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...

This article reports the simultaneous reconstruction of maxillary and mandibular defects caused by a close-range gunshot blast to the face with one fibular osteocutaneous flap combined with an anteroateral fasciocutaneous flap. A fibular osteocutaneous flap was used for both mandibular and maxillary defects, using multiple osteotomies and discarding a central bony segment and an oral floor defect. An anterolateral thigh flap was used to cover a three-dimensional defect of both the intraoral mucosal region, as well as external skin and soft tissue defects, including some on the upper and lower lips. The results demonstrated that the method was a good choice in the reconstruction of large composite facial defects, both aesthetically and functionally.

Reconstructing a mangled extremity requires careful, complete examination of the functional and structural status of the injured part. Although the vascular status of the injured extremity is a priority, simultaneous reconstruction of skeletal, vascular, and neuromuscular structures should be considered in a combined approach. The purpose of this study was to describe a one-stage reconstruction of both soft-tissue coverage and revascularization for a lower extremity, along with functional restoration of an anterior lower leg. For this purpose, the functioning transfer of a free latissimus dorsi musculocutaneous flap as a flow-through type was performed. The results demonstrate that the technique is extremely useful in limb-salvage procedures from both functional and structural viewpoints.

Ischemic preconditioning is a useful manipulation to reduce the undesirable effects of ischemia. The beneficial results of this phenomenon against ischemia-reperfusion have been seen in different flap models; however, all these studies have focused on primary ischemia. In this study, we investigated the effects of ischemic preconditioning on secondary ischemia in a skin flap model. We used the 6- x 3-cm-sized epigastric skin flap in 40 Wistar rats. In all animals, primary global ischemia of 2 hours was followed by 4 hours of either arterial or venous secondary ischemia 24 hours after the primary ischemia and ischemic preconditioning (IP) was tested in this protocol. Ischemic preconditioning was performed by 2 cycles of 15 minutes of repeated ischemia/reperfusion periods. The animals were allocated into 4 groups: group 1 (n = 10 animals): primary ischemia (2 hours) + secondary arterial ischemia (4 hours); group 2 (n = 10 animals): IP + primary ischemia (2 hours) + secondary arterial ischemia (4 hours); group 3 (n = 10 animals): primary ischemia (2 hours) + secondary venous ischemia (4 hours); group 4 (n = 10 animals): IP + primary ischemia (2 hours) + secondary venous ischemia (4 hours). Flap viability was assessed 1 week after the surgical procedure, and surviving flap area was recorded as a percentage of the whole flap area. Group 1 was compared with group 2, and group 3 was compared with group 4 to evaluate the effects of ischemic preconditioning against secondary arterial and venous ischemia. t test and Mann-Whitney rank sum tests were used for statistical analysis. There were statistical differences both between groups 1 and 2 and groups 3 and 4. The results revealed that ischemic preconditioning was an effective procedure to reduce the flap necrosis as a cause of secondary ischemia in skin flaps.

This study describes a free flow-through flap model in the rat for use in the evaluation of the physiologic and hemodynamic characteristics of this type of flap in clinical practice. The rat is a preferred animal model because it is inexpensive, readily available, and reliable. There is no free flow-through flap model available for laboratory animals, although this model gained popularity in clinical use recently. Twenty Wistar rats weighing 200-250 g were used in our experiment. In 5 rats, the vascular anatomy of the groin and proximal thigh region was determined by anatomic dissection. The experimental design consisted of two groups. In the experimental group (N = 5), a flow-through epigastric skin flap was harvested based on the femoral artery, preparing both its proximal and distal stumps. The flap was transferred to the contralateral groin, and end-to-end vascular anastomosis was performed between a proximal and distal stump of the femoral arteries of the flap and recipient site. The proximal stump of the femoral vein of the flap was anastomosed to the femoral vein of the recipient site. The control group was divided into two subgroups. In all control group rats (N = 10), the flap was harvested in the same manner, and transferred to the contralateral groin, but standard free-flap procedure with one artery and one vein anastomosis was performed in 5 rats (conventional free-flap subgroup), and anastomosis was not performed between the flap and the recipient site in the remaining 5 rats (graft subgroup). Survival of the flap was evaluated on postoperative day 7 by direct observation, and microangiography was performed to delineate the vascularity of the flow-through flap. The results showed that all flaps survived in the experimental group and the conventional free-flap subgroup of the control group, whereas in the graft subgroup, all flaps underwent total necrosis. The authors conclude that the flow-through epigastric flap for the rat is a simple and reliable model for future physiologic and pharmacologic studies.

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.

The data demonstrate that surgical delay after long-term abdominoplasty can enhance the survival rate of the skin paddle of the TRAM flap.

Bone dust and diced cartilage are used for contour restoration because their minimal donor site morbidity. The purpose of this study is to investigate permanence of bone dust, diced cartilage and bone dust/diced cartilage mixture in rabbits over 12 weeks. New Zealand white rabbits were used for this study. There were three groups in the study: Group I: 1 mL bone dust. Group II: 1 mL diced cartilage. Group III: 0.5 mL bone dust + 0.5 mL diced cartilage mixture. They were placed into subcutaneous tissue of rabbits and removed 12 weeks later. The mean volumes of groups were 0.23 +/- 0.08 mL in group I, 0.60 +/- 0.12 mL in group II and 0.36 +/- 0.10 mL in group III. The differences between groups were found statistically significant. In conclusion, diced cartilage was found more reliable than bone dust aspect of preserving its volume for a long period in this study.