BACKGROUND:Mandibular osteoradionecrosis is the most devastating complication after radiation therapy for head and neck malignancies. Quality of life (QOL) after surgical treatment is unclear. METHODS:A retrospective cohort analysis (1997-2007) was conducted of all patients treated at our institution for stage II and III mandibular osteoradionecrosis. Nineteen of 35 patients responded to a modified University of Washington QOL questionnaire. Twenty had undergone reconstruction using free flaps, and the remainder with plates, plates and local flaps, or debridement alone. RESULTS:Complications included 3 infections, 5 with hardware, 5 flap-specific, and 1 nonunion. Four patients had recurrent squamous cell carcinoma (SCC). The factors of greatest concern to patients were appearance, swallowing, and chewing. Average overall QOL was good to very good, and very good compared to preoperative. CONCLUSION:Despite a 37% complication rate, a multidisciplinary team approach with adequate debridement, resection, and reconstruction can greatly improve QOL.

BACKGROUND Free flap success depends on rapid identification and subsequent salvage of failing flaps. Conventional free flap monitoring techniques require an external component, whereas an implantable monitor readily indicates changes in free flap perfusion, especially in buried flaps used in head and neck reconstruction. METHODS This is a retrospective review of 169 consecutive head and neck free flaps reconstructed mostly for oncologic surgical defects in 155 patients from April of 2000 to December of 2006, all of which were monitored by an implantable venous Doppler device. RESULTS There were 25 buried flaps, representing 14.8 percent of 169 flaps. Flap ischemia caused by thrombosis (n = 16), hematoma (n = 2), or tight closure (n = 1) occurred in 11.2 percent of the cases. The Doppler probe detected all of the failing free flaps, and we were able to salvage 18 of 19 ischemic flaps (94.7 percent). All Doppler-detected ischemic nonburied flaps (100 percent) and three of the four buried free flaps were salvaged (75 percent). There were 33 total complications (19.5 percent), with thrombosis occurring in 9.5 percent of the flaps, whereas 12 flaps required reoperation for vascular revision (7.1 percent). The mortality rate was less than 1 percent (0.6 percent). The overall success rate using the implantable Doppler probe was 98.2 percent, which was similar to that of the most recent reported cases of all free flaps in the literature, with significant improvement in the salvage rate for both buried and nonburied head and neck free flaps. CONCLUSION The implantable Doppler probe is a useful monitoring device in buried free flaps and should be considered for use in head and neck reconstruction.

For more than 70 years Plastic and Reconstructive Surgery® has been the one consistently excellent reference for every specialist who uses plastic surgery techniques or works in conjunction with a plastic surgeon. The journal brings readers up-to-the-minute reports on the latest techniques and follow-up for maxillofacial reconstruction, burn repair, cosmetic reshaping, as well as news on medicolegal issues. The cosmetic section provides expanded coverage on new procedures and techniques.

BACKGROUND:In harvesting free fibula composite flaps, preoperative knowledge of the lower limb vascular anatomy is essential to prevent ischaemic complications or flap failure. Magnetic resonance angiography (MRA) allows imaging of the septocutaneous perforators (< or = 1-2mm diameter) of the peroneal artery used in the free fibula flap. METHODS:We investigated seven patients undergoing the free fibula flap preoperatively with high-resolution MRA images to study the following: 1) tibio-peroneal anatomy, 2) peripheral artery disease, 3) the positions of the perforator vessels on the peroneal artery and their course in the posterolateral intermuscular septum and 4) the cutaneous distribution of the perforators, and to compare them to surgical findings. RESULTS:MRA demonstrated tibio-peroneal anatomy in sufficient detail to exclude anatomic variants and significant peripheral vascular disease, detected septocutaneous perforators arising from the peroneal artery coursing in the posterolateral intermuscular septum and determined the skin terminus of the septocutaneous perforators. All septocutaneous perforators found during surgery were detected prospectively on high-resolution MRA. CONCLUSION:Lower leg vascular anatomy assessment with high-resolution MRA determined the location of the septocutaneous perforators of the peroneal artery preoperatively with accuracy and precision. This anatomical knowledge provides for a safer procedure and the opportunity to plan surgical details preoperatively.

Obesity is an inflammatory disorder characterized by heightened activity of the innate immune system. Innate immune activation is central to the development of obesity-related insulin resistance; it also plays an important role in obesity-related tissue damage, such as that seen in atherosclerosis. Recent research has implicated the innate immune system in the pathophysiology of obesity-related liver disease. This review summarizes how innate immune processes, occurring both within and outside the liver, cause not only insulin resistance but also end-organ damage in the form of nonalcoholic fatty liver disease.

Recent refinements of magnetic resonance angiography (MRA) allow imaging vessels as small as the septocutaneous perforators (< or = 1 to 2 mm diameter), but a Medline review reveals no report of septocutaneous vessel imaging for free flap surgery. Challenges in fibula free flap preparation include knowledge of: (1) tibioperoneal anatomy, (2) the positions of the perforator vessels on the peroneal artery and their course in the posterolateral intermuscular septum, and (3) the cutaneous distribution of the perforators. Questioning whether high-resolution MRA could image these, we studied the lower extremities of nine healthy volunteers. MRA demonstrated tibioperoneal anatomy in sufficient detail to exclude anatomic variants and significant peripheral vascular disease and showed septocutaneous perforators arising from the peroneal artery and coursing in the posterolateral intermuscular septum to the skin. High-resolution MRA provided anatomic and clinical information that conventionally has been impossible to obtain preoperatively or has required multiple tests, often of an invasive nature.

BACKGROUND:Although free flap transfer is commonly performed to reconstruct defects of the upper two-thirds of the face and scalp, the superficial temporal artery and vein have historically not been considered adequate for microsurgical reconstruction and have rarely been described as recipient vessels. The purpose of this study was to determine the indications for and effectiveness of using the superficial temporal vessels for scalp and face reconstruction. METHODS:Retrospective chart review on all patients undergoing microsurgical reconstruction for defects of the upper two-thirds of the face between 1996 and 2003 revealed 45 free tissue transfers in which the superficial temporal artery and vein were considered for use as recipient vessels. Flap success rates and postoperative course were evaluated. RESULTS:Forty-three patients underwent 45 free flap transfers. The superficial temporal artery was used as the recipient artery in every case. In three cases, the superficial temporal vein was not suitable as the recipient vein and required use of a vein in the neck. The median length of follow-up was 4 years. Flap survival was 96 percent. Five patients required reoperation for vascular compromise. One of these patients ultimately had flap failure. In that patient, a subsequent attempt at microvascular flap reconstruction was successful using the same superficial temporal artery and vein as recipient vessels. CONCLUSIONS:Use of the superficial temporal artery and vein for scalp and face reconstruction is reliable and safe. The superficial temporal artery and vein should be considered as primary recipient vessels in microsurgical reconstruction of the upper two-thirds of the face and/or scalp.