Adequate venous drainage: the most critical factor for a successful free jejunal transfer.

Reconstruction of the cervical esophagus with free jejunum can yield excellent functional results. Flap survival alone, however, does not guarantee satisfying functional outcomes. Critical factors that determine the level of function of the flap include the duration of ischemia and degree of venous congestion. An attempt is made in this study to evaluate the degree that these 2 factors influence outcome and to establish safe methods for avoiding suboptimal functional results. Out of 71 patients that underwent free jejunal transfer for the reconstruction of the cervical esophagus between January 1995 and December 1999, 60 patients with available chart records were included into this study. A retrospective chart review was performed on all 60 patients to evaluate the degree of venous congestion in those patients and the choice of recipient veins and method of anastomosis of those veins (end-to-end versus end-to-side). A more detailed review was performed on the 8 patients that underwent reexploration and detailed history, operative method, ischemia time, choice of recipient vessels, technique of anastomosis, immediate postoperative course, and outcome were determined. Following exploration of the flaps, all flaps survived. Two developed partial necrosis. When smaller veins were used as recipient vessels, the chances of venous congestion were found to be higher than when larger recipient veins were used (chi2 analysis, P <0.02). Method of anastomosis and previous radiotherapy were both found to be significant determinants of venous congestion (chi2 P <0.05 for both). Venous problems accounted for 87.5% (7/8) of all reexplorations. In 75% (6/8) of the reexplored patients, pharyngocutaneous fistula formation or stricture formation was noted.The degree of venous congestion and previous radiotherapy are factors that influence the functional outcome of free jejunal flaps. Proper selection of the recipient veins is a critical factor in providing adequate venous outflow and minimizing venous congestion. End-to-side anastomosis to large vessels is a more reliable method that was found to have a significant influence on minimizing venous congestion and is a useful method for the salvage of venous congested flaps.

Adolescent↗
PubMed2004

Microcirculation study of rabbit ear arterial and venous flow-through flaps using a window chamber model.

Venous flaps are used widely for finger reconstruction because they provide thin tissue, and the flap harvest is associated with less donor-site morbidity. The viability of the venous flap, however, is not as good as that of the ordinary perfused skin flap, and its microcirculation is questionable according to various indirect observations and hypotheses in the literature. Using a window chamber model in a rabbit ear, both arterial and venous flow-through flaps were studied. Factors evaluated were flap viability, flap weight, flap circulation as assessed by laser Doppler flowmetry, and direct observation of the microcirculation. Statistical analysis was performed using the two-sample t test. There was no statistically significant difference in viability between arterial and venous flow-through flaps (p = 0.661). The arterial flow-through flap had better perfusion than thevenous flow-through flap, as measured by laser Doppler perfusion studies (10.40 perfusion units [PU] vs 4.50 PU). However, no statistically significant difference was noted (p = 0.0717). Flap weight assesseed 1 week after surgery and oxygen saturation measured immediately after surgery showed significant differences between the arterial and venous flow-through flaps (p = 0.0001 and 0.0279). These datasuggest that the arterial flow-through flap is subjected to more congestion becauseof the abnormal flow pattern seen, andpossibly because of a superior inflow or nutritional status found in these flaps. Using vital microscopy, direct evaluation of the microcirculation was performed. A to-and-fro phenomenon was noted in both arterial and venous flow-through flaps,which was followed by a reversed direction of flow in part of the microvasculature. With both types of flaps, the blood was directed eventually from the postcapillary venules to the capillaries, through the terminal arterioles, and then to the arterioles. These findings may be explained partially by the normal physiologic pressure gradients present in the microvasculature of these flaps. In this study, direct observation of the microcirculation was used as well as other objective measures to determine the flow patterns and clinical behaviors found in these types of flaps. A model in a rabbit ear for the study of venous and arterial flow-through flaps is described, and clinical correlations are discussed.

Animals↗
PubMed2004

Sixty-five clinical cases of free tissue transfer using long arteriovenous fistulas or vein grafts.

Traumatic limb injuries requiring free tissue transfer for coverage, often lack healthy recipient vessels adjacent to the defect. In these patients, vein grafts are required to bridge the gap of either the artery, vein or both. For the latter situation, a temporary arteriovenous fistula (AVF) can be created and allowed to mature and then divided and used as recipient artery and veins for the free flap. These cases are challenging and several variables including vein graft length, vein graft diameter, and arterial inflow affect the patency of the vessels and the final outcome of the reconstruction. Sixty-five defects were reconstructed with free tissue transfers using vein grafts of significant length (>20 cm for the arterial gap). The ipsilateral or contralateral great saphenous veins were used for vessel lengthening in all cases. Inflow arteries were either major arteries (superficial femoral, popliteal or brachial), or lesser arteries (sural, anterior or posterior tibial, thoracodorsal, or superior gluteal). The patients were divided into those that underwent AVF followed by free tissue transfer in two stages (n = 6), AVF followed by free tissue transfer in one stage (n = 28) and patients that underwent vein grafting for the arterial defect only with (n = 6) or without (n = 25) a simultaneous bypass graft for lower limb revascularization. In the two-stage AVF group, the rate of occlusion of the graft after AVF creation was 50% (3/6); re-exploration rate was 33.3% (2/6); free flap failure rate was 33.3% (2/6); and limb salvage rate was 83.3% (5/6). In the one-stage AVF group: re-exploration rate was 28.6% (8/28); free flap success rate was 89.3% (25/28); and limb salvage rate was 92.9% (26/28). In the long vein graft group for arterial defects only: re-exploration rate was 25.8% (8/31); free flap success rate was 96.8% (30/31); and limb salvage rate was 87.1% (27/31). In patients where the graft was anastomosed to a major artery the re-exploration rate and free flap failure rate were 22.4% (11/49) and 8.2% (4/49). In patients where the graft was anastomosed to a lesser artery, the re-exploration rate and free flap failure rate were 43.4% (7/16) and 12.5% (2/16). The limb salvage rate was comparable in both groups (89.8%, 44/49, versus 87.5%, 14/16). In all groups, patients undergoing re-exploration were noted to have a an arterial gap of 31.78 cm as compared with the patients that did not require re-exploration which had an arterial gap of 26.26 cm. Vein grafting for bridging vascular defects is a safe procedure when proper indications and techniques are followed. Although a longer graft length seemed to be associated with a higher re-exploration rate, there was no statistical significance. One-stage AVFs can be used with good results, however, two-stage AVFs are associated with a high graft occlusion rate, wound failure rate and limb amputation rate. In all cases, a large caliber graft such as the great saphenous vein provided a large (relatively low resistance) conduit for bridging the defect.

Adolescent↗
PubMed2003

Critical oropharyngocutaneous fistulas after microsurgical head and neck reconstruction: indications for management using the "tissue-plug" technique.

Despite advances in head and neck reconstruction with free-tissue transfer techniques, oropharyngocutaneous fistulas continue to present challenging and potentially lethal complications. The authors present a system for prioritizing these fistulas and the surgical management of nine patients in whom critical fistulas developed after microsurgical head and neck reconstruction. The indications for aggressive management of these fistulas were primarily dependent on their location. Three peristomal and six midneck fistulas were considered critical because of the risk of aspiration pneumonia and carotid artery blowout, respectively. Fistulas located in the submental and/or submandibular region were considered noncritical and were managed conservatively. Using the concept of a "tissue plug" for fistula repair, a dermal component (i.e., a deltopectoral or pectoralis major pedicled flap) is guided through the fistula, and with external traction the tissue "plugs" the tract. No sutures are placed directly in the surrounding friable tissue. There were no partial or total flap losses. There were two fistula recurrences in patients who had received postoperative radiation therapy. One of these recurrences was due to tumor recurrence within the previous fistula and was managed with palliative measures. The other fistula recurrence was closed with a local-flap procedure on an outpatient basis. All patients resumed oral feeding, except for the patient in whom tumor recurrence was suspected. This tissue-plug technique can be used in the management of critical peristomal and/or midneck oropharyngocutaneous fistulas not only to obliterate the tract but also to augment volume and vascularity in already damaged, ischemic, and deficient tissue.

Cutaneous Fistula↗
PubMed2003

The thigh as a model for free style free flaps.

Following a set of principles, free style free flaps may be harvested from any region of the body where a Doppler signal is heard. By using a retrograde dissection technique, the skin vessel is traced through its subfascial course (intramuscular or septocutaneous), until adequate length or vessel size is achieved. If a "free style free flap" is not originally planned, this approach can be usedwhen anatomic variations or unexpected events are encountered. The thigh, a region that is familiar to the surgical team at Chang Gung Memorial Hospital, was chosen as the site to begin exploring this style of flap harvest. Nine flaps were harvested as free style free flaps from the thigh and were used successfully for the reconstruction of complex defects.

Adult↗
PubMed2003

Resource cost comparison of implant-based breast reconstruction versus TRAM flap breast reconstruction.

Relatively little has been published to date comparing the resource costs of transverse rectus abdominis musculocutaneous (TRAM) flap and prosthetic breast reconstruction. The data that have been published reflect the experience at just one medical center with a previously known clear preference for autologous breast reconstruction. The goal of this study was to compare the resource costs of TRAM flap and prosthetic reconstruction in an institution where both procedures continue to be performed using modern techniques and at a relatively equivalent frequency. All available medical records were reviewed for patients who had completed their breast reconstruction between 1987 and 1997. Records of patients who had undergone TRAM flap or prosthetic reconstruction were reviewed to compare resource costs, including hospital stay, operating room time, anesthesia time, prosthetic devices, and physician's fees. Of 835 patients reviewed who had completed breast reconstruction, a total of 140 suitable patients were identified who had all the necessary financial information available. The patient population comprised 64 patients who received TRAM flaps and 76 patients who had undergone prosthetic reconstruction. The length of stay for the TRAM flap group, including all subsequent admissions for each patient, ranged from 2 to 24 days (mean, 6.25 days), and that for the prosthetic reconstruction group ranged from 0 to 20 days (mean, 4.36 days). Operating room time for the complete multistage reconstructive process for a TRAM flap ranged from 5 hours, 20 minutes to 12 hours, 25 minutes (mean, 7 hours, 34 minutes); with implant-based reconstruction, operating time ranged from 1 hour, 45 minutes to 8 hours, 56 minutes (mean, 4 hours, 6 minutes). With prostheses costing from $600 to $1200, a surgeon's fee of $160/hour, and an assistant's fee of $45/hour, the average cost of TRAM flap reconstructions was $19,607 (range, $11,948 to $49,402), compared with $15,497 for prosthetic reconstructions (range, $6422 to $40,015). The results were statistically significant (p < 0.001). Several factors weigh into the decision as to which reconstructive operation best suits the patient's needs. These factors include surgical risk, potential morbidity, and aesthetic results. On the basis of this review of autologous and prosthetic breast reconstruction in an institution where both are performed frequently, during a 10-year period with a mean time elapsed since reconstruction of 7.45 years, prosthetic reconstruction was significantly less expensive.

Breast Implantation↗
PubMed2003

Long-term follow-up and unusual findings after microvascular transfer of hair-bearing skin for pubic hair restoration.

Alopecia in the pubic area can be restored successfully with hair transplantation using minigrafts and micrografts or with free tissue transfer of a hair bearing flap. In this report the authors present the successful transfer of hair bearing tissue from the temporoparietal scalp for the correction of a congenital form of alopecia of the pubic region. In addition, they present long term results of this transfer. Auxiliary procedures such as tissue expansion before or after transferring the flap, hair epilation and minigraft and micrograft transplantation could help to achieve a more natural result. Tissue expansion of the donor site could also be performed to enhance the outcome of the procedure. Of note is the rapid rate of hair growth in the transplanted tissue. This type of reconstruction using a hair bearing temporoparietal flap for restoration of hair to the pubic region is a useful method that can yield good results.

Adult↗
PubMed2002

Assessment of bilateral cleft lip nose deformity: a comparison of results as judged by cleft surgeons and laypersons.

Reconstruction of bilateral cleft lip nose deformity is difficult and the outcome is inconsistent. This study was conducted to evaluate the gross outcome and the difference in the assessment of nasal appearance as judged by two groups of raters, cleft surgeons and laypersons. Sixty-four patients with bilateral cleft lip were selected for review. The patients' ages ranged from 5 to 30 years. All patients had undergone primary cleft lip repair and secondary nasal reconstruction, and had been followed for at least 6 months. One image for each patient, which included a digitized frontal, lateral, and worm's-eye view, was projected for evaluation by the raters. The raters included five cleft surgeons and five laypersons. A rating scheme was used in which a score of 3 was given for a good, close to normal nasal appearance, 2 for an average result that needed minor revision, and 1 for a poor result that needed major reconstruction. The scores were averaged for each patient in each group and for each group as a whole. The final outcome was judged as good, fair, or poor on the basis of the mean score for each patient. Statistical analysis was performed. The mean score for all patients was 2.08 as assessed by the laypersons and 2.18 as assessed by the cleft surgeon group. There was no statistically significant difference between the two groups. Comparisons on rating scores among different raters revealed a fair agreement on the ratings within each of the two groups. The results were found to be good in 29.7 percent, fair in 64.1 percent, and poor in 6.3 percent of patients when evaluated by the surgeons. When rated by the laypersons, the nasal appearance was found to be good in 26.6 percent, fair in 60.9 percent, and poor in 12.5 percent of patients. This difference in distribution between the two groups was not statistically significant. When comparing the results given by the two groups of assessors, there was agreement on the nasal appearance in 65.6 percent of patients, and a difference in grading in the rest. For the patients who received different grading, the surgeons rated them one grade higher in 63.6 percent and one grade lower in 36.4 percent. There was no difference in grading between any of the evaluators that reflected a two-grade discrepancy in evaluation of results. This study shows that the surgical outcome of bilateral cleft lip nose deformity repair, at the authors' institution, is less than optimal. When assessing bilateral cleft lip nose appearance, the judgment of results by cleft surgeons was similar to that of the laypersons. However, different rating of results existed within each of the two groups, supporting the importance of clearly assessing patient/parent expectations and defining realistic surgical goals.

Adolescent↗