[Show abstract][Hide abstract] ABSTRACT: To examine donor-site complications after omental harvest for the reconstruction of extraperitoneal wounds and defects.
The omentum, with its immunologic and angiogenic properties, is a versatile organ with well-documented utility in the reconstruction of complex wounds and defects. However, the need for laparotomy and the potential for intraabdominal complications have been cited as relative contraindications to the use of the omentum as a reconstructive flap. Further, few series have assessed long-term results, and no reports have focused on donor-site complications.
Patients who underwent reconstruction of extraperitoneal defects with the omentum at a single university healthcare system were identified by searching discharge databases and office records. Charts were reviewed to determine patient demographics, surgical indications and technique, postoperative complications, and outpatient follow-up. Patients with donor-site complications were compared with patients who had no complications using the Student t test and chi-square analysis. Statistical significance was defined at P <.05.
From 1975 to 2000, the authors successfully harvested 135 omental flaps (64 pedicled, 71 free transfer) for reconstruction of the following defects: scalp (n = 16), intracranial (n = 1), orbitofacial (n = 33), neck (n = 8), upper extremity (n = 7), lower extremity (n = 4), intrathoracic (n = 3), sternal (n = 34), breast (n = 3), chest wall (n = 18), abdominal wall (n = 1), and perineal (n = 7). Donor-site complications in 25 patients (18.5%) included abdominal wall infection (n = 9), fascial dehiscence (n = 8), symptomatic hernia (n = 8), unplanned reexploration (n = 6), postoperative ileus (n = 3), gastrointestinal hemorrhage (n = 2), delayed splenic rupture (n = 1), gastric outlet obstruction (n = 1), and late partial small bowel obstruction (n = 1). Factors associated with increased donor-site complications included the use of pedicled flaps (compared with free tissue transfer), mediastinitis, advanced age, and pulmonary failure. Of note, 53 patients had undergone previous abdominal surgery; of these, 26 patients required extensive adhesiolysis and 4 patients sustained enterotomies. Eleven patients (8.1%) had partial flap loss and three patients (2.2%) had total flap loss. Mean length of stay was 28 days. Average follow-up was 2.4 years. The death rate was 5.9%.
The omentum can be safely harvested and reliably used to reconstruct a diverse range of extraperitoneal wounds and defects. Donor-site complications can be significant but are usually limited to abdominal wall infection and hernia. Risk factors associated with complications include the use of pedicled flaps, mediastinitis, and pulmonary failure. This low rate of donor-site complications strongly supports the use of the omentum in the reconstruction of complex wounds and defects.
Annals of Surgery 07/2002; 235(6):782-95. DOI:10.1097/00000658-200206000-00005 · 8.33 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Microvascular free flaps continue to revolutionize coverage options in head and neck reconstruction. This article reviews our 25-year experience with omental free tissue transfers.
All patients who underwent free omental transfer to the head and neck region were reviewed.
Fifty-five patients were included with omental transfers to the scalp (25%), craniofacial (62%), and neck (13%) region. Indications were tumor resections, burn wound, hemifacial atrophy, trauma, and moyamoya disease. Average follow-up was 3.1 years (range, 2 months-13 years). Donor site morbidities included abdominal wound infection, gastric outlet obstruction, and postoperative bleeding. Recipient site morbidities included partial flap loss in four patients (7%) total flap loss in two patients (3.6%), and three hematomas.
The omental free flap has acceptable abdominal morbidity and provides sufficient soft tissue coverage with a 96.4% survival. The thickness \and versatility of omentum provide sufficient contour molding for craniofacial reconstruction. It is an attractive alternative for reconstruction of large scalp defects and badly irradiated tissue.
Head & Neck 05/2002; 24(4):326-31. · 3.01 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: This study provides a retrospective analysis of 60 patients who underwent thoracic reconstruction with the omentum. Patients were identified by searching several databases to determine demographics, indications for surgery, operative technique, and postoperative course, including donor and recipient site morbidity. From January 1975 to May 2000, the authors harvested and transferred the omentum successfully (57 pedicled, 3 free) in 60 patients (mean age, 60 years; age range, 21-86 years) for sternal wound infections (N = 34), chest wall resections (N = 17), pectus deformities (N = 2), intrathoracic defects (N = 4), and breast reconstruction (N = 3). The omentum was used as a primary flap in 39 patients and as a salvage flap in 21 patients. Average operative time was 3.9 hours and average hospital stay was 34.3 days. Partial flap loss occurred in 7 patients, with no total flap failures. Morbidity included six abdominal wound infections and seven epigastric hernias. Mortality was 11.7%. The omentum can be harvested safely and used reliably to reconstruct varying thoracic wounds and defects. Specific indications from this series include osteoradionecrosis, chest wall tumors, massive sternal wounds, and refractory mediastinitis. Hultman CS, Culbertson JH, Jones GE, et al. Thoracic reconstruction with the omentum: indications, complications, and results.
Annals of Plastic Surgery 04/2001; 46(3):242-9. DOI:10.1097/00000637-200103000-00007 · 1.46 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The purpose of the study is to define those patient variables that contribute to morbidity and mortality of median sternotomy wound infection and the results of treatment by debridement and closure by muscle flaps.
Infection of the median sternotomy wound after open heart surgery is a devastating complication associated with significant mortality. Twenty years ago, these wounds were treated with either open packing or antibiotic irrigation, with a mortality approaching 50% in some series. In 1975, the authors began treating these wounds with radical sternal debridement followed by closure using muscle or omental flaps. The mortality of sternal wound infection has dropped to < 10%.
The authors' total experience with 409 patients treated over 20 years is described in relation to flap choices, hospital days after sternal wound closure, and incidence rates of morbidity and mortality. One hundred eighty-six patients treated since January 1988 were studied to determine which patient variables had impact on rates of flap closure complications, recurrent sternal wound infection, or death. Variables included obesity, history of smoking, hypertension, diabetes, poststernotomy septicemia, internal mammary artery harvest, use of intra-aortic balloon pump, and perioperative myocardial infarction and were analyzed using chi square tests. Fisher's exact tests, and multivariable logistic regression analysis.
The mortality rate over 20 years was 8.1% (33/49). Additional procedures for recurrent sternal wound infection were necessary in 5.1% of patients. Thirty-one patients (7.6%) required treatment for hematoma, and 11 patients (2.7%) required hernia repair. Among patients treated since 1988, variables strongly associated with mortality were septicemia (p < 0.00001), perioperative myocardial infarction (p = 0.006), and intra-aortic balloon pump (p = 0.0168). Factors associated with wound closure complications were intra-aortic balloon pump (p = 0.0287), hypertension (p = 0.0335), and history of smoking (p = 0.0741). Factors associated with recurrent infection were history of sternotomy (p = 0.008) and patients treated for sternal wound infection from 1988 to 1992 (p = 0.024). Mean hospital stay after sternal wound reconstruction declined from 18.6 days (1988-1992) to 12.4 days (1993-1996) (p = 0.005). To clarify management decisions of these difficult cases, a classification of sternal wound infection is presented.
Using the principles of sternal wound debridement and early flap coverage, the authors have achieved a significant reduction in mortality after sternal wound infection and have reduced the mean hospital stay after sternal wound closure of these critically ill patients. Further reductions in mortality will depend on earlier detection of mediastinitis, before onset of septicemia, and ongoing improvements in the critical care of patients with multisystem organ failure.
Annals of Surgery 06/1997; 225(6):766-76; discussion 776-8. DOI:10.1097/00000658-199706000-00014 · 8.33 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Surgical treatment for short bowel syndrome has been directed toward slowing intestinal transit or increasing the absorptive surface area of the bowel. In the present work, we attempted to enhance bowel absorption by increasing vascularity, using the omentum's unique ability to revascularize incorporated tissue. After a 90% resection of small bowel with primary anastomosis in 5 mongrel dogs, an omental flap based on the right gastroepiploic vessels was incorporated into a seromuscular incision on the antimesenteric border of the remnant small bowel. Five control dogs underwent a similar resection and seromuscular incision with an omentectomy. Serum d-xylose assays, hemoglobin, and total protein levels were measured preoperatively and at 3, 6, 9, and 12 weeks postoperatively. Weekly weights were followed. The mean percent d-xylose absorption in the experimental group increased from 96% of the baseline at 3 weeks to 136%, 163%, and 179% at 6, 9, and 12 weeks respectively (p < 0.5). The control group maintained absorption levels between 54% and 74%. Weight loss in the experimental group was significantly less than the controls at weeks 6 and 9, but by 12 weeks, weights were similar for the two groups. Small bowel absorption of d-xylose was significantly enhanced by incorporation of the omentum into the bowel remnant.
Annals of Plastic Surgery 08/1996; 37(1):84-9; discussion 89-90. DOI:10.1097/00000637-199607000-00013 · 1.46 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: This represents the initial report of intestinal revascularization with pedicled omental flaps producing bowel segments that are capable of surviving without their native mesenteric perfusion. In 10 mongrel dogs, a pedicled omental flap supplied by the left gastroepiploic arcade was sutured along a seromuscular incision in the antimesenteric border of an isolated 15-cm segment of proximal jejunum. After 5 weeks, to allow for revascularization, the mesenteric blood supply to each isolated segment was completely divided at its base. Total survival of all bowel segments occurred based solely on omental perfusion. With each animal serving as its own control, the capacity for absorption of D-xylose in isolated jejunal segments perfused only by an omental "neomesentery" was demonstrated to be equal to control jejunal segments perfused by their native mesenteries. Arteriographic evaluation of the revascularization process revealed that the omental "neomesentery" is capable of supplying the entire isolated bowel segment through anastomoses with the vascular channels already present in the bowel wall. The mechanism of the revascularization process was further explored and found to be intimately dependent on an intact marginal arterial arcade in the mesentery.
Annals of Plastic Surgery 01/1995; 33(6):606-10. DOI:10.1097/00000637-199412000-00007 · 1.46 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The ability of pedicled omental flaps to revascularize isolated jejunal segments was determined in the initial phase of this project. These bowel segments were capable of surviving independent of their mesenteric perfusion, and absorptive function was equal to that of controls as measured by D-xylose assays. In the second phase of this research, we studied in 10 dogs the absorptive capacity of isolated jejunal segments with both an intact mesentery and an omental flap sutured to the antimesenteric border compared with controls that were perfused only by the mesentery. Absorption was measured at 1, 2, 5, and 10 weeks after application of the omental flap. Absorptive function was augmented an average of 25.8% at 2 weeks, reaching 67.6% (p < 0.001) at 5 weeks. This result remained consistent at 10 weeks. Laser Doppler and colored microsphere studies were performed during a secondary laparotomy at 10 weeks and revealed 42.3% and 53.5% increases, respectively, in blood flow to bowel segments receiving both mesenteric and omental perfusion. This finding suggested that the augmentation of absorptive function was a result of increased blood flow.
Annals of Plastic Surgery 12/1994; 33(6):611-4. DOI:10.1097/00000637-199412000-00008 · 1.46 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Lymph-node metastasis is the single greatest predictor of survival in patients with oral cavity cancers. Tumor angiogenesis has been correlated with metastasis in breast cancer and may have prognostic value in other tumors.
Sixty-six patients with clinically node-negative oral cavity squamous cell cancers were reviewed. Samples were cut and stained for factor VIII. The percentage of area of tissue stained for factor VIII was quantitated by a computerized image analyzer. Tumor depth was measured with an ocular micrometer to the nearest 0.1 mm. Variables were statistically examined against regional recurrence.
The probability of metastasis (%) was 2 for tumor staining of < or = 10% and 93 for tumor staining > 10% (P < 0.0001). The tumor depth was < or = 4 mm in 10 and > 4 mm in 83 (P < 0.0001). Patients with < or = 4 mm and < or = 10% staining had a 2% rate of recurrence, and patients with > 4 mm and > 10% staining had a 100% rate of recurrence (P < 0.0001).
Although tumor thickness was suggestive of predictability, only angiogenesis was a statistically significant predictor of recurrence in a multivariate analysis (P < 0.0001). Angiogenesis showed a strong correlation with regional recurrence and may be used as an independent prognostic indicator.
The American Journal of Surgery 11/1994; 168(5):373-80. DOI:10.1016/S0002-9610(05)80079-0 · 2.41 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: We evaluated the effect of topical epidermal growth factor treatment on healing of chronic wounds in a prospective, open-label, crossover trial. Five males and four females who ranged in age from 40 to 72 years (average 57 +/- 9 years) were enrolled. Four patients had adult-onset diabetes mellitus, two had rheumatoid arthritis, two had old burn scars, and one had a failed abdominal incision. The average duration of the ulcers prior to treatment with epidermal growth factor was 12 +/- 5 months (range 1 to 48 months). Following failure of the wounds to heal with conventional therapies, including debridement, skin graphs, and vascular reconstruction, wounds were treated twice daily with Silvadene alone for periods ranging from 3 weeks to 6 months. No evidence of healing was observed in any of the patients' wounds during Silvadene treatment, and patients were crossed over to twice a day treatment with Silvadene containing 10 micrograms epidermal growth factor per gram. Wounds of eight patients healed completely with epidermal growth factor-Silvadene treatment in an average of 34 +/- 26 days (mean +/- SD, range 12 to 92 days) and did not reoccur for periods ranging from 1 to 4 years. One patient failed therapy. These results suggest that topical treatment of chronic wounds with epidermal growth factor may stimulate healing.
[Show abstract][Hide abstract] ABSTRACT: Between 1978 and 1987, 15,595 median sternotomies were performed at Emory University Hospitals. Sternal wound infections developed in 246 patients (1.6 percent). Mediastinitis was present in 211 patients, while superficial infections were detected in the remaining 35 patients. Debridement and muscle or omental flap closure were performed in all instances of mediastinitis, with an overall mortality rate of 5.3 percent. The results of this treatment are reviewed, and the evolution of current therapeutic guidelines is described. When compared with closed-catheter irrigation and open granulation techniques, flap closure is shown to result in a fourfold decrease in mortality, an increased success of primary therapy, and a diminished length of hospitalization following treatment. This evidence supports the conclusion that debridement and flap closure should be considered the primary therapy for patients with poststernotomy mediastinitis.
Plastic & Reconstructive Surgery 10/1989; 84(3):434-41. · 3.33 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Between 1978 and 1987, 15,595 median sternotomies were performed at Emory University Hospitals. Sternal wound infections developed in 246 patients (1.6 percent). Mediastinitis was present in 211 patients, while superficial infections were detected in the remaining 35 patients. Debridement and muscle or omental flap closure were performed in all instances of mediastinitis, with an overall mortality rate of 5.3 percent. The results of this treatment are reviewed, and the evolution of current therapeutic guidelines is described. When compared with closed-catheter irrigation and open granulation techniques, flap closure is shown to result in a fourfold decrease in mortality, an increased success of primary therapy, and a diminished length of hospitalization following treatment. This evidence supports the conclusion that debridement and flap closure should be considered the primary therapy for patients with poststernotomy mediastinitis. (C)1989American Society of Plastic Surgeons
[Show abstract][Hide abstract] ABSTRACT: Experimental studies in animals have demonstrated that the topical application of epidermal growth factor accelerates the rate of epidermal regeneration of partial-thickness wounds and second-degree burns. We conducted a prospective, randomized, double-blind clinical trial using skin-graft-donor sites to determine whether epidermal growth factor would accelerate the rate of epidermal regeneration in humans. Paired donor sites were created in 12 patients who required skin grafting for either burns or reconstructive surgery. One donor site from each patient was treated topically with silver sulfadiazine cream, and one was treated with silver sulfadiazine cream containing epidermal growth factor (10 micrograms per milliliter). The donor sites were photographed daily, and healing was measured with the use of planimetric analysis. The donor sites treated with silver sulfadiazine containing epidermal growth factor had an accelerated rate of epidermal regeneration in all 12 patients as compared with that in the paired donor sites treated with silver sulfadiazine alone. Treatment with epidermal growth factor significantly decreased the average length of time to 25 percent and 50 percent healing by approximately one day and that to 75 percent and 100 percent healing by approximately 1.5 days (P less than 0.02). Histologic evaluation of punch-biopsy specimens taken from the centers of donor sites three days after the onset of healing supported these results. We conclude that epidermal growth factor accelerates the rate of healing of partial-thickness skin wounds. Further studies are required to determine the clinical importance of this finding.
New England Journal of Medicine 08/1989; 321(2):76-9. DOI:10.1056/NEJM198907133210203 · 54.42 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Retrospective analysis by chart review, personal interview, and physical examination identified 88 patients who received 96 jejunal free flaps over a 10 year period. Seventy-nine of these patients had cancer. There were 13 operative failures (13.5 percent) in 10 patients. Failures were attributed to arterial thrombosis in four instances, venous anastomotic problems in four instances, fistula and infection in the neck in one instance, carotid blowout in one instance, psychosis with avulsion in one instance, and an unknown cause in two instances. Seven second attempts at salvage of jejunal flaps were performed with five successes. There were five deaths in the perioperative period (6 percent). Of these, one was directly attributed to graft failure. The following eight abdominal complications required operation: wound dehiscence (four instances), small bowel obstruction (one instance), Mallory-Weiss tear (one instance), gastrostomy tube leak (one instance), and acute gastric dilatation (one instance). Complications in the neck included infection (six instances), infection requiring operation (three instances), hematoma (three instances), and suture line dehiscence (one instance). Fistulas developed in 28 patients (32 percent), 12 of whom required operative closure (43 percent). Significant stenosis developed in six patients, two of whom required operative revision. Of 79 patients treated for cancer, 34 died from progression of disease which recurred an average of 9.7 months postoperatively. Death ensued an average of 16.7 months postoperatively. Ten patients died with no evidence of disease. At last follow-up, 28 patients were alive without apparent disease. Twenty-six of these patients have good swallowing function. Significant palliation and a high rate of restoration of function are possible with the free jejunal autograft. Careful patient selection should markedly decrease operative morbidity and mortality.
The American Journal of Surgery 11/1987; 154(4):394-8. DOI:10.1016/0002-9610(89)90011-1 · 2.41 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Chest wall reconstruction following radiation no longer need be a protracted sequence of multiple stage tissue transfer with potential necrosis of the flap at each step. Muscle flaps with or without the overlying skin provide very reliable and effective methods of single-stage repair. For the anterior chest the latissimus dorsi, the rectus abdominis, and pectoralis muscles are the choices with omen turn as an alternative in salvage cases. For the posterior chest, choices are the latissimus dorsi or trapezius.
In selected patients, breast reconstruction can be offered. The use of either the rectus abdominis or latissimus dorsi musculocutaneous flap, singly or in tandem, is the current preferred choice.La reconstruccin de la pared torcica despus de irradicin ya no debe ser una prolongada secuencia de multiples transferencias escalonadas de tejidos con el peligro de necrosis potencial en cada paso. Los colgajos musculares con o sin piel significan un mtodo confiable y efectivo de reparacin en una sola etapa. Para reconstruir la pared anterior del trax se prefiere el uso de los msculos dorsal ancho, rectus abdominis y pectorales, con el epipln mayor como alternativa en casos potencialmente curables. Para reconstruir la pared posterior se prefiere al dorsal ancho o al trapecio. En casos seleccionados se puede ofrecer la reconstruccin mamaria. La preferencia actual reside en los colgajos musculocutneos de rectus abdominis o dorsal ancho aislados o en combinacin.La restauration de la paroi thoracique altre par irradiation ne ncessite plus d'avoir recours la greffe classique avec ses multiples tapes, le greffon tant expos la ncrose au cours de chaque tape. Les lambaux musculaires recouverts ou non de la peau attenante et ayant conserv leur pdicule vasculaire permettent en effet de procder avec efficacit et scurit une opration en un temps. En ce qui concerne la paroi antrieure, le grand dorsal, le grand droit de l'abdomen et les pectoraux reprsentent les greffons de choix ainsi que le grand piploon dans les cas difficiles. En ce qui concerne la paroi postrieure, le grand dorsal et le transverse sont les lments qui conviennent. Dans certains cas particuliers la reconstruction du sein est possible. Elle peut tre effectue l'aide d'un lambeau du grand droit de l'abdomen, du grand dorsal ou des 2 lments.
World Journal of Surgery 05/1986; 10(2):206-19. DOI:10.1007/BF01658137 · 2.35 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The purpose of this paper is to present a 5-year experience using a comprehensive surgical approach to reconstruct what we have chosen to call the "end-stage cleft lip and palate deformity." The deformity consists of varying degrees of midface retrusion, malocclusion, nasal deformity, and lip deformity. Most of the patients afflicted had unacceptable upper lip anatomy characterized by tightness and lack of cupid's bow and bulk. All had severe palatal scarring with resulting arch collapse and severe malocclusion. Most had had multiple surgical attempts to improve nasal aesthetics using standard rhinoplasty techniques with little or no improvement. The procedure involves splitting the upper lip with incisions extending into the upper buccal sulcus and rim of the nose allowing wide skeletalization of the maxilla and osteocartilagenous nasal skeleton. LeFort I or II maxillary advancement, nasal reconstruction, and upper lip modification (with Abbé flap if indicated) are done. The jaws are placed in intermaxillary fixation for 6 to 8 weeks. This comprehensive approach has been used in 16 patients, aged 15 to 29 years, with follow-up of up to 5 years. Excellent functional and aesthetic improvement has occurred in all patients, and complications have been minimal.