Rudolf F Buntic

Massachusetts General Hospital, Boston, MA, United States

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Publications (48)79.86 Total impact

  • Arash Momeni, Rudolf F Buntic, Gregory M Buncke
    Journal of the American College of Surgeons 02/2014; 218(2):308-9. · 4.50 Impact Factor
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    ABSTRACT: OBJECTIVES:: To determine long-term outcomes and costs of Ilizarov bone transport and flap coverage for lower limb salvage. DESIGN:: Case series with retrospective review of outcomes with at least six year follow-up. SETTING:: Academic, tertiary care medical center. PATIENTS:: Thirty-four consecutive patients with traumatic lower extremity wounds and tibial defects who were recommended amputation but instead underwent complex limb salvage from 1993 to 2005. INTERVENTION:: Flap reconstruction and Ilizarov bone transport. MAIN OUTCOME MEASUREMENTS:: Outcomes assessed were flap complications, infection, union, malunion, need for chronic narcotics, ambulation status, employment status, and need for re-operations. A cost analysis was performed comparing this treatment modality to amputation. RESULTS:: Thirty-four patients (mean age, 40 years) were included with 14 acute Gustilo IIIB/C defects and 20 chronic tibial defects (nonunion with osteomyelitis). Thirty five muscle flaps were performed with one flap loss (2.9%). The mean tibial bone defect was 8.7 cm, mean duration of bone transport was 10.8 months, and mean follow-up was 11 years. Primary nonunion rate at the docking site was 8.8% and malunion rate was 5.9%. All patients achieved final union with no cases of recurrent osteomyelitis. No patients underwent future amputations, 29% required re-operations, 97% were ambulating without assistance, 85% were working full time, and only 5.9% required chronic narcotics. Mean lifetime cost per patient per year after limb salvage was significantly less than the published cost for amputation. CONCLUSIONS:: The long-term results and costs of bone transport and flap coverage strongly support complex limb salvage in this patient population. LEVEL OF EVIDENCE:: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
    Journal of orthopaedic trauma 02/2013; · 1.78 Impact Factor
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    ABSTRACT: BACKGROUND: Soft tissue defects of the scalp may result from multiple etiologies and can be challenging to reconstruct. We discuss our experience with scalp replantation and secondary microvascular reconstruction over 36 years, including techniques pioneered at our institution with twin-twin scalp allotransplant and innervated partial superior latissimus dorsi (LD) for scalp/frontalis loss. METHODS: A retrospective review of all patients presenting with scalp loss requiring microvascular reconstruction at a single center was performed from January 1971 to January 2007. Medical records were reviewed for age, gender, defect size/location, etiology, type of reconstruction, recipient vessels used, vein grafts, and complications. RESULTS: Thirty-three patients were identified; mean age was 33 years (range, 7-79). Mean scalp defect size was 442 cm(2) (range, 120-900 cm(2) ). Thirty-six microvascular reconstructions were performed; of these, 10 scalp replants and 26 microvascular tissue transfers. Of these 26, 17 were LD based (partial superior LD with and without reinnervation, LD combined with serratus, LD combined with parascapular, LD combined with split rib, LD only) and 2 free scalp allotransplant among others. The superficial temporal artery and vein was used as recipient vessels in 70% of cases. Overall, microvascular success rate was 92%; complications occurred in 14 cases, nine major (tumor recurrence [n = 2], partial flap loss [n = 2], replant loss [n = 3, size <300 cm(2) ], hematoma [n = 2]) and five minor (donor site seroma /hematoma [n = 3], flap congestion [n = 1], superficial wound infection [n = 1]). CONCLUSIONS: Every attempt should be made at scalp replantation when the patient is stable and the parts salvageable. Larger avulsion defects had higher success rates after replantation than smaller defects (<300 cm(2) ), with the superficial temporal artery and vein most commonly used for recipient vessels (P = 0.0083). Microvascular tissue transfer remains a mainstay of treatment for scalp defects, with LD-based flaps, demonstrating excellent versatility for a range of defects. © 2012 Wiley Periodicals, Inc. Microsurgery, 2012.
    Microsurgery 08/2012; · 1.62 Impact Factor
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    ABSTRACT: INTRODUCT ION : Harvesting the entire lastissimus dorsi muscle results in loss of this particular muscle function and loss of definition of the posterior axillary fold. Partial muscle harvest has the advantage of preserving the donor site function and avoids the need for future flap debulking, while still providing sufficient well vascularized soft tissue flap for reconstructive options. We want to highlight our flap harvesting technique and report our results with our first 90 patients. METHODS: A retrospective chart review of all of our patients who had partial superior latissimus flap transplantation between 2003 and 2010 was performed. Patients demographics, indications for the procedure, outcomes and donor site morbidity following the harvest were reviewed. The usual latissimus dorsi muscle harvest was modified to preserve innervation and perfusion to the lower two thirds of the muscle, while harvesting the upper portion of the muscle based on the transverse branch of the thoracodorsal vessels. RESULT S: Ninety partial superior latissimus flaps were performed to reconstruct the head and neck (36), lower extremity (33) and upper extremity (21) for various reasons. Our average follow up time was about 9 months. All flaps survived except one flap that developed venous congestion in the second postoperative day and eventually lost despite salvage attempts. Our average operative time was 4.5 h. There was no significant long term donor site morbidity in any patient. Conclusion: This technique of flap harvest preserves the donor site muscle function, posterior axillary fold definition and may help avoiding another surgery to debulk the flap. This muscle flap is an alternative to rectus abdominis flap, and is a useful option for coverage of medium size defects.
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    ABSTRACT: A typical consultation is based on a phone conversation between the consulting service and the surgeon. If the description given to the surgeon misrepresents the severity of the condition, unnecessary transfer of the patient could follow. In an attempt to reduce the occurrence of unnecessary transfers, we started supplementing our consultation with video captured with a cell phone camera demonstrating specific points in clinical examination of the hand. These videos were sent to the surgeon to clarify the clinical picture. We found this method useful in some cases in ruling out the need for urgent transfer.
    Annals of plastic surgery 04/2012; 68(4):389-90. · 1.29 Impact Factor
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    ABSTRACT: Limb salvage in fungal osteomyelitis of the post-traumatic lower extremity represents a difficult clinical problem requiring aggressive management. We report lower extremity salvage by radical bony debridement, free tissue transfer, distraction osteogenesis with bone-docking, and a novel antifungal regimen in a clinical setting of infection with Scedosporium inflatum, historically requiring amputation in 100% of cases. We treated Scedosporium inflatum osteomyelitis of the tibia and calcaneus with radical debridement of infected bone, free partial medial rectus abdominis muscle flap coverage, transport distraction osteogenesis, and combination voriconazole/terbinafine chemotherapy, a novel antifungal regimen. We achieved successful control of the infection, limb salvage, and an excellent functional outcome through aggressive debridement of infected bone and soft tissue, elimination of dead space within the bony defect, the robust perfusion provided by the free flap, the hypervascular state induced by distraction osteogenesis, and the synergism of the novel antifungal regimen.
    Microsurgery 02/2012; 32(2):144-7. · 1.62 Impact Factor
  • Plastic and reconstructive surgery 02/2012; 129(2):375e-376e. · 2.74 Impact Factor
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    ABSTRACT: The inner thigh skin and fat based on the transverse upper gracilis musculocutaneous flap blood supply provide an autologous donor area with qualities favorable to microvascular breast reconstruction. The flap can be shaped to mimic a mastectomy specimen, providing excellent contour and projection, and has a consistent blood supply. The characteristics and skin color of the flap allow for immediate nipple-areola complex reconstruction in skin-sparing mastectomy. From 2004 to 2007, the authors performed 32 free inner thigh flap microvascular breast reconstructions after mastectomy for breast cancer in 20 patients, in both delayed and immediate settings. All flaps survived without any soft-tissue loss or fat necrosis. Complications were a single take-back for venous thrombosis with salvage, donor-site skin breakdown in eight flaps, and five seromas. There was no functional loss at the donor site, and all patients resumed normal activity. Transverse upper gracilis musculocutaneous flap microvascular breast reconstruction is an excellent option for patients who desire autologous reconstruction and who do not have adequate abdominal donor tissue or who do not desire abdominal scarring. Therapeutic, IV.
    Plastic and reconstructive surgery 12/2011; 128(6):607e-13e. · 2.74 Impact Factor
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    Kacie Rounds, Rudolf Buntic, Darrell Brooks
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    ABSTRACT: We present a case of partial amputation of the forearm resulting in soft-tissue and radial artery defects that were simultaneously repaired using a large artery-vein-artery venous flap. The flap measured 4 × 11 cm, and we attribute its complete survival and long-term durability to the artery-vein-artery configuration.
    The Journal of hand surgery 06/2011; 36(8):1339-42. · 1.33 Impact Factor
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    ABSTRACT: With high success rates, flap survival should no longer be the sole criterion in judging success in dorsal hand and wrist reconstruction. The authors sought to determine the best flap for dorsal hand coverage in terms of aesthetic appearance, donor-site morbidity, and minimization of revision surgery. A retrospective review of all free flaps for dorsal hand and wrist coverage from 2002 to 2008 was performed. Flaps were divided into four groups: muscle, fasciocutaneous, fascial, and venous flaps. Outcomes assessed included need for debulking, blinded grading of aesthetic outcomes, and flap and donor-site complications. A total of 125 flaps were performed with no flap losses. There was no difference in partial loss or infection among the different flap groups. There was a significant range in the need for future debulking procedures, with debulking required in 67 percent of fasciocutaneous, 32 percent of muscle, 5.8 percent of fascial, and 0 percent of venous flaps. There was a significant difference in aesthetic outcomes: venous flaps had the best overall aesthetic outcomes; fascia and muscle flaps scored equally in terms of overall aesthetics, color, and contour match; and fasciocutaneous flaps had significantly worse aesthetic, contour, and color match results compared with all other flap types. Fasciocutaneous flaps had greater donor-site morbidity in terms of need for skin grafting and wound breakdown. The aesthetic outcome of dorsal hand reconstruction is dependent on flap choice, with statistically significant differences in revision surgeries and aesthetics among flap types.
    Plastic and reconstructive surgery 11/2010; 126(5):1630-8. · 2.74 Impact Factor
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    Rudolf F Buntic, Darrell Brooks
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    ABSTRACT: Artery-only fingertip replantation can be reliable if low-resistance flow through the replant is maintained until venous outflow is restored naturally. Injuring the tip of the replant to promote ongoing bleeding augmented with anticoagulation usually accomplishes this; however, such management results in prolonged hospitalization. In this study, we analyzed the outcomes of artery-only fingertip replantation using a standardized postoperative protocol consisting of dextran-40, heparin, and leech therapy. Between 2001 and 2008, we performed 19 artery-only fingertip replants for 17 patients. All patients had the replanted nail plate removed and received intravenous dextran-40, heparin, and aspirin to promote fingertip bleeding and vascular outflow. Anticoagulation was titrated to promote a controlled bleed until physiologic venous outflow was restored by neovascularization. We used medicinal leeches and mechanical heparin scrubbing for acute decongestion. By postoperative day 6, bleeding was no longer promoted. We initiated fluorescent dye perfusion studies to assess circulatory competence and direct further anticoagulant intervention if necessary. The absence of bleeding associated with an initial rise followed by an appropriate fall in fluorescent dye concentration would trigger a weaning of anticoagulation. All of the 19 replants survived. The average length of hospital stay was 9 days (range, 7-17 d). Eleven patients received blood transfusions. The average transfusion was 1.8 units (range, 0-9 units). All patients were happy with the decision to replant, and the cosmetic result. A protocol that promotes temporary, controlled bleeding from the fingertip is protective of artery-only replants distal to the distal interphalangeal joint until physiologic venous outflow is restored. The protocol described is both safe and reliable. The patient should be informed that such replant attempts may result in the need for transfusions and extended hospital stays, factors that can help the physician and patient decide whether to proceed with replantation. Therapeutic IV.
    The Journal of hand surgery 09/2010; 35(9):1491-6. · 1.33 Impact Factor
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    Darrell Brooks, Sendia Kim, Rudolf F Buntic
    Plastic and reconstructive surgery 12/2009; 124(6):460e-1e. · 2.74 Impact Factor
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    ABSTRACT: Not all patients seeking autogenous breast reconstruction have sufficient donor tissue for a bilateral reconstruction. Identical twin isotransplantation, as a model system for allotransplantation without immunologic barriers, broadens the definition of "spare parts" surgery. In this case, we demonstrate the simultaneous transplantation of both autogenous and syngeneic deep inferior epigastric perforator flaps for bilateral breast reconstruction. As our understanding of immunology evolves, allotransplantation may further increase our reconstructive options for other postmastectomy patients.
    Annals of plastic surgery 10/2009; 63(5):496-8. · 1.29 Impact Factor
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    Darrell Brooks, Rudolf F Buntic, Harry J Buncke
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    ABSTRACT: HYPOTHESIS: Artery only fingertip replantation can be reliable if combined with a post-operative protocol which promotes low-resistance flow through the replant until venous outflow is restored. METHODS: This is a retrospective study of patients with artery-only fingertip replantation. Artery-only fingertip replantation is defined as a complete amputation distal to the distal interphalangeal (DIP) joint replanted with repair of an inflow artery but without benefit of an outflow vein due to level or mechanism of amputation. All patients had the replant nail-plate removed and received intravenous Dextran and heparin to promote fingertip bleed and low-pressure flow across the repaired vessel. Anticoagulation was titrated to promote a controlled bleed until physiologic venous outflow was restored. Medicinal leeches and mechanical heparin scrubs were utilized for acute decongestion. By post-operative day 6 bleeding was no longer promoted. Fluoroscein studies were initiated to assess circulatory (arterial and venous) competence and direct further anticoagulant intervention. Lack of bleeding associated with a rise and fall in fluoroscein concentration would trigger a weaning of anticoagulation. Lack of bleeding associated with congestion or lack of a fall in fluoroscein concentration would result in reinstitution and maintenance of bleed from the fingertip. Length of hospitalization, complications, number of units of blood transfused, and patient satisfaction, were followed as well as characteristics of the injury including the finger amputated, mechanism of amputation, and zone of amputation as described by Ishikawa.
  • Journal of Plastic Reconstructive & Aesthetic Surgery 08/2009; 63(3):e310-1. · 1.44 Impact Factor
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    ABSTRACT: The objective of this study is to review a single institution's 10-year experience of simultaneous double second toe transplantations for reconstruction of traumatic hand injuries. Eleven cases of traumatic hand injuries treated with simultaneous double second toe transplantation for digital reconstruction were retrospectively reviewed. All patients sustained traumatic injury resulting in multiple digit loss not amenable to replantation. A simultaneous three-team approach was performed in all cases. The average operating time was 9 hours (range 7 to 15 hours). The mean time to reconstruction was 5.7 months following injury (range 2 to 15 months). Mean hospital stay was 8 days (range 6 to 11 days). Complications included microvascular thrombosis in two toes, loss of one transplanted toe, hematoma, and wound infection. Twenty-one toes survived; secondary surgery was performed in ten patients. Average moving 2-point discrimination was 8 mm in each digit at 7-month follow-up. Mean grip and pinch strength approached 67% of the contralateral hand. Mean time to return to work after finger reconstruction was 10 months. Simultaneous double second toe transplantation is a useful and efficient option for multidigit reconstruction. A three-team approach allows for single-stage reconstruction resulting in decreased operative time, decreased hospital stay, and good functional outcomes when compared with alternative techniques.
    Journal of Reconstructive Microsurgery 05/2009; 25(6):369-76. · 1.00 Impact Factor
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    Ron Hazani, Darrell Brooks, Rudolf F Buntic
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    ABSTRACT: We report a case of a 24-year-old patient who sustained a mutilating crush injury to the left forearm. After thorough debridement and stabilization of the skeletal injury, the dorsal thoracic fascial flap was used to resurface the circumferential wound, protect the underlying structures, and provide a gliding surface for the exposed tendons. The flap was safely transected during revision surgery, and at 6-months follow-up, excellent functional and cosmetic results were achieved. The dorsal thoracic fascia is a thin, durable, and pliable tissue that is based on a long vascular pedicle. We consider the dorsal thoracic fascial flap as a valuable option for coverage of complex upper extremity injuries and highly recommend its use.
    Microsurgery 01/2009; 29(2):128-32. · 1.62 Impact Factor
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    ABSTRACT: Limb salvage techniques of traumatized extremities using free-tissue transfer and microsurgical techniques have become standard reconstructive methods. To our knowledge there is no published data on the incidence or likelihood of equinus following free tissue transfer about the ankle, although in our experience we have perceived an unacceptable incidence of equinus following free tissue transfers about the ankle and therefore initiated prophylactic ring fixation across the ankle. Fourteen patients were placed in circular external fixation spanning the ankle at the time of free tissue transfer for a mean of 12 weeks (Median 7 weeks, Range 6-28 weeks). The results were evaluated using the degree of active ankle dorsiflexion and return to independent ambulation. Six patients had excellent results with active ankle dorsiflexion beyond neutral, and four patients had good results with neutral ankle alignment that did not require further intervention. All patients saved their limb and returned to independent ambulation. When performing free tissue transfer about the ankle, temporary spanning with a circular fixator is effective in preventing equinus deformity and provides a stable mechanical construct protecting the flap.
    Microsurgery 11/2008; 28(8):623-7. · 1.62 Impact Factor
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    Darrell Brooks, Rudolf F Buntic, Ramon De Jesus
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    ABSTRACT: The authors describe the non-orthotopic insertion of an Ascension two-piece pyrocarbon proximal interphalangeal joint at the osteosynthesis level of bilateral toe-to-digit transplantations in an attempt to restore both anatomic length and composite fist formation after traumatic multidigit loss. The non-orthotopic joints provided an additional 30 and 35 degrees of stable flexion to the reconstructed index and longs digits enabling the patient to form a composite fist. There was no evidence of joint instability or loosening. Total active motion was 240 and 235 degrees at the index and long fingers, respectively. Creation of two four joint fingers by the addition of non-orthotopic joints in toe-to-digit reconstructions successfully restored form and function after multidigit loss.
    Microsurgery 11/2008; 28(8):628-31. · 1.62 Impact Factor
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    Rudolf F Buntic, Darrell Brooks, Gregory M Buncke
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    ABSTRACT: Replantation/revascularization of severely injured single digits is controversial, especially at the index position. Conventional wisdom is that these digits if salvaged will ultimately worsen residual hand function and they should be amputated. Twenty-eight cases of such index salvages were reviewed to test this hypothesis. Five cases involved children and were excluded. Twenty-three replants/revascularizations survived (100%). Total active motion was 170 degrees in zone 1, and 133 degrees for zone 2 injuries. Patient satisfaction was high in all cases. In selected cases, salvage of severely injured and amputated index fingers has the potential for satisfying survival and functional results and dogmatic treatment with completion amputation should be avoided.
    Microsurgery 11/2008; 28(8):612-6. · 1.62 Impact Factor

Publication Stats

224 Citations
79.86 Total Impact Points

Institutions

  • 2012
    • Massachusetts General Hospital
      • Division of Plastic and Reconstructive Surgery
      Boston, MA, United States
  • 2002–2011
    • California Pacific Medical Center Research Institute
      San Francisco, California, United States
  • 2008–2009
    • University of Louisville
      • Division of Plastic Surgery
      Louisville, KY, United States
    • Rutgers New Jersey Medical School
      Newark, New Jersey, United States