1096 CURRENT LITERATURE

Kiefer- und Gesichtschimrgie der Julius Maxiliams-Universitlt Wtirz- burg, Pleicherwall 2, D-97070 W&burg, Germany.

Postoperative Pain Management. Hopf HW, Weitz S. Arch Surg 129:128, 1994

In this article, the authors investigate the relationship be- tween analgesia and clinical outcome. A review of new methods of delivering opioid analgesic agents is also pre- sented. As competition between hospitals increases, medical centers and health care givers emphasizing patient comfort are likely to be more successful. Administration of opioids by patient-controlled analgesia pump or epidural catheter yield excellent analgesia with a low rate of side effects com- pared with intramuscular opioids. The use of opioids to treat postoperative pain is limited by side effects such as pruritus, nausea, vomiting, prolonged ileus, urinary retention, and re- spiratory depression. Introduction of several nonnarcotic, parenteral drugs such as ketorolac tromethamine and alpha2- adrenergic agonists (eg, clonidine hydrochloride) are altema- tives. They decrease the amount of opioids required and thus decrease the incidence of serious side effects. The authors conclude that as new routes of analgesic administration be- come available, increased patient satisfaction will be accom- panied by a reduction in noted side effects. The development of Acute Pain Service teams in many hospitals is a pro- active effort to address patient concerns regarding effective pain management. Advancas in the area of analgesic admin- istration will target improved pain control with fewer side effects.-K.N. CHOW

Reprint requests to Dr Hopfi University of California, San Francisco, 1652 HSW, Box 0522, 513 Parnassus Ave, San Francisco, CA 94143-0522.

Head and Neck Reconstruction With the Rectus Abdomi- nis Free Flap. Kroll SS, Baldwin BJ. Clin Plast Surg 21:97- 105, 1994

The rectus abdominis free flap in soft tissue reconstruction has a long pedicle that will allow it to reach almost any defect, large-caliber vessels that are relatively easy to work with, a good blood supply to facilitate thinning and shaping, and a donar site remote from the ablative surgery. When harvesting this flap, the skin paddle is marked vertically over the side of the abdomen. The skin incision is made with a scalpel but the remaining dissection can be performed with electrocautery to minimize hemorrhage. The flap is then ele- vated off the external oblique fascia until the lateral row of perforating vessels are vjsualized. The rectus abdominis muscle can then be harvested. After harvest and completion of the anastomosis, a two-layered closure is performed. For reconstruction of the orbit, this flap provides a blood source for temporalis fascia or lyophilized dura. It can create bulk after tongue resection. Through and through cheek defects can be satisfactorily repaired if the patient is not obese. Ear and neck defects may also be reconstructed without the risk of complications from other modalities. Disadvantages in- clude the possibility that it may be too bulky, or that it may lead to an abdominal bulge or hernia.-R.H. HAUG

Reprint requests to Dr Kroll: Department of Reconstructive and Plastic Surgery, Box 62, The University of Texas M.D. Anderson Cancer Center, 1515 Holcombe Blvd. Houston, TX 77030.

Soft-Tissue Reconstruction of Craniofacial Defects. Shes- tak KC. Clin Plast Surg 21:107-111, 1994

Optimal treatment for patients presenting with advanced cancers of the paranasal sinuses entail a combination of sur- gery and radiation therapy. The surgical extirpation often requires extensive ablation, resulting in defects of the cheek, palate, orbital region, and nasal and oral cavities. The goals to be satisfied include the restoration of palatal competence and function, filling of the orbital cavity, obliteration of the maxillary defect, sealing off of the anterior cranial base when excisions involve this region, and restoration of satisfactory facial contour and appearance. Soft tissue reconstruction of complex craniofacial defects has been greatly facilitated by advances in microvascular free transfer of tissues like the latissimus dorsi musculocutaneous flap. A single-stage two- team procedure is preferred. The patient is positioned in the semilateral position. The skin paddle(s) is(are) designed to meet the specific needs of the palate, nasal cavity, and facial skin. The skin and muscle are harvested on a flap that is based on the thoracodorsal artery. The palatal inset is per- formed first with a watertight closure. Next the skin is inset into the facial skin and lip segments. Next, additional skin paddles are precisely sized for cheek and nasal reconstruc- tion. The vascular pedicle is then passed through a tunnel and reanastomized. Postoperative care includes use of low- molecular-weight dextran, antibiotics, alimentation, back drains, and monitoring of the flap by appearance and Dopp- ler.-R.H. HAUG

Reprint requests to Dr Shestalc Magee-Womens Hospital, 300 Hal- ket St, Room 2541, Pittsburgh, PA 15213.

Osseous Reconstruction of the Midface and Orbits. Cole- man JJ. Clin Plast Surg 21:113-124, 1994

The midface or orbitonasomaxillary complex is an intri- cate three-dimensional entity with important functional and aesthetic purpose. The midface affords protection to the neu- rocranium, provides immunologic reservoirs, resonates speech, and supports the pillars and buttresses of the face. The midface contains two truncated pyramids that are air filled, lined by mucosa, and surrounded by a complex bony structure. Nonvascularized bone grafts are not well suited to midfacial reconstruction unless a vascularized matrix is provided by flaps providing soft tissue coverage. One such composite graft is the free scapular flap. Free transfer of skin, muscle, and bone are provided by the subscapular ar- tery. Bone can be based on the angular branch, whereas skin and muscle are based on the circumflex scapular artery. The microvascular reanastamosis is performed to a branch of the external carotid artery. This modality provides maximum flexibility for various midfacial and orbital reconstruc- tions.-R.H. HAUG

Reprint requests to Dr Coleman: Division of Plastic Surgery, Indiana University Medical Center, 545 Barnhill Dr, Emerson Hall 234, Indianapolis, IN 46202-5 124.

Minimally Invasive Techniques of Tissue Harvest in Head and Neck Reconstruction. Miller MJ. Clin Plast Surg 211149-159, 1994

Increasingly complex invasive procedures are being per- formed with minimal direct surgical exposure through skin incisions often only 1.0 cm long. This type of surgery has been made possible by the development of specially de- signed instruments, refinements in miniaturized optical sys- tems, and advances in video technology. These techniques of minimally invasive surgery (MIS) have been termed closed