Surgical Treatment of the Infected Aortic Graft

The primary goal of treatment in dealing with an infected aortic graft is to save life and limb. This goal is best accomplished by eradicating all infected graft material and maintaining adequate circulation with appropriate vascular reconstruction. This review describes the choice of procedures, including an extra-anatomic bypass, an aortic allograft, an antibiotic-treated prosthetic graft, and an in situ autogenous reconstruction. Once a procedure has been decided on, preoperative evaluation and operative planning must take place. The review describes operative technique from the thigh incision and exposure of the femoral vessels to closure. Postoperative care is described. Outcomes and complications are discussed. Special consideration is given to aortoenteric fistulas. This review contains 8 figures, 2 tables, and 83 references. Key words: antibiotic-impregnated Dacron, aortic graft infection, aortoenteric erosion, aortoenteric fistula, axillobifemoral bypass, cryopreserved allograft, neoaortoiliac surgery

Aesthetic reconstruction of the severely disfigured burned face: a creative strategy for a “natural” appearance using pre-patterned autogenous free flaps

The author reviews his pioneering work in aesthetic restoration of the severely disfigured burn face first introduced in 1995 and refined over the past two decades. The reader will be exposed to the step by step approach to achieving cosmetic enhancement and functional rehabilitation of advanced facial burns. The “keystone” of the autogenous reconstruction is the pre-patterned, sculpted microvascular free flap designed to fit like the “piece of a puzzle” into the aesthetic units of the face to replace disfiguring burn scars. Aggressive intraoperative “sculpting” is employed both “in situ” at the donor site and during the flap transfer to simulate the normal facial contours and planes. Comparisons of the author’s approach are made to the whole spectrum of reconstructive modalities ranging from conventional grafting to expanded pre-fabricated flaps and even to CTA face transplants; advantages/disadvantages of each are discussed. The pre-patterned, sculpted microvascular (MV) free flap offers the benefit of a single-stage transfer of composite skin/soft tissue hiding the seams at the junction of facial planes. When harvested from distant donor sites, the donor deformities can easily be concealed. The MV free tissue transfer offers the substrate that can be sculpted into nuanced facial components as well as the “palette” upon which the face can be painted with creative camouflage makeup. The soft contour and texture of the autogenous patterned transfers translates into a “natural” facial appearance while preserving fluid motions of facial expression.