The combination of advances in microsurgery and the improvement of anesthetic management with increased understanding of the physiology of preoperative and postoperative care has significantly raised the upper age limit for free-flap transfer in elderly patients. Despite pessimistic opinions regarding elderly patients who have poor recovery potential and decreased physiological reserves, the unique feature of free-tissue transfer is that it allows the transfer of well-vascularized tissue to defects in a single-stage procedure, and leads to improved quality of life. In this report, a retrospective analysis of 55 patients aged 50 and older who underwent microsurgical tissue transfer is presented. Hospital and our own records were used to review various parameters. The preoperative medical status of each patient was assessed using the American Society of Anesthesiologists (ASA) Classification of Physical Status. Each patient's preoperative medical records, age, sex, transferred tissue type, and length of operation were outlined. Postoperative recorded parameters were the fate of flaps and the short-term postoperative outcome, including surgical complications, medical morbidity, and death within 30 days of surgery. Fifty-eight microvascular tissue transfers were performed in 55 consecutive patients. The study comprised 38 male and 17 female patients, with a mean age of 64.8 years. ASA classification status was class 1 for 15 patients, class 2 for 26 patients, and class 3 for 14 patients. Twenty-five flaps were used for lower extremity reconstruction, 32 flaps were used for head and neck reconstruction, and 1 was used for breast reconstruction. The average operative time was 5.7 h, ranging between 2-13 h. There were 14 major medical complications, resulting in an overall medical complication rate of 25%. There were 3 deaths within 30 days postoperatively. Thus, the overall surgical mortality rate was 5.4%. The longer operation times were associated with the development of postoperative total medical and surgical complications (P = 0.008). While the relationship between ASA class and medical complications was significant (P = 0.0007), no significant relation was determined between ASA class and surgical complications (P = 0.66). It was revealed that the greater the age group, the greater the occurrence of postoperative medical complications (P = 0.0001). The relationship between postoperative surgical complications and age groups was not significant (P = 0.07). It was also demonstrated that the advanced age of patients was associated with a higher ASA class (P = 0.0017). Eleven flaps required reoperation for vascular compromise. While 10 of these were salvaged with vascular anastomosis revisions, one flap was lost. Thus the overall flap success rate was 98.3%. In conclusion, if a patient's medical problems do not constitute a handicap, age itself should not be considered a barrier to free-flap transfer. It is important to be familiar with preoperative medical problems and possible postoperative medical complications in...

Complications of miniplates and screws used for maxillofacial fractures were analyzed, and complications were evaluated in relation to fracture site. Motor vehicle accidents were the cause of all fractures in this study. During the last 7 years (1994-2001), noncompressive titanium miniplates and screws were used for stabilization of maxillofacial fractures. In 66 patients, 87 fracture sites were stabilized using 296 miniplates and 1,184 screws. The mean age of the patients was 31 years (age range, 6-64 years). The percentage of male patients was 77% and the percentage of female patients was 23%. Miniplates and screws were used in 6 patients (10%) who were younger than 15 years of age at the time of the surgery. The follow-up period ranged between 3 months and 7 years. The overall miniplate and screw removal rate was 7%. The rates of removal according to the fracture site are as follows: mandible, 4.4%; zygomaticofrontal junction, 1.4%; inferior orbital rim, 0.7%; maxilla, 0.3%; and frontal sinus wall, 0.3%. Removal causes were infection, 2%; extrusion, 1.7%; visibility, 1.4%; pain, 1%; malunion, 0.7%; and miniplate fracture, 0.3%. The minimum time period between insertion and removal was 3 months and the maximum period was 14 months. Infection and extrusion were the main complications for removal of miniplates and screws from the mandible, whereas miniplates and screws were removed from the zygoma because of visibility (zygomaticofrontal region) under the skin in the vast majority of the patients. The maxilla was the least operated region for miniplate and screw removal. In all patients in this study, the preoperative physical symptoms were relieved after miniplate and screw removal. Miniplates and screws are very useful tools in maxillofacial fracture management, but sometimes they have to be removed. In the authors' series, the removal rate was 7%, and this rate can vary with the severity of the trauma and location of the fracture.

The purpose of this study was to investigate the effects of insulin-dependent diabetes mellitus (IDDM) on the viability of perforator-based flaps (pbf) in diabetic rats. Random-pattern flaps were also used as a control flap group. Wistar Albino rats, female, n = 60, were used. The study was done with four groups: Group 1 (diabetic rats, pbf), Group 2 (non-diabetic rats, pbf), Group 3 (diabetic rats, McFarlane flap), and Group 4 (non-diabetic rats, McFarlane flap). Streptozocin (STZ, 55 mg/kg) in a vehicle (sodium citrate, pH 4.5) was injected into the rats intraperitonally to create an IDDM model in the diabetic groups. Only the vehicle without STZ was injected into the rats intraperitonally in the non-diabetic groups. All flaps were elevated 10 weeks after injections. Measurements of the surviving areas of the flaps, and microangiographic and histopathologic studies were done 7 days after flap elevation. Blood glucose levels of the diabetic rats were significantly higher than those of the non-diabetic groups ( p < 0.001). The surviving flap areas were 41 +/- 21 percent in Group 1, 65 +/- 25 percent in Group 2, 49 +/- 10 percent in Group 3, and 66 +/- 10 percent in Group 4. The surviving flap areas of the diabetic groups were significantly less than those of the non-diabetic groups ( p < 0.001). Specific histopathologic changes of IDDM were seen only in the diabetic groups. Microangiographies in the diabetic and non-diabetic groups were very similar. The surviving flap areas of the perforator-based and random-pattern skin flaps in the diabetic rats were decreased by IDDM. If a flap is planned for diabetic wounds, it should be kept in mind that the area of flap necrosis may be larger than those of non-diabetics.

Animal research has added a great deal of understanding to flap hemodynamics. The rat is the most commonly used animal in flap research, and various flap models have been devised. In the current study the authors developed a single-perforator-based flap model in rats. In 30 rats, anatomic dissection and flap elevation based on a single musculocutaneous perforator artery arising from the biceps femoris muscle were performed. The vascular basis of this new flap was cleared by anatomic dissection of the posterior thigh in 6 rats. The survival pattern of the proposed flap was investigated in three groups of rats. Each group consisted of 8 rats and had different flap dimensions. In the first group the flap was located in the posterior thigh and was 3 x 2 cm. All flaps survived in this group at the end of the first week. In the second group the same flap was extended to the gluteal region and was 3 x 4 cm. Again, all flaps survived. In the last group an oversized flap (3 x 12 cm) was planned from the posterior thigh to the scapular region based on the same perforator artery. In this group only 61 +/- 7.2% (mean +/- standard deviation) of the flap survived at the end of the first week. Microangiography was performed in each group and the vascular architecture of the pedicle (perforator artery) was seen. This new posterior thigh perforator-based flap model is simple and reliable with a constant survival pattern. Thus, it could be used in studies investigating the physiological and pathophysiological changes of perforator-based flaps.

The interdomal fat pad (IFP) is an important structure related to tip deformity in rhinoplasty. This study aimed to evaluate the IFP by ultrasonography before surgery, and to demonstrate the existence of the IFP as a distinct anatomic structure in cadavers and patients. Three dimensions of the IFP were measured in 23 patients using ultrasound before rhinoplasty and in 10 cadavers using dissection. All fat pads were examined by histopathologic methods. In the cadavers, three dimensions of the IFP were found: 2.3 x 3.7 x 12.8 mm. In the patients, three dimensions of IFP were measured by ultrasonography: 2.8 x 4.1 x 13.7 mm. Histopathologic examinations showed that the IFP is a structure differentiated from subcutaneous tissue. The IFP was demonstrated in all cadavers and patients by surgical and radiologic methods. All cases had a fat pad in the interdomal space with varying sizes.