text:
TITLE: Free Flap Reconstruction of Head and Neck Defects
SOURCE: Grand Rounds Presentation, UTMB, Dept. of Otolaryngology
DATE: May 22, 2002
RESIDENT PHYSICIAN: Christopher Muller, M.D.
FACULTY PHYSICIAN: Shawn Newlands, M.D., PhD. and Ann
M. Pou, M.D.
SERIES EDITORS: Francis B. Quinn, Jr., MD and Matthew W. Ryan, MD
material was prepared by resident physicians in partial fulfillment of
educational requirements established for the Postgraduate Training Program of
the UTMB Department of Otolaryngology/Head and Neck Surgery and was not
intended for clinical use in its present form. It was prepared for the purpose
of stimulating group discussion in a conference setting. No warranties, either
express or implied, are made with respect to its accuracy, completeness, or
timeliness. The material does not necessarily reflect the current or past
opinions of members of the UTMB faculty and should not be used for purposes of
diagnosis or treatment without consulting appropriate literature sources and
informed professional opinion."
Over the past three decades, many advances have been made in the treatment of head and neck cancer. These include the combination of radiation therapy and chemotherapy with surgery, conservation laryngeal surgery, and modifications of the classic radical neck dissection. The desire to improve postoperative outcomes by focusing on preservation of tissue and function led to these advances and resulted in more rapid recovery and decreased cosmetic deformities while maintaining equal cure rates to prior techniques. Despite the fact that these changes have decreased morbidity, overall survival rates for patients with head and neck cancer has reached a plateau over the past several decades. Because of this, the focus of many head and neck surgeons in the past 20 years has been directed at further decreasing morbidity from surgery and improving functional and reconstructive outcomes.
The use of free tissue transfer and microvascular re-anastomosis for the reconstruction of head and neck defects from extirpative oncologic surgery is a relatively recent practice. Prior to the past 3 decades, the majority of head and neck defects were closed with either local tissue or random skin flaps that were pedicled and "walked" up to the head and neck region from other sites such as the trunk. Very rarely were large soft tissue and bony defects replaced with anything other than skin. In 1963 McGregor first introduced his forehead flap for reconstruction of oral defects. This was an axial pattern skin flap and was much more reliable than random flaps. In addition it did not require the tedious relocation from distant sites. The problem with this flap was that it left a large skin defect on the forehead and scalp requiring a skin graft, which was rather deforming. Subsequently in 1965, Bakamjian introduced the deltopectoral flap based on the perforators of the internal mammary artery. The donor site was the shoulder and chest, which was much more cosmetically acceptable. The shortcomings of the flap, however, were that its reach was limited by its pedicle. McGregor's forehead flap and Bakamjian's deltopectoral flaps were the standard flaps available for head and neck reconstruction during the 1960s and 70s.
Although microvascular transfer of free tissue grafts did not gain favor until the mid 1970s it was performed as early as 1959 when Seidenberg used revascularized free jejunum segments to repair pharyngoesophageal defects. McLean and Buncke used omentum pedicled on the gastroepiploic vessels to cover a cranial defect in 1972. In 1973, Daniel and Taylor described the first free cutaneous flap and in 1976, Baker and Panje was the first to publish the use of free cutaneous flaps for the reconstruction of head and neck defects. He followed this in 1977 with a free groin flap based on the superficial circumflex iliac artery to reconstruct an intraoral defect. This flap was met with some favor during this time and was performed by other surgeons, however it was a bulky flap and its vascular pedicle was inconsistent and the vessels were very small in diameter.
Other flaps such as the axillary free flap and dorsalis pedis flap were also described but had short-comings such as an inconsistent pedicle and significant donor site morbidity respectively. In 1976, Harii and colleagues developed the latissimus dorsi musculocutaneous flap. This was a very reliable flap based on the thoracodorsal artery and vein. It has remained a favorable flap for certain head and neck defects to this date.
During the 70s limited numbers of surgeons were performing free flaps for a number of reasons. First, there were only a few to choose from. In addition they did not always provide all the tissue needed to reconstruct head and neck defects requiring combinations of bone, skin, and muscle. Most importantly, the majority of flaps at this time had inconsistent small pedicles making them technically difficult to perform.
Towards the end of the 1970s free flaps grew out of favor and an old technique was revisited. In 1896, Tansini had described the pedicled latissimus dorsi flap. In 1976, Olivari brought this back into favor. Subsequently other pedicled cutaneous and myocutaneous flaps arose such as the pectoralis and trapezius flaps. The pectoralis myocutaneous flap was considered the "work Horse" flap of head and neck reconstruction during this time. In 1979, Ariyan used the pectoralis flap in combination with rib and in the same year Demergasso and Piazza described harvest of the spine of the scapula with the trapezius musculocutaneous flap. These pedicled flaps became the choice of most head and neck surgeons over the next decade. They were reliable, quick, and easy to harvest. They also required only one stage, had minimal donor site morbidity, and provided more bulk than the free flaps available at that time. They required only one surgical team, were technically easier, and provided nonirradiated tissue (Chepeha and Teknos, 2001).
In the past fifteen years, limitations of pedicled flaps and desire by surgeons for new and better donor sites has lead to a resurgence of free tissue transfer. Pedicled flaps were not well suited for reconstruction of defects requiring very large bulk or those needing thin pliable tissue. In addition their reach was constrained by the length of their pedicle. As further investigations continued new donor sites for free flaps emerged that possessed longer and larger vascular pedicles and were made up of various tissues including skin, muscle, bone, and nerve. This allowed for much more refined tailoring of harvested tissue to the recipient site. Free flaps can provide a much wider range of skin characteristics that can match the host site well. In addition microvascular transfer makes much more efficient use of harvested tissue as nearly all is used directly in the reconstruction. Pedicled flaps require less efficient use of tissue as entire muscles are defunctionalized in order to safely transfer enough tissue to fill a defect. Because free flap donor sites are often located at a distant location from the extirpative site, a two team approach can be used to decrease operating room time. The excellent perfusion of free flaps significantly improves wound healing and serves to protect against wound breakdown and osteoradionecrosis when postoperative radiotherapy or brachytherapy is utilized. Free flap reconstruction also affords the ability for water-tight closures in skull base defects to prevent CSF leaks. Because revascularized tissue transfers maintain their independent blood supply, they are not as subject to resorption, providing for greater long-term stability and cosmesis to the reconstruction. Resorption, which plagued non-viable bony transfers in the past, is virtually eliminated with free flap reconstruction. Finally, many of free flaps have the potential for functional neurosensory and motor innervation from recipient nerves as well as the ability for primary placement of osseointegrated implants for improve oromandibular function
In 1979, Taylor and colleagues described the iliac crest composite flap based on the deep circumflex iliac artery. This was followed by the radial forearm fasciocutaneous flap (Yang, 1981), the scapular skin flap (dos Santos, 1980), the parascapular skin flap (Nassif, 1982), the lateral arm fasciocutaneous flap (Song, 1982), the scapular osseocutaneous flap (Swartz 1986), the lateral cutaneous thigh flap (Baek 1983), and the rectus abdominis myocutaneous flap (Drever, 1985).
Today microvascular free-tissue transfer to the head and neck has become an accepted method of reconstruction. This is due primarily to increased success rates for free-flap surgery (93 to 94%, Schusterman, 1993 and Urken, 1994 respectively) and superior aesthetic and functional results. Increasing numbers of surgeons have become adept at this surgical subspecialty for a number of reasons: (1) widespread application of microvascular techniques by a variety of different surgical disciplines; (2) Advances in technique and instrumentation; and (3) expanding number of dedicated training fellowships.
Planning for reconstruction of head and neck defects after ablative surgery for cancer requires an enormous amount for foresight. Each patient must be evaluated on an individual basis and a number of factors considered in determining what will be the best reconstructive option for them. Those factors include the following: (1) amount and type of tissue that will be required; (2) if innervation is required; (3) anticipated functional gains; (4) anticipated donor morbidity; (5) success rate; (6) patient positioning and donor location; (7) operative time; (8) surgical skills required and most importantly (9) patient factors including general medical status and the patients wishes and expectations. Patients should be thoroughly counseled in the preoperative period of all options for reconstruction after extirpation (including secondary intention, primary closure, skin grafting, regional flaps, and free tissue transfer). The experienced reconstructive surgeon should have a plan in mind as to which surgical procedures will likely be used however there is never any guarantee as to what the best options will be until the tumor is removed and the final defect is analyzed. In addition the quality of vessels for chosen flaps will be evaluated only after they are isolated. Instances have arisen where a flap was not used because of vessels that were too small, requiring use of flaps from other donor sites. The patient must be aware of these factors.
Successful free tissue transfer begins with proper patient selection. There are a number of patient characteristics which can additively increase the likelihood of failure.
Diabetes and other systemic illnesses such as hypercholesterolemia can increase the likelihood of microvascular disease and muscular artery atherosclerosis. In addition, poorly controlled diabetes often impairs proper wound healing. Microvascular disease delays healing and neovascularization between the flap and surrounding tissues. It also increases the likelihood of infection with potential flap loss. Atherosclerosis is most problematic when using lower extremity vasculature such as in fibula flaps and the dorsalis pedis flap. Atherosclerotic disease is less problematic with upper extremity, truncal, and visceral vasculature. Within the head and neck, the facial artery is the peripheral branch of the external carotid system which is most susceptible to atherosclerotic plaques. Still, this vessel is frequently used as a recipient vessel for anastomosis because of its close proximity and good vessel caliber. It should also be taken into account that patients who have had previous radiation therapy are at increased risk of atherosclerosis.
Patients with existing cardiac disease have increased morbidity and mortality with any large operation requiring anesthesia. This is particularly true in the treatment of head and neck cancer where surgeries run for extended periods of time. Free flaps significantly increase the operating time for these surgeries (4 to 6 hours), although at many institutions this is no longer an issue secondary to the development of an increased number of distant donor sites which allow for a two team approach. Postoperative cardiac complications pose a major threat to the viability of free-flaps, which are dependent on adequate blood flow. Cardiac function should be optimized in these patients in the perioperative period through invasive monitoring and appropriate medical management by cardiac and anesthetic specialists.
Decreased flap perfusion, hypercoagulation, and impaired wound healing have been associated with smoking. Thus, smoking should be discontinued for at least one week prior to surgery and forbidden in the postoperative period. Obesity may also decrease the success of free tissue transfer as the increased adipose tissue makes dissection of the vascular pedicle more difficult and interferes with the microvascular anastomosis, insetting, and flap tailoring after transfer.
Collagen vascular diseases are another relative contraindication to free flap transfer. These diseases can compromise the cardiovascular system, particularly in individuals with an active vasculitic process. These individuals have a much higher incidence of anastomotic thrombosis and thus may not be candidates for free tissue transfer.
Coagulopathies are another relative contraindication. Most are secondary to coumadin therapy for those who have a history of cerebrovascular disease, deep vein thrombosis, or mechanical heart valves. As such, most can be modulated with cessation of the coumadin, and the use of replacement blood products such as fresh frozen plasma. However, patients with a history of ethanol-induced hepatic insufficiency will often have a less easily controlled coagulopathy and the risk for severe intraoperative bleeding, postoperative hematoma, and consequent risks to the vascular anastomosis are greater. The only absolute contraindication for free tissue transfer is a hypercoagulable state. In these persons (i.e. polycythemia, sickle cell disease), the risk of anastomotic thrombosis is too great to justify the use of free tissue transfer.
The details of the microvascular technique will not be covered in this text but selected important principles will be mentioned. The operating microscope needs to be checked prior to the case to ensure it is in working order. All necessary instruments, including the proper suture materials, should be readily available. The operating room nurse should have warm physiosol, 1% lidocaine without epinephrine, heparin, and papavarine available for immediate irrigation. No systemic pressor agents (i.e. dopamine or phenylephrine) should be used by anesthesia. The use of various anticoagulants and vascular expanders is employed by some to reduce the probability of vascular thrombosis. Some have been shown to produce an advantage in experimental models, and also potential clinical benefit in retrospective analysis. However, because the rate of thrombosis is quite low with good techniques, detection of a difference between groups is difficult. The three most commonly used substances include heparin, aspirin, and low molecular weight dextran (a volume expander). Heparin (5000 units) may be given during the last quarter of the venous anastomosis and continued as a low continuous rate of infusion to achieve a PTT of approximately 1.5 times normal value. Aspirin is often given at 5 to 10 grains per day (per rectal or per NGT). Low molecular weight dextran is usually given at a low rate of infusion (20-30 cc/hr) either continuously or as a serial infusion (i.e. 12 hours on and 12 hours off).
Patency of an anastomosis can be tested in various ways. Venous patency is easily evident when the vessel is translucent. Direct observation of expansive pulsation is a reliable indicator of vessel patency, whereas longitudinal pulsation usually indicates a partial or complete obstruction. The Doppler ultrasound can be also used as an indicator of vessel patency. The chances of thrombosis are greatest at the site of anastomosis 15-20 minutes following closure. Therefore, it is customary to observe the anastomosis and test its patency during this period of time. If partial obstruction occurs, gently squeezing the vessel with forceps or massaging the vessel may break up the thrombus. A complete thrombus necessitates resection of the damaged segment and reanastomosis.
Vascular thrombosis is most commonly due to technical error in suture placement or pedicle kinking, or the use of a vessel with a damaged intimal layer. Thrombosis at the venous anastomosis accounts for 9 of 10 thromboses and is more likely due to the slower venous flow and relative stasis of blood at this site. After the first 20 minutes, the next critical period is within the first 3 postoperative days as 90% of vascular thromboses occur during this time. After this time, vascular thrombosis is more often associated with the late development of a hematoma, infection, or fistula. Although neovascularization may be complete in a short period of time in thin flaps, which have a large surface to volume ratio, thicker flaps may take several weeks before they are independent of their anastomosed blood supply.
Radial forearm
The radial forearm free flap (RFFF) has become one of the work horse flaps for reconstruction in head and neck surgery. It is primarily used defects in the oral cavity, oropharynx, and hypopharynx. Its vascular supply is based on the radial artery and paired venae comitantes (which accompany the radial artery). The cephalic vein can also be used for venous anastomosis. It has many advantages including the following: (1) consistent vascular anatomy (2) long vascular pedicle – up to 18-20cm; (3) vessels are large – up to 2.5 mm in diameter; (4) location allows for a two team approach; (5) pedicle can be outlined on the skin prior to incision; (6) it can be raised as a composite graft including bone and nerve; and (7) has acceptable donor site cosmesis. The forearm has some of the thinnest, most pliable skin in the whole body making it an excellent donor for reconstruction of the oral cavity and pharynx. The flap may include skin from the antecubital fossa to the flexor crease at the wrist.
Disadvantages of the RFFF include potential donor site morbidity (hand ischemia), limited bulk, and requirement of a split thickness skin graft (STSG) to cover the donor site. An Allen's test should be performed on all patients considered for a RFFF. The nondominant hand should be chosen first. This involves having the patient squeeze their fist tightly to expel blood from the hand. Pressure is then placed over the ulnar and radial artery and the patient is asked to release their fist. The hand should appear pale. The ulnar artery is then released and the hand is watched for capillary refill. It may take up to 60 seconds to see adequate refill. If there is uncertainty, doppler of the digital artery should be performed (Chepeha, Teknos, 2001).
The steps of the surgical procedure can be learned from most head and neck surgical atlases and will not be discussed here. There are some considerations to keep in mind. Venepuncture should be avoided from the antecubital fossa of the forearm selected for harvesting the flap. If possible, skin should not be elevated over the ulnar artery. The paratenon of the flexor tendons (flexor carpi radialis tendon) should be left down as this provides blood supply to the STSG. If paratenon is violated, muscle flaps may be created to increase vascular supply to the graft. A volar splint should be used with the wrist in 10-15 degrees of extension and the digits in the "position of function." The splint is left on for 2 weeks.
Lateral Arm
The lateral arm flap may be raised as a fasciocutaneous flap or as a composite graft with bone (humerus), and two nerves, one of which (posterior cutaneous nerve of the arm) serves as sensory supply and the other (posterior cutaneous nerve of the forearm or posterior antebrachial cutaneous nerve) as a vascularized nerve graft. The skin flap that is raised is similar in texture, pliability and size as the RFFF but it has distinct advantages. First, the donor site can be closed primarily and does not require a skin graft if the skin flap is limited to 6-8 cm, or one-third the circumference of the arm. Second, its vascular supply is based on the profunda brachii, which is not essential to the vascularity of the distal upper extremity. There is no risk of ischemia to the arm with this flap.
The pedicle to this flap is based on the terminal branches of the profunda brachii artery and the posterior radial collateral artery (PRCA) and its venae comitantes. These vessels travel in the spiral groove with the radial nerve. As the PRCA enters the lateral intermuscular septum, its average diameter is approximately 1.55mm. The blood supply to the skin is derived from four to five septocutaneous perforators that arise from the PRCA. The maximum length of the vascular pedicle is 8-10mm. This length can be achieved by extending the dissection proximally between the lateral and long head of the triceps muscle. This involves creating a tunnel underneath the triceps insertion to gain access to the spiral groove to access more of the vessel. This maneuver can risks the muscular branches of the radial nerve to the triceps muscle. There are several disadvantages to the lateral arm flap. The donor site requires a pressure dressing postoperatively which has been associated with radial nerve palsies. If a large flap is required, a STSG may be required.
Lateral Thigh
The lateral thigh flap is a fasciocutaneous flap whose blood supply is based on the third perforator of the profunda femoris artery and its venae comitantes. This flap, like the RFFF is used primarily used in reconstruction of oral cavity and pharyngeal defects. It has many advantages including: (1) a long vascular pedicle (up to 15cm); (2) large vessels (2-4mm); (3) large skin paddle (up to 10X20cm); (4) distant from the head and neck allowing for a two team approach; (5) donor site can be closed primarily with minimal functional loss; (6) the skin is pliable and usually hairless; and (7) the flap may be harvested as a sensate flap if the lateral femoral cutaneous nerve of the thigh is preserved. In obese patients, particularly women, these flaps may be very bulky. Other disadvantages include the difficulty of dissection deep in the leg near the profunda femoris artery requiring an assistant to retract the vastus lateralis. The vascular pedicle is often inconsistent. The most common variation is for the pedicle to arise from the fourth perforating branch of the profunda femoris artery.
Rectus Abdominis
The rectus abdominis is an extremely versatile free flap used for reconstruction of multiple soft tissue defects in the head and neck. Most commonly it is used for large defects in the midface and cranial base region. It has also been used on the scalp and in the oral cavity (particularly for patients undergoing total or subtotal glossectomy). The flap may either be raised as a muscle flap or a musculocutaneous flap. The blood supply to the rectus abdominis muscle is based on the deep superior and inferior epigastric arteries while the skin overlying it is based on musculocutaneous perforators arising from these arteries within the muscle belly. The muscle is very large and can fill in large defects and can reliably separate the oral from the cranial cavity in cranial base surgery. There are a large numbers of musculocutaneous perforators that supply the overlying skin making it possible to create spatially separated skin paddles. This allows for closure of defects involving more than one epithelial site such as the cheek and the oral cavity or the buccal mucosa and the palate.
Other advantages of the rectus abdominis free flap include: (1) constant anatomy; (2) ease of flap elevation; (3) change of position is not necessary allowing simultaneous elevation with extirpation of the primary; (4) large diameter vessels (mean of 3.4mm) with a pedicle up to 8-10cm in length.
Patients should be evaluated preoperatively for any previous abdominal surgery. If so, it should be determined whether or not there may have been disruption of blood supply to the flap. If uncertain, another donor site should be chosen. In addition, the amount of abdominal wall fat will determine the bulk of the flap if skin and subcutaneous fat is to be taken as well. If it is too bulky, the muscle can be transferred alone and a skin graft can be used. This is often why other donor sites such as the forearm, are chosen for reconstruction of smaller defects particularly in the oral cavity.
A multitude of flap designs have been described. Each flap should be tailored to the patient's particular defect
In order to successfully elevate the rectus abdominis free flap, a thorough understanding of the rectus sheath is required. It is composed of different layers of facial extensions from the external oblique, internal oblique, and transverse abdominis muscles depending on the location along the abdominal wall. The rectus abdominis muscle originates from the pubic symphysis and extends cephalad to insert on the costal cartilage syncytium of ribs 8 to 11. In the upper two thirds of the muscle, the anterior sheath is formed by the aponeurosis of the external and internal abdominal oblique muscles. The posterior sheath is formed by the aponeurosis of the transverse abdominis muscle and the transversalis fascia. At approximately the level of the anterior superior iliac spine and important transition occurs. The aponeurosis of the transverse abdominis muscle courses anterior to the rectus muscle interdigitating with the external and internal oblique muscles. This area is called the arcuate line. Below this point the posterior sheath is composed of the transversalis fascia only.
When designing a flap, it is important to preserve the anterior rectus sheath to prevent herniation or bulging of the abdominal contents. This is of particular concern below the arcuate line. There is usually no need to remove the anterior rectus sheath below this level. The only portion of this sheath that is routinely removed is in the periumbilical area where the major musculocutaneous perforators surface. Some authors have advocated preserving the anterior rectus sheath in the periumbilical area as well by making fascial cuts to isolate the perforators (Taylor et al., 1984).
Latissimus Dorsi
The latissimus dorsi flap (LDF) has long been a useful flap to reconstruct very large defects of the head and neck. The latissimus dorsi muscle is a large fan shaped muscle that originates from the thoracolumbar fascia, lower thoracic spinous processes, and the iliac crest and inserts onto the humerus. Its neurovascular supply is based on the thoracodorsal artery with its paired vena comitantes, and the thoracodorsal nerve. The thoracodorsal artery is a terminal branch of the subscapular artery. The pedicle based on this artery ranges from 7 to 10 cm. Additional length can be obtained by ligating the circumflex scapular artery and including the subscapular artery with the pedicle. The diameter of the artery in this area is 2 to 3 mm. The vein is approximately 3 to 5 mm. The thoracodorsal nerve can be reanastomosed to a recipient nerve in the neck to reinnervate the muscle and prevent wasting.
The vascular supply to the skin paddle of the LDF is provided by musculocutaneous perforators branching from the thoracodorsal artery which span a large surface area of skin. The skin flap that can be elevated is the second largest available in the body next to the rectus abdominis flap. The difference between these two flaps is that the skin of the latissimus flap is centered over muscle. This makes the flap extremely large. It is great for filling very large defects but usually to thick to tube or use in the oral cavity. Multiple skin paddles can be designed with this flap.
The donor
site for the latissimus flap is usually easily closed primarily with little
cosmetic deformity. Functional deficits
from removing this muscle are prevented by the compensatory action of other
muscles that act across the glenohumeral joint.
It is important to note that progressive morbidity to the shoulder does
occur with the sacrifice of the latissimus dorsi is combined with loss of
either the trapezius muscle or the pectoralis major muscle. To harvest this flap, the patient must be in
a 30 to 45 degree lateral oblique position.
Although synchronous head and neck surgery can be performed, there may
be some difficulty, especially if bilateral neck dissections must be
Radial forearm
The RFFF free flap may be raised with a segment of bone from the radius to reconstruct mandibular or midface defects. A segment of bone up to 10cm may be harvested. The segment of radius that can be taken is vascularized by the vessels passing from the radial artery through the lateral intermuscular septum and perforating vessels through the muscle belly of the flexor pollicis longus. Only 30% of the cortex of the radius may be removed. If more is taken there is a high risk of developing a pathologic fracture. Compared to other osseocutaneous flaps such as the iliac or fibular free flaps, the amount of bone that can be raised with the RFFF is much less. The radius is best suited for reconstructing lateral defects in the mandible. If the periosteum is preserved on the volar and radial aspects of the bone, 2 or 3 osteotomies can be made through the medullary side to reconstruct symphyseal and parasymphyseal defects. Reconstruction in this manner, however, does not allow for dental rehabilitation. Prior to the operation, posterior and lateral x-rays should be taken of the forearm to assess the cross-sectional area of the radius. The rest of the preoperative evaluation is the same as for the cutaneous flap.
The fibular free flap (FFF) can be an osseus or osteocutaneous flap. Its blood supply is based on the peroneal artery and the accompanying vena commitantes. The fibula can provide up to 25cm of vascularized bone for grafting. This is why it has become the preferred technique for reconstruction of segmental defects in the long bones of the upper and lower extremities. The peroneal artery provides a dual blood supply to the fibula via endosteal and a periosteal vasculature. Because multiple segments of this bone can receive enough blood supply from the periosteal component, their viability can be maintained after multiple osteotomies. This makes the fibular free flap an ideal donor site for mandibular reconstruction which requires contouring of bone. Other advantages of the FFF include the following: (1) it provides the longest and strongest bone stock of any other osseus free flap; (2) low donor site morbidity; (3) easy positioning and two team approach; (4) easily supports osseointegrated dental implants; and (5) its thickness roughly approximates the body of the mandible.
The length of the vascular pedicle to the FFF is limited proximally by the bifurcation of the posterior tibial artery. Additional length can be gained by harvesting a more distal segment of bone. With this technique, pedicle length as long as 12cm has been attained (Hidalgo, 1994). The variability in blood supply to the FFF is one reason this flap may not be acceptable in certain patients. Aberrations in blood supply to the feet can occur in up to 10% of the population with the peroneal artery being the dominant supply to the entire foot. In order to verify that this in not the case, it is necessary to perform an imaging study of the lower extremity vasculature (i.e. an angiogram or MRA). Peripheral vascular disease can also affect the normal circulation of the foot thereby necessitating a preoperative imaging study. Other disadvantages include a limited cutaneous paddle and soft tissue bulk often requiring a second free flap or pectoralis flap for extensive soft tissue defects, slight reduction in ankle strength and limited great toe flexion, and slight risk of chronic ankle pain. The skin paddle has an unpredictable blood supply and may be lost in up to 5 to 10% of patients. This can only be determined after the harvest. The patient must be informed that a second cutaneous flap may be needed.
Loss of the lateral mandible (posterior to the mental nerve foramen), will result in a concavity of the cheek, mandible rotation to the defect side with cross bite malocclusion, remnant rotation superiorly and medially, and mental nerve loss. These losses are much easier to adjust to than anterior loss. However, in a relatively fit patient with or without dentition, the advantages of reconstruction compared to primary closure without reconstruction can be dramatic. The iliac bone is often chosen over the fibula for these defects because of the close approximation of the shape of the anterior iliac spine to the angle and body of the mandible.
Operative considerations in raising the FFF are as follows: (1) leave a 1 mm cuff of soleus and peroneal muscle attached to the fibular during dissection to protect the periosteum; (2) leave 6 cm of distal and proximal fibula preserve the stability of the ankle and knee joint and to help avoid injury to the common peroneal nerve; (3) the bone should be oriented so that the vascular pedicle is located on the lingual surface of the neomandible. This places the skin paddle at the inferior border. It can be wrapped over the buccal surface allowing for coverage of the fixation hardware; (4) the lateral sural nerve can be harvested to provide a sensate flap.
Postoperative care should include splinting of the leg and non-weight bearing until postoperative day three.
Scapular and Parascapular Free Flaps
The subscapular system of flaps is unique in that it can provide a wide range of tissue types based on a single pedicle. The branching pattern of the subscapular artery and vein permits the transfer of the following flaps: scapular fasciocutaneous flap, parascapular fasciocutaneous flap, scapular-parascapular osteofasciocutaneous flap, latissimus dorsi flap, latissimus dorsi musculocutaneous flap, latissimus dorsi rib osteomusculocutaneous flap, serratus anterior flap, serratus anterior musculocutaneous flap, and the serratus anterior rib flap. Advantages of all these flaps include a long pedicle (10-14cm) with large diameter vessels, abundant surface area of relatively thin hairless skin, and separation of the soft tissue and bone flaps, which allows for freedom in three dimensional insetting.
The scapular and parascapular free flaps are both fasciocutaneous flaps which can be harvested independent of bone or as a composite graft and have the circumflex scapular artery as their pedicle. The accompanying vena commitantes drain the flap. As the circumflex scapular artery emerges from the triangular space bounded by the teres major and minor muscles and the long head of the triceps, it branches into horizontal and vertical fasciocutaneous branches (the tranverse cutaneous branch and descending cutaneous branch respectively) overlying the scapula. Scapula (horizontally oriented) or parascapular (obliquely oriented) fasciocutaneous or osteofasciocutaneous flaps can be harvested from these two branches. Up to 10 cm of bone can be removed from the lateral aspect of the scapula. This bone is thick enough to allow for osseointegrated implants for dental reconstruction.
The main disadvantage to this donor site is
positioning, which may prevent a two team approach, increasing operative time
substantially. The lateral decubitus
positioning has also been associated with morbidity to the brachial
plexus. Injuring to the glenoid fossa
has also been reported. Harvesting of
bone necessitates detachment of the teres major and minor muscles, which may
result in shoulder weakness and decreased range of motion.
The ilium free flap is usually raised as an osseomusculocutaneous flap which is usually used in head and neck surgery for reconstruction of mandibular defects. The most reliable vascular supply for free tissue transfer of iliac crest is the blood supply from the deep circumflex iliac artery and vein. The rich vascularity of the ilium allows for great flexibility in the size and shape of the segment of bone that is harvested. The amount of bone that can be taken from the ilium provides the greatest cross-sectional surface area compared to the fibula, scapula, and radius. Its thick bone stock can easily support osseointegrated bone implants. The bone can be harvested by incorporating the anterior iliac spine which can nicely reconstitute the mandibular angle when this is taken with the resection. When symphyseal defects are present, a straight piece of iliac bone is harvested that requires osteotomies to achieve a gentle curvature that matches the anterior mandible. Care must be taken to maintain continuity of the inner perichondrium to preserve its vascular supply. When insetting the flap, the pedicle should always be oriented so that it is on the lingual side of the oral cavity. This requires careful planning so that the correct donor side is chosen. This also depends on the desired location of the pedicle (angle, mid-body or parasymphyseal) so that it easily reaches the chosen recipient vessels in the neck.
The size of the skin paddle must be large enough to incorporate a sufficient number of musculocutaneous perforators. Unfortunately, the skin component is often too thick and immobile to allow good intraoral coverage. Increased mobility can be obtained by placing the skin paddle more cephalad on the abdominal wall. Care must be taken to include the cutaneous perforators in the inferior portion of the skin paddle. If the skin is thin enough it may be used for oral cavity reconstruction of soft tissue defects. Again, the donor side chosen should be planned depending on where the recipient vessels are (ipsilateral or contralateral to the defect). The skin should always be oriented in its original anatomic position to avoid any torsion on the delicate musculocutaneous perforators. The internal oblique muscle component is usually harvested with the flap and draped into the oral cavity and allowed to mucosalize by secondary intent or can be skin grafted.
Review of the favorable characteristics of the iliac free flap include; thick bone stock, easy positioning and two team harvest, defect can be closed primarily, and minimal donor deformity. Disadvantages include; bulky soft tissue component, poor reliability of skin paddle, pelvic pain and the risk for hernia formation, decreased postoperative ambulation, possible risk to peritoneum and bowel, and paralysis of the rectus abdominus muscle.
Postoperative care should include progressive mobilization, which should begin on the third or fourth postoperative day and is followed by assisted ambulation on the seventh day. Stair climbing should not be performed until 3 weeks after surgery.
In the history of free tissue transfer with
microvascular reanastomosis, the jejunal flap holds particular importance
because it was the first tissue to be transplanted in humans. In 1959 Seidenberg et al. reported their
experience in one patient where they used a free jejunal autograft to
reconstruct a patient who had undergone a pharyngoesophagectomy for recurrent
cancer. Although this patient did not
fair well (survived 5 days) this flap has since become a standard
reconstructive method for pharyngoesophageal defects. Interestingly, this first report of free
tissue transfer with microvascular reanastomosis in a human was done before the
advent of the operating microscope. The
first successful transfer of a free jejunal flap was performed by Roberts and
Douglas in 1961 in which their patient survived and was able to resume
Although in the past the jejunum was
used as a pedicled flap to reconstruct the thoracic esophagus, it is now
primarily used as a free flap. It is
most commonly used as a mucosal tube or a mucosal patch for functional
reconstruction of the pharyngoesophagus.
Prior to the jejunal free flap, reconstruction of the pharyngoesophagus
had been tried with a number of techniques including tubed pedicled skin flaps
(pectoralis, deltopectoral), gastric pull-up, and colonic interposition
grafts. Each of these had definite
disadvantages compared to the jejunal free flap. Pedicled skin flaps were often
too bulky. When the gastric pull-up was
used in heavily radiated tissues, its weight and the effect of gravity led to
problems with wound healing. In addition
it was often unable to reach more cephalad defects extending into the
oropharynx. The colonic interposition
graft also had limited reach and because of its natural flora would often
result in abdominal and chest infections.
The vascular supply to the jejunum
is based on branches from the superior mesenteric artery (SMA). There are 12 to 15 jejunal arteries that
arise from the left side of the SMA.
These arteries divide into two smaller arteries which unite to form
vascular arcades. The arcades give off
smaller straight branches called vasa recta, which enter the small intestine on
its mesenteric border. The venous supply
comes from paired vena commitantes which accompany each artery and drain into
the superior mesenteric vein. The
particular segment of jejunum used must be supplied by a single vascular arcade
(usually the second or third) with nutrient vessels of sufficient size for
microsurgical transfer.
Performing free transfer of the jejunum requires a two or three team
approach. A general surgery team
isolates a segment of jejunum which is left attached to its vascular supply in
the abdomen. After extirpation of the
tumor has been completed in the neck, evaluation the exact size and shape of
the defect is carried out. The jejunal
segment is then harvested and insetting into the defect is carried out in an
isoperistaltic fashion. This is followed
by microvascular reanastomosis to recipient vessels. Sewing of vessels is performed after
insetting of the flap for two reasons: (1) it provides more accurate geometric
arrangement of the vessels based on the final positioning of the flap to reduce
tension and (2) prevents excessive
bleeding from the edges of the flap which can make insetting very difficult
particularly if the distal end of the defect is low in the thorax.
Use of the jejunal free flap is contraindicated in a number of situations
including patients with ascites, history
of extensive abdominal surgery, involvement of cancer in the thoracic esophagus
(gastric pull-up should be used), and history of chronic intestinal disease
such as Crohn's disease.
Disadvantages of the jejunal free flap
include: (1) requires laparotomy with potential complications; (2) lacks neovascularization resulting in total
depends on anastomosed blood supply; (3) short pedicle; and (4) results in
gurgly voice when voice restoration procedures are performed.
The basic goal in reconstruction of head and neck defects is to maximize cosmesis and function while minimizing the complexity and risk involved. Free tissue transfer is not only expensive and many times difficult to perform, the donor site morbidity and more complex postoperative care make it an option that must be considered carefully. Therefore, for each reconstructive problem, one must always consider all forms of reconstruction from simple to complex. In many instances, a non-free flap option should be employed. There is almost always more than one form of reconstruction available and only after carefully weighing the potential added advantage of free tissue transfer as compared to more simplistic methods, should it be employed. Options that should be considered in each patient include 1) healing by secondary intent, 2) primary closure, 3) skin grafts, 4) local flaps, 5) myocutaneous flaps, and finally 6) free flaps. Although reconstruction is often approached in an algorithmic fashion, it is important to realize that exceptions do arise and not all patients with similar defects would be best suited to one particular reconstructive option.
Oral Cavity and Oropharynx Reconstruction
Within the oral cavity and pharynx, thin pliable mucosa is found. The goal in reconstructing these sites include a watertight seal as well as minimal wound contracture to maintain mobility of the tongue so that function may be preserved. All reconstructive options should be considered. Methods that result in contracture and reduced mobility of the tongue should be avoided. Myocutaneous flaps are often too bulky to reconstruct the thin resected surfaces. Therefore, fasciocutaneous free flaps and split jejunum would be possibilities. The radial forearm is used most often.
Tongue Reconstruction
The tongue is one of the most specialized tissues within the oral cavity. Reconstructive efforts for the tongue should be focused on preserving what has not been lost and preserving an adequate shape, volume, sensation, and motion. The extent of the defect, coupled with the adjacent tissues lost (i.e. floor of mouth) and neural integrity of remaining tongue, should dictate what reconstruction may be appropriate. For mobile tongue defects, most forms of reconstruction are adequate as long as they prevent tethering of the remaining tongue. Free tissue transfers may be useful when it is anticipated that contracture with primary closure or skin graft will make speech or bolus manipulation difficult. This is particularly true with defects involving over one-third to one-half of the oral tongue. Reconstruction of the entire anterior 2/3's of the tongue may be best accomplished with a tubed or coned fasciocutaneous.
For reconstruction of the tongue base and for total glossectomy defects, one must consider the patient's pulmonary reserve and ability to tolerate aspiration. Criteria used for supraglottic laryngectomy should be used to determine this. The goal with total glossectomy defects is to create an adequate oral mound such that the patient can have some approximation of the flap tissue with the palate. Only in this way will they have the potential for intelligible speech and some ability to move a food bolus into the oropharynx. Once in the oropharynx, the bolus must initiate the pharyngeal phase of swallowing and be transferred into the cervical esophagus without significant aspiration. This requires an intact pharynx and an anteriorly based larynx.
Rectus abdominus and latissimus dorsi musculocutaneous free tissue transfers for total tongue reconstruction offer abundant subcutaneous tissue to create the oral mound. The rectus flap has an added advantage of allowing suspension of the anterior rectus sheath to the mandible to prevent gravitational drop of the oral flap tissues. If the larynx is preserved additional measures such as laryngeal suspension to the mandible should be carried out to reduce aspiration. If patients are too sick to undergo a free tissue transfer, a pectoralis major myocutaneous flap is a reasonable alternative.
Hypopharynx and Cervical Esophageal Reconstruction
Because pharyngeal and laryngopharyngeal carcinomas often have significant submucosal spread beyond the obvious tumor boundary, the extent of surgical defect can be greater than anticipated preoperatively. Therefore, with the exception of the smallest tumors, a plan for reconstruction of a complete circumferential defect should be considered preoperatively. Typically, if 3 centimeters or more of mucosa remains, primary closure is advocated. If less than 3 centimeters remain, consideration for a pectoralis major regional flap or radial forearm free flap could be considered. For total loss above the thoracic inlet, a tubed pectoralis major flap, fasciocutaneous free flap, or free jejunum flap could be considered. Currently, in relatively healthy patients, the free jejunal flap remains the reconstructive technique of choice for these defects. If total loss occurs below the thoracic inlet, a gastric pull-up is the reconstruction of choice.
Mandibular Reconstruction
Loss of the anterior mandibular arch results in loss of chin and lip support and sensation, malocclusion, and retrognathia. These result in severe cosmetic deformity and functional deficits, including lack of oral competence and extreme difficulties with eating and speaking. Reconstruction of this portion of the mandible is considered by some as one of the few absolute indications for a free tissue transfer. Other methods of reconstruction such as the use of reconstruction plates and nonvascularized bone grafts result in much poorer functional and cosmetic results, and are associated with much higher rates of failure. Reconstruction with regional bone containing flaps is much less optimal as all such flaps have a tenuous blood supply to the attached bone and usually result in some bone resorption. Regional flaps such as the sternocleidomastoid muscle with clavicle, pectoralis major with rib, trapezius with spine of scapula, and latissimus with rib have been utilized but do have a higher likelihood of flap failure. The usual candidates for bone containing free flaps used for mandibular reconstruction include the fibula, iliac crest, scapula, and radius as discussed previously.
Skull Base Reconstruction
Skull base reconstructions are usually accomplished with bulky, well vascularized flaps such as the rectus or latissimus flaps. These flaps are positioned against the skull base with the flap muscle packed into the orbital, nasal, paranasal, infratemporal, or temporal skull base defects. Thus, the contaminated extracranial space can be separated from the dural repair.
Proper care after surgery requires nursing and surgical personnel who understand the principles behind free tissue transfer. With this knowledge, it is common sense to avoid any pressure in the vicinity of the pedicle or flap. An anastogram at the bedside can illustrate the sites of anastomosis to those not present during the procedure. Supplemental oxygen and cool humidified air can cool a superficial flap and inhibit its blood flow. Strict orders to keep the head in neutral position will limit the tension placed on the anastomosis. Hemodynamics and blood volume should be monitored closely. Although there is little scientific evidence supporting the ideal hematocrit in free flap patients, the consensus among experienced surgeons is somewhere between 27-29, with 30 an appropriate goal. Close surveillance for hematoma formation is necessary to avoid vascular compression and blood pressure needs to be maintained appropriately for tissue perfusion. As stated previously, systemic pressure agents should be strictly avoided in managing blood pressure fluctuations in these patients.
Pharmacotherapy has become routine is free tissue transfers. As discussed earlier, aspirin is initiated after surgery using 5-10 grains daily for 2-3 weeks in order to inhibit platelet and endothelial cyclooxygenase. Dextran is used for its viscosity lowering properties and inhibition of rouleaux formation. Heparin is continued as part of some postoperative protocols for at least the first 3 postoperative days but its use increases the risk of hematoma. Antibiotics are given as usual for head neck procedures and delirium tremens prophylaxis should be administered for at risk individuals.
As the majority of free tissue transfer fails secondary to vascular anastomosis problems, early detection and timely repair can often salvage the flap. Although many different methods exist, the current standard is clinical evaluation. This is accomplished by visually inspecting the flap color, turgor and capillary refill, dopplering the pedicle frequently during the first 3 days, and performing the prick test daily. A healthy flap will be pink, warm, minimally edematous, and will have a capillary refill time of 1-3 seconds. The prick test will produce 1-3 drops of bright red blood. Venous anastomotic thrombosis, implicated in over 90% of flap failures, is clinically evident with a dark blue congested appearance of the cutaneous portion of the transferred tissue and often with concurrent hematoma within the operative site. This occurs as thrombosis of the venous outflow causes a high-pressure buildup within the flap, and consequent diffuse bleeding from the flap soft tissue. This is usually obvious clinically and recognition is followed by immediate return to the operating room for exploration, thrombectomy, and revision anastomosis. Using established techniques, over 50% of those flaps developing venous thrombosis can be salvaged. If the anastomosis cannot be salvaged, heparinization and the use of medicinal leeches can occasionally buy enough time for peripheral revascularization to occur so as to result in partial or total flap salvage. This is very costly, however, and usually results in multiple blood transfusions for the patient. However, these later measures never replace exploration unless there is some reason the patient is unfit to return to the operating room. Arterial anastomotic thrombosis is uncommon but produces a pale, cold flap with no bleeding after pricking. Treatment is immediate return to the operating room with reanastomosis.
Because early detection of flap compromise allows for earlier intervention and higher chances for successful salvage, numerous adjuncts to clinical assessment have been devised. Temperature measurements have demonstrated reliability with a sensitivity of 98% and a predictive value of 75%. However, thin skin flaps and those placed intraorally have negligible temperature drops, especially with venous thrombosis. In addition, fluctuations in surface, peripheral, or core temperature can provide misleading data about the viability of the flap. Technetium scanning within the first week after surgery can be valuable for evaluating the perfusion of composite bone grafts, however its use after the first week is unreliable. Single-photon emission computed tomography (SPECT) may be a useful indicator of flap viability, however few centers have such technology. A recently introduced technique utilizes infrared spectroscopy to noninvasively monitor the concentrations of oxy- and deoxy-hemoglobin in the flap. Transcutaneous and intravascular devices which measure oxygen tension, pH, and carbon dioxide levels have met with great enthusiasm however may not live up to its lofty goals. The laser Doppler flowmeter also holds promise, however it is not applicable to deep flaps in the oropharynx. At present, as there is no perfect objective device that accurately indicates flap failure consistently, clinical assessment remains the standard.
Ariyan, S.: The pectoralis major myocutaneous flap. Plast. Reconstr. Surg. 63:73, 1979
Chepeha, D. B., Teknos, T. N.: Microvascular free flaps in head and neck reconstruction
in Head and Neck Surgery – Otolaryngology, Editor Bailey, B. J., Lippincot
Williams and Wilkins, 3rd ed., 2001, pgs 2045-2065
Baek, S. M.: Two new cutaneous free flaps: The medial and lateral thigh flaps. Plast.
Reconstr. Surg. 71:354, 1983
Bakamjian, V. Y.: A two-stage method for pharyngoesophageal reconstruction with a
primary pectoral skin flap. Plast. Reconstr. Surg. 36:1732, 1965.
Daniel, R. K., and Taylor, G. I.: Distant transfer of an island flap by microvascular
anastomoses. Plast. Reconstr. Surg. 52:111, 1973
Demergasso, F., and Piazza, M. V.: Trapezius myocutaneous flap in reconstructive
surgery for head and neck cancer: an original technique. Am J. Surg. 138:533,
Drever, J.: Closure of the donor defect for breast reconstruction with rectus abdominus
myocutaneous flaps. Plast Reconstr Surg 76:558-567, 1985
dos Santos, L. F.: Retallro escapular: um novo retalbro livre microcirurgico. Rev. Bras.
Cir. 70:133, 1980
Harii, K., Ohmori, K., and Torri, S.: Free gracilis transplantation with
microneurovascular anastomoses for the treatment of facial paralysis. Plast.
Reconstr. Surg. 57:133, 1976
Hidalgo, D.: Discussion of "Fibula osteoseptocutaneous flap for reconstruction of
composite mandibleular defects" by Wei F, Seah C, Tsai Y, Liu S, Tseu M. Plast Reconstr Surg. 93:305, 1994
McGregor, I. A.: The temporal flap in intraoral cancer; its use in reforming the
postexcisional defect. Br. J. Plast. Surg. 16:318, 1963
Panje, W. R., Bardach, J., and Krause, C. J.: Reconstruction of the oral cavity with a free
flap. Plast. Reconstr Surg.
58:415, 1976
Roberts, R. E., Douglas, F. M.: Replacement of the cervical esophagus and hypopharynx
by a revascularized
free jejunal autograft: report of a case successfully treated. N
Engl J Med 264:342, 1961
Scusterman, M. A. et. al.: A single center's experience with 308 free flaps for repair for
head and neck cancer defects. Plast Reconstr Surg. 93(3):472-478, 1993
Seidenberg, B., Rosznak, S. S, Hurwittes, et al: Immediate reconstruction of the cervical
esophagus by a revascularized isolated jejunal segment. Ann Surg 149:162, 1959
Song, R., Song, Y., Yu, Y., Song, Y.: The upper arm free flap. Clin Plast Surg. 9:27-35,
Swartz, W. M., Banis, J. C., Newton, E. D., et al.: The osteocutaneous scapular flap for
mandibular and maxillary reconstruction. Plast. Reconstr. Surg. 77:530, 1986
Taylor, G., Corlett r. J., boyd, B.: The versatile deep inferior epigastric )inferior rectus
abdominis) flap. Br J Plast Surg. 37:330-350, 1984
Taylor, G. I., and Watson, N.: One-stage repair of compound leg defects with free
revascularized flaps of groin skin and iliac bone. Plast. Reconstr. Surg. 61:494, 1978
Urken, L. M. et. al.: Microvascular free flaps in head and neck
reconstruction. Arch
Otolaryngol Head Neck Surg. 120:633-640, 1994


text:
Bold Moves JVP146
FalconStudios.com Member Price:
Bold Moves is about the crazy things that happen when director Bruno Bond takes seven testosterone-charged Falcon Studs and puts them together to see what happens. Exclusive stars Landon Conrad and Andrew Jakk waste no time in getting into each other's pants, as Christopher Daniels watches from the stairway. As Landon fucks Andrew with his rock hard cock, lean, cut, and stunning Adrian Long arrives on the scene. Christopher starts deep throating Long's thick shaft. Watch as his balls roil around like overloaded sperm tanks! Soon the entire house is fucking, and cocks are twitching with energy. Fan favorite Colby Keller gets in on the action with Blake Daniels and J. R. Matthews joins the fun with a fantastic fuck with Adrian Long. This movie is a masterpiece and takes the Jocks line back to the days when good porn was GOOD PORN. Bold Moves is so excellent that we are offering a 100% money back guarantee on every DVD purchase. If you do not like this film for any reason, simply return it for a full refund!
Scene 1
Landon Conrad and Andrew Jakk make the moves on each other, completely losing themselves in the moment. This hot couple can feel the sexual heat churning deep within their loins as they make out with a burning passion. Sensing something's sizzling upstairs, Christopher Daniels sneaks up on the horny twosome and watches them from a safe distance. Andrew dives face-first into Landon's crotch and begins sucking on his big stiff cock with slow and steady slurps. Christopher's caught off-guard when Adrian Long quietly joins him and they start fooling around, matching the first couple's sexual gameplay blow for blow; then the intruders take off and leave. Landon continues celebrating his horn dog partner by rimming Andrew's tight asshole. After priming the puckered hole, he fucks him every which way. They finish with Andrew down on his back and Landon between his legs holding his ankles high as he charges in and out of his butthole until they both finally climax.
Scene 2
After getting turned on by each other and by watching their buddies go at it, Adrian Long and Christopher Daniels can't contain their sexual attraction any longer. They started with each other while they were aroused by their voyeuristic adventure, but now they have time alone. Christopher resumes sucking Adrian's dick. Both of them are feeling energetic and sexually frisky. Adrian begins munching on Christopher's asshole, letting his tongue dig as far up through the tight crack to tickle the sensitive tissue. Rimming becomes fucking as Adrian hits it with his boy toy, fucking him from down under and from behind, putting Christopher through the ringer. Needing a break, Christopher sits collapsed on the floor as his rough'n'ready beau stands over him. With dick in hand, Adrian jerks himself off until he splashes Christopher's mug with his cum. Not to be outdone, Christopher strokes himself fast and furious until he finally busts his nut.
Scene 3
Freshly showered, horny and wrapped in a towel, Colby Keller spots Blake Daniels stretched across the bed dozing. Not wanting to rouse the sleeping hottie, he walks out onto the deck and starts to masturbate. Blake wakes from his slumber and happily joins Colby. They greet each other with soulful kisses before Blake boldly moves down to suck some huge cock. He teases Colby's dick and balls with loving licks and nibbles. Then they go back inside and get comfortable on the bed. Colby eats out Blake's ass, coaxing his playmate into an even more erotic state. Grabbing onto Blake's waist to steady himself, Big Boy Colby goes right for the bull's-eye, hitting Blake's spot . After a while, Blake flips onto his back and with one leg stretched up to rest on Colby's shoulder, they continue screwing. Colby cums in solid streaks all over his lover and Blake finishes himself off by hand until he climaxes onto his own stomach.
Scene 4
It's late in the day, the sky's growing dark and Adrian Long and JR Matthews are in the hot tub soaking their troubles away. JR makes the first move on his tub-mate, getting in position to suck his schlong. The stirring sensation of cock-in-mouth quickly overwhelms them both inspiring serious action. Adrian can't wait for his turn. He greedily gets his licks in on JR, first rimming his asscrack and then nursing on his dick. Straddling Adrians pole, JR gets on for a ride, bouncing up and down like a crazed buckaroo. They continue to fuck with gusto in different configurations until JR is flat on his back. Pulling his pud excitedly, he finally shoots his wad. Exhausted and content, JR awaits his partner's matching explosion of creamy goo and Adrian does not disappoint.

subset: commoncrawl


text:
FilePlanet Batch 5 - Free for everyone!! Already got my key http://www.fileplanet.com/promotions/crysis/beta/ (edit) The beta is now closed. (edit2) The beta is back up again but for subscribers only!
The first time I clicked that link I came to a page where I had to specify my system, and then they said I didn't qualify for the beta. Strange.. Place - 550... I don't think it's worth it, but as I have broadband nowadays I should use it.
Any mirrors to the client? If your system didnt meet specs, just delete any fileplanet cookies and re-login.
70 minutes wait here, feck, and im tired and need to sleep, some1 come along and press the download button for me..


text:
Amber Atherton
Amber Atherton Photo
Winter Whites Gala in Aid of Centrepoint at Kensington Palace in London on November 26, 2013
41st Annual American Music Awards - Press Room
Jesse Tyler Ferguson wants a baby
Katy Perry pleased with Grammy nominations
Shia LaBeouf in London pub clash?
Mila Kunis takes Ashton Kutcher to wedding
Cher: I don't want a Kim Kardashian butt
Kanye West's career is a 'giant art project'
Carmen Electra 'happy' for Simon Cowell
Josh Cuthbert's nocturnal screams
Jessica Simpson seeing tantric sex therapist?
Nicole Scherzinger to sing at Nelson Mandel's funeral?
One Direction reality show in the works?
Daniel Radcliffe 'loves' New York


text:
Artie and Olivia, that show was a riot!
Well, in the end, as seen on this board: "Artie always wins"!
Gar.. This is art I can't come in today...cough...cough.. I'm sick.. I'll for sure be there tomorrow.
Not only is Adrienne much, much, much prettier than Beefus, she's not driving a wedge between her man and his family. Artie's mom and sister actually willingly spend time with Adrienne.
Conversely, two of Howard's three kids headed for ze hills, and you can't find Rae or Ellen anywhere near Beefus.
Artie is marrying as well as Howard didn't.
Artie just said on his show he's thinking about having kids on his show tonight, Baby, Baby Gorilla could be on the way.
Why does any girl even go to high school?? Their job is to find a rich guy & marry them... learn to fuck ugly guys & pretend to like them. That's their "college" not fucking what your attracted to but a guy who has money
I tuned into artie's show and he looks so fat c'mon art!


text:
Log In
16 May 2013
Read about the work of Millie, Sam and other members of Ringwood School who took part in the Send My Friend To School campaign.
08 May 2013
On Friday 5th July 2013 schools all over the country will be learning outside for Empty Classroom Day. Empty Classroom Day is the day to celebrate all the learning outside the classroom that takes place and to encourage even more. The day was created by schools and organisations at London Sustainable Schools Forum and the idea is simple: One class, outdoors, for one lesson on one day.
01 May 2013
We'd like to introduce you to our new Eco-Schools Ambassadors 2013-2015!
29 April 2013
Now once you've logged in at www.eco-schools.org.uk, you'll now have the opportunity to do more, see more and take more control of your Eco-Schools journey. We've also improved and relaunched our Energy awards, so schools can gain recognition for the amazing improvements they are making.
23 April 2013
Keep Britain Tidy, and SEEd (Sustainability and Environmental Education) have joined forces with high-profile charities and organisations to urge the Government to keep sustainability in the National Curriculum.
18 April 2013
A UNICEF UK poll published yesterday has proved what we at Eco-Schools have known for some time. English school students are deeply concerned about the effects of climate change on their future and the future of young people like them in developing countries all around the world.
09 April 2013
Keep Britain tidy has an exciting role in Wakefield; educating schools, organisations and communities with the aim of increasing awareness of waste minimisation and recycling.
08 April 2013
As this March was the second coldest since records began and unusual in many ways, why not use this opportunity to incorporate climate science into your lessons or Eco-projects. We've brought together a range of useful resources to help you.
04 April 2013
Enter the Green School scholarship competition and find out if you're school could win a trip to Bali.
03 April 2013
More than 90% of teachers want the environment to stay part of the English National Curriculum, a study by Keep Britain Tidy has today revealed.


text:
DIY Paper USS Enterprise 1701 Kit
Paper . . . the final frontier.
- Contains all the pieces needed to build the ultimate paper model of the original USS Enterprise 1701.
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- Includes book chronicling the different Enterprises of the Star Trek universe.
- Read more...
Paper . . . the final frontier.
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- Dimensions: almost 1 foot in length (when put together, of course).
Wanna chat about DIY Paper USS Enterprise 1701 Kit?
Have questions about DIY Paper USS Enterprise 1701 Kit or your order? We monitor these comments daily, but it may be faster to email us directly or call us at 1-888-GEEKSTUFF.


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Hey guys so my current project at the moment is building a server that will host a few websites, game server and file sharing. Here are the parts I have to work with. Asus K8N-DRE Server board 2x AMD Opteron 275 dual core 2.2ghz cpus 16gb if ddr 400 ram Adata 128gb ssd 3x Seagate 1tb drives As far as software I have windows server 2012 and a bunch more at my disposal all are legal. My current internet is dynamic IP FIOS 25down 25up and I'm going to upgrade it to static IP FIOS 50down 25up that will be the coming months once the server is up and running correctly. So this came from a friend of mine who owns a big company running a bunch of servers: Mike "Well if the server is a retail one, I would go with VMware and break stuff up. The web server and games server are both presumable public. By breaking things up on different 'computers' you can cut down on risk of attack and compromise of your important stuff. If he is buying a new OEM server and it is on the HCL this is easy. If he is building from scratch he can look at forums for suggestions on supported parts that you can buy retail that will still work with VMware. I would install VMware on the server to the SSD. I would then load two or three OS's. I would put a really small Ubuntu LAMP server on the SSD for the website. It's very light weight and rocks for web hosting. By breaking this off you can forward one port to the webserver and keep everything else safe. I would then install server 2008 with the "c" drive on residing on the SSD (you should have a good 50gb still for that). Then mount the three TB raid for storage to VMware and hack off a few TB for the DATA disk on the server OS for the files and such. You can use server 2008 as a game server too if you want. What I would do is build a small windows 7 box entirely on the 3tb array. Again assuming that this is public, it isolates it and ensures the best compatibility with the game makers. In my experience most don't support server OSs directly. If VMware is out of the picture. Server 2008 is going to host files fine, will likely work with more games than any other OS (windows 7 kernel) and has IIS 7 so you can run the latest PHP." So I am trying to understand all of this just a lot of stuff to take in especially with college but I have my break coming up so I plan on getting it running then just need some advice and help. I would greatly appreciate it. Thanks again guys! (PICS TO COME SOON)
separating is indeed a nice idea (that & i dont like dealing with website hosting that's not linux) what specific games & how complex websites?
I'm going to host a minecraft server for my baby brother that's the first game not sure on other ones at the moment. Website I have one lined up for a pediatric office for my doctor friend. Im probably going to make a blog website from me, My one friend will also make a site for himself too, and we may get his dad to switch his site to our server its a bails bondman website. And probably a few more sites also unsure yet.
You checked with the FIOS agreement that your not breaking of their rules running dedicated servers ?. I know Comcast has a such rule but not to sure about your FIOS.
Yeah, some ISPs go so far to block new port 80 packets going to your IP address, while allowing outgoing new port 80 packets as well as established or related packets returning to your network. It's a routing thing and it's annoying. Comcast doesn't block port 80 and they honestly don't care unless you start exceeding your bandwidth cap and at that point you really should sign up for business class which gives you better speeds with higher boost speeds and priority when the network fails. They also expect you to be hosting and they don't impose a bandwidth cap. So it really depends on the service you sign up for. They don't care all that much unless you're using a lot of bandwidth or an exorbitant amount of upstream, but as I said before. At that point you really should be consider business class if you're serious about hosting and if Comcast contacts you and you tell them what you want to do they will help you out.
Doctors office stuff? Be aware of HIPAA restrictions and any info that might be stored on that machine from the docs office. lawsuits suck. http://www.hhs.gov/ocr/privacy/
I'm not really sure to tell you but I am switching to business class so a few months wont hurt for testing. And I am HIPAA certified for his office I do major work. The website though will not have any info like that it is just for advertisement and mostly about him like a bio.
So I just ordered a new board its the same one except rev 1.05g which has a sata 2 controller any way it came with this extra card the sits in the mini I/o slot. Their is a link below. Was wondering is someone can shed some light on what it might be? Thanks. http://support.asus.com/faq/list.aspx?SLanguage=en&p=5&m=ASMB2&s=9&hashedid=n/a&os=
It's a management card. It adds functionality in cases where you're going to be managing a lot of systems in a distributed network. I doubt that you will need it and it isn't worth a whole lot either. I have a 1U server sitting in the closet with dual 3.2ghz xeons that has a bigger version of it.
For what its worth, if your custom server doesn't have the juice ... I always see decent looking commercial servers on craigslist, hp or dell dual xeons etc $300-500.
Thanks guys! Another question so I installed windows server 2012 and installed VMware player and I am going to install Ubuntu LAMP in VMware player. Their are some network settings though that I am unsure off. Bridged, NAT, and Host-only. Which one should be used for 24/7 web server and to give me protection in my internal home network. Thanks again guys!
The CPUs you picked out do not support hardware virtualization (at least from what I read,) if you're going the VM route, then you should get better hardware. For hosting you want bridged, unless you have a dedicated Ethernet or network adapter for it. It's the only option where your VM gets an IP on your network. NAT and Host-Only do exactly as they say they do. NAT puts you on an internal network inside the computer that uses NAT to resolve addresses (can't host off it,) and Host-Only is an internal network that only VMs and the Host can communicate with. This is nice if there is a lot of communication between the VM and the host or the VM and other VMs.
Yea I just checked them out the processor he is using is a first generation K8 opteron based on a 939 Athlon 64 x2 this was a generation before AMD-V hardware virtualisation. The problem with this is the virtual performance will be a fraction of your processors performance due to the huge overhead because Without hardware acceleration your essentially emulating the processor hardware in software. Most socket am3 motherboards also support ecc ram. You would have been easier to just go with a basic am3 box, quad and a few gb of ecc ram. It would support VMware or any other flavour of virtualisation and out perform the server you have now.
This is the first time I've heard this. Where did you find this? I'm a bit skeptical to say that this is true. Also, it's not about the motherboard supporting it as much as it is about the CPU and the IMC supporting it.
All am3 processors support ecc unbuffered ram but its up to motherboard manufacturers support it In the bios. My asus board and my last Foxconn am3 board supported it I just wish my servers MSI 890fx-GD70 did. Only intel makes the distinction that celeron,pentium,i3,i5,i7 has no ecc and that you have to pay for server parts and a Xeon to get ecc.
I had VMware workstation running with both Ubuntu and server 2012 and it was running pretty fast. But I had to pay for it so I then switched to windows server 2012 and installed VMware player. As far as it doesn't support is that something internal in the cpu?
Also if I cant do virtualization could I just host through server 2012 what are the drawbacks compared to Ubuntu LAMP?
vmware player is just the same as workstation minus a few features but the performance should be the same. if all your doing is hosting a couple of pages on the vm it should be fine but it will struggle with anything cpu intensive.
Well as far as windows software I can get most of what I need for free do to the agreements between Microsoft and the college I got to. So know I was thinking if I should just stick with windows server 2012 and just do everything from their? How intensive can a website get plus a game server. One thing that is going to run for sure is a minecraft server will have maybe 50 to 100 people logged into it and a website for the mincraft server. Hopefully that can give you a better idea?
It is internal of the cpu, later architecture cpu accelerate virtual environments instead of emulation so are much faster they have specific abstraction layer api's that virtualize the hardware layer , you already mentioned alternative plans that might perform whilst not being quite so secure so its a tradeoff , and one I know nothing of as four os, s might still run ok on your system idk.
Thanks, I going to skip the whole virtualization stuff and stick to server 2012 just wondering know on what I need and how to make it secure and safe.
Looks like I'm back to plan A. I got the Ubuntu LAMP server running in VMware player. I have 2gb ram and 2 cpus assigned to it with 20gb hd space. What other things do I need at this point?


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But the toilet and shower are not. The day i stayed here we had to wait until the bucket full with water before we can take shower. When go downstairs to checkout one of the staff yelled at us like we would sneak out and won't pay the towel (2rm each). read all of the review on the wall i... More
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- Backpacker's Stay Kuching, Sarawak
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Patents Sponsored by
Sunscreen compositions comprising metal oxide mineral pigments and hydroxyalkylurea compounds
The compositions contain metal oxide-based mineral pigments and at least one hydroxyalkylurea having a formula specified in the patent. The compositions, which contain no kojic dipalmitate, are intended for reducing, or even eliminating, the whitening effect on the keratin material after application.
Societe d'Extraction des Principes Actifs S.A.
Cosmetic or pharmaceutical composition containing peptides
Disclosed are compositions containing, as the active ingredient, at least one peptide with a sequence specified in the patent for use in treating, for example, the signs of cutaneous aging.
Unilever Home & Personal Care USA
Cosmetic compositions containing Nigrospora sphaerica extracts
Disclosed are extracts of Nigrospora sphaerica as cosmetic skin benefit agents, preferably as skin lightening agents alone or in combination with other skin benefit agents and together with a cosmetic vehicle. The inventive extracts, compositions and methods have effective skin lightening properties, may be easier to deliver to the skin, and are commercially available or cost-effective and available in nature. PatentPicks of Patents Published during the month of July 2008 by the World Intellectual Property Organization WO/2008/091161 F Bjerke Cosmetic composition containing spermine and emu oil Composition in form of a cream, liniment or oil for application on the skin for treatment of skin conditions such as wrinkles, burns, sunburns, aging, tired and stressed skin, and distinguished by the inclusion of a mixture of spermine, emu oil and possibly aloe vera.
Coreana Cosmetics Co., Ltd
Cosmetic composition for protecting skin against UV light and wrinkle improvement containing Magnolia sieboldii flower extracts
The active ingredient, Magnolia sieboldii extract, can protect the skin against UV lights and skin damage by suppressing skin cell death and cell DNA damage, and can reduce skin wrinkles by promoting the biosynthesis of collagen and suppressing the synthesis of collagenases.


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Hotel was good, location a little far out of town with minimal to do without a car. Room was sufficient, minimal staff to be seen but easy access to rooms. Quite quiet and only stayed for one evening.
France >
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Ranked #2 of 9 hotels in Lattes
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The Lynnfield Board of Health will hold a Flu Clinic for those age 9 or older at theTown Hall, 55 Summer Street, on Thursday, January 3, 2013, from 5:00 p.m. to 8:00 p.m.. This clinic is open to non-Lynnfield residents as well as Lynnfield residents. Flu Mist will be available.
Those seeking flu vaccine must not have allergies to eggs or egg products and must have no history of Guillain Barre Syndrome (GBS).
Most insurance is accepted. Please bring all insurance cards. There will be a $10 fee for those whose insurance is not accepted.
Flu Clinic
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I did call to Expedia on August 2013. I did ask to help me to find the nice hotel which one located very close to the ocean because we need to swim every day. Expedia sold to me the room at El Sabanero Beach hotel. I am 60 and my husband's sister is 55. We are from Washington State- it's... More
- Also Known As:
- Estela De Fuego Hotel Playa Flamingo
- Estela De Fuego Hotel
- El Sabanero Beach Hotel Costa Rica/Playa Flamingo
- Official Description (provided by the hotel):
- El Sabanero Beach Hotel is an Ocean Front Hotel in exclusive Playa Flamingo. In addition to sporting its own privately accessed beach El Sabanero Beach Hotel is close to Conchal Beach, and Penca Beach and only a short distance from Tamarindo Beach and Hermosa Bay Beach.El Sabanero Beach Hotel also features multiple dining venues, the best of indoor and outdoor dining, ample meeting and banquet space, multiple bars including a swim up bar and spacious Ocean Front terraces. ... more less
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Valet Key Ring in Sterling Silver
This key ring features a detachable ring for valet use. Pull apart and spring mechanism releases valet key ring.
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(MSNBC.com) Rachel Maddow gives an easy-to-understand breakdown of what is happening -- and causing problems -- at Japan's Fukushima nuclear power plant.
Deutsche Welle provides this Anatomy of a Nuclear Meltdown. According to Mark Hibbs, senior associate for the Nuclear Policy Program at the Carnegie Endowment for International Peace, a Chernobyl-like meltdown is "not possible" at the Fukushima plant.
More information about the Sendai Earthquake from Wikipedia
Google Person Finder: 2011 Japan Earthquake
Find out what you can do to help in the saving and rebuilding of lives in Japan


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Compress property donated to city
By JAMIE PATTERSON
Managing Editor
The Federal Compress was donated to the city of Yazoo City this week, pending the owners are given time to clean out any salvageable items.
The Yazoo landmark, located on Water Street, was heavily damaged last year when a fire consumed it. The owners of the property have spent the last several months cleaning the shell of the once bustling agriculture center.
The owners appeared before the Board of Mayor and Aldermen this week, requesting that city leaders accept their donation of the property.
-------for the rest of the story see The Yazoo Herald printed edition or subscribe to the Digital Edition.----------


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a place for zinesters - writers and readers
printed on 120gsm paper, wax ink, 25 sheets, glue bound with backing board
$5 each
(pencil not included)
Albums: STATIONERY
257 members
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Ist preference given to distros and zines. Rates and details are here. Limited space. Very Low Cost!
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If it's crap ... We'll tell you
Welcome to
The Spill Movie Community
Say what you want about the idea of remaking 'Judge Dredd,' I am still pumped to see Karl Urban's take on the violent, fascist law enforcer. I know the guy is a huge fan of the comic books and whether or not the movie is a success, I admire his dedication to getting the character right. This brand new, and evidently last, poster for Pete Travis' 'Dredd'has just hit the web and I love how it feels like a throwback to an 80s b-movie. Seriously, I want this thing on the wall in my office right the hell now. Take a look at the poster below and let us know what you think.
'Dredd'comes crashing into theaters September 21st
Source: Yahoo
Please Be Good!
At least with Batman, everything's color coordinated correctly so it can look dark and brutal and menacing. I don't even really notice the bat ears.
Here you got the monochromatic police superdude get-up....then BAM. Bright ass red helmet outta nowhere. That'd be like if all the sudden Batman suddenly decided to put on pink wings to his costume.
Just LIKE with Batman and many superheros, hopefully they can sell folks on the wardrobe at least. At least the one person on the lonely island of Haterade like I'm apparently on...
yeah.....but a guy in bat ears and a cape is fabulous.......snicker
I'm sorry, but that bright red helmet looks goofy as hell....
what do you get when you cross "The Raid and Lockout"? This SHITTY MOVIE!!!!!!!!!!
As long as he his suit has cod-piece on it, I'll be just fine.
Not Photoshop = Good Sign
Should be ok at least, I doubt it's going to downright flop given what I've seen so far but of course people are going to blow it out of proportion either way.
To Richard Dempsey: I don't think it will. I heard it was well revieved at Comic Con, so maybe it will do well everywhere else.
This movie just wont be the same without that Legend of Acting that is Rob Schneider...............DERP
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A Guide to Brass Mutes
Never confuse your brass mutes again with this handy lil' guide. Every single mute ever invented (minus many) are represented here on this chart. Show off this handsome 11" x 17" finely printed poster in your music room.
Whenever you buy 4 or more posters from our store you will get 25% off the cost of each poster. No codes needed! Just add the posters to the cart and the prices will adjust themselves in the cart!
See more: Posters


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- Musician's Friend Best Selection, Price & Service. Guaranteed.
Need Help? Ask our Experts or call 800-449-9128
Asistencia en Español 866-226-2919
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Soft, supple leather guitar strap is 3" wide and is beautifully finished with double-ply, caramel floral tooled leather end tabs, giving it an elegant Old World appeal. Adjusts from 46" to 56".
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2 Meetup Groups match "SciFi & Fantasy Books" near Reston, VA
There are no upcoming Meetups.
Ok, so we have a few friends who are into the same type of movies, books, and tv shows as us... but not nearly enough! This group is for the adult watchers of the Vampire Diaries, True Blood, Twilight (even those who hate on it), Teen Wolf and the like. Are you excited for the Originals? This group is for you! Do you love paranormal romance and urban fantasy series?! We're talking Anita Blake, Night Huntress, Mercy Thompson, and the like. Want a group of friends where you can talk non-stop about …
Home of the North Virginia Browncoats We are a multi-cultural group comprising all ages and sexes. Our standard monthly activity is a Nerd Lunch held the first Saturday of the month, but have small meetups held throughout the month. These small meetups can be a simple movie outing or a trip to a local gathering, ie. the Maryland Renaissance Festival, Comic Book shows, Sci-Fi conventions, etc. Come on out and make new friends and geek out over your favorite genre topic. We would love to meet you!
Get an alert email when new Meetup Groups like this start near you.
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If nothing else,the appointment of Jon Cooper as new head coach of the Tampa Bay Lightning buys general manager Steve Yzerman some time out of the dreaded spotlight of fan scrutiny.
The Pride will move on after three abysmal seasons in Hempstead.
Barney Cotton may need more room on his business card, but the Huskers could've used a staff change in a far more crucial place.
Former Arizona State coach is said to have interviewed today for the job
Utah coach had reportedly accepted an offer with BYU yesterday.
Roderick was the most senior offensive coach on the staff.
Kelly Sheffield has been named the next women's volleyball coach at Wisconsin after a stellar five-year run at Dayton, where he posted a 131-33 (.799) record. Sheffield is a three-time Atlantic-10 Coach of the Year who has guided the Flyers to four straight regular season and conference tournament titles. He has a 273-112 (.709) lifetime record in 12 years as a head coach.
The Utes might be replacing a couple assistants in the coming weeks.
Todd Graham has done wonders for the ASU football program. He brought in high talent players and reformed the once discipline-less team into a calm, cool and collected unit. He took the reigns in...
How do the firing of Ron Wilson and the non-firing of Brent Sutter contrast? A look at the stories that define their tenures with their respective teams.
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New Apple iPad
New Apple iPad
Given the nearly identical dimensions, the new iPad will retain compatibility with existing Smart Covers.
- Visit Connected Traveler for the latest in Tech Travel - Sponsored by Canon
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Florene Lovins, 67, of Manchester, passed away Friday at the U.K. Medical Center at Lexington.
Funeral services for Florene Lovins will be held Wednesday at 2:00 PM at the Britton Funeral Home Chapel with Sill Lee and Paul Stewart officiating. Burial will follow at the Manchester Memorial Gardens.
Last Updated on Monday, 28 March 2011 20:45
Elijah Stewart, 73, of Oneida, was born May 9, 1937. He went home to be with the Lord March 24, 2011.
He leaves these sisters and brother: Roma Riley, Union, KY., Zelda Stewart, Oneida, and Elbert Stewart and Wife Ruby, Cold Springs, KY. Along with several nieces and Nephews. Elijah was a very special part of the Stewart family and loved to sing, play the banjo and sit on the front porch.
He was a member of the Antepast Baptist Church.
He was preceeded in death by his parents Boyd and Sylvania Stewart and the following brothers and sisters: Hubert, Boyd Jr., Forester, Elmer, Joseph Lawton, Florence and Mallie.
Funeral services for Elijah Stewart were held Monday at 11:00 AM at the Britton Funeral Home Chapel with Tip Smith and Robert Hacker officiating. Burial followed at the Johnny Martin Cemetery at Oneida.
Visitation was Sunday evening at the Britton Funeral Home.
Last Updated on Monday, 28 March 2011 20:44
Lola Lee Bush born September 10, 1948 passed away March 21st, 2011. She leaves behind her husband Donnie, one son Donnie Michael & wife Rachel of London KY. & one grand daughter Kendall. She also leaves behind two brothers A.C. Henson of Billy's Branch & A.T. Henson of London. She was preceded in death by her father and mother Hugh and Lillie Henson. Funeral services for Lola Lee Bush will be held Friday at 1:00 PM at the Britton Funeral Home Chapel with Jerry Holland & Jerry McKinley Holland officiating. Burial will follow at the McKinley Bush Cemetery at Elk Creek. Visitation was after 6:00 PM Thursday at the Britton Funeral Home.
Last Updated on Thursday, 24 March 2011 16:03
Mary Rose Couch, age 75, of the Tranquility Area near Seaman, Ohio, died Thursday, March 18, 2011 at her home with her family by her side. She was born April 18, 1935 in Oneida, Kentucky, the daughter of the late Roscoe and Sarah Hensley Burns. She was a member of the Tranquility Full Gospel Tabernacle. She enjoyed playing the piano at home and church, she wrote and sang many original gospel songs. She is survived by her daughter and son-in-law Joan and Jesse Disher of Seaman; four grandchildren, Evelyn Rose (Charles) Jones, Jonie Marie (Bobby) Sannan, Jennifer Lynn (Scott) Hargett, and Jesse Eugene (Heather) Disher all of Seaman; eight great grandchildren, Charles Jacob Jones, Joshua Timothy Jones, Makayla Rose Marie Jones, Michael Hacker, Robert Sannan, Jesse Isiah Hargett, Faith Noel Hargett, and Lani Jean Disher; two sisters, Doris Jean Burns of Dayton, Ohio, and Ozzie Bowling of Booneville, Kentucky; one brother, Ambrose Burns of Harrodsburg, Kentucky; and four step grandchildren, Lorie, Faye, Madison, and Natalie. In addition to her parents, she is preceded in death by her husband Homer Couch on February 27, 2008; and several brothers and sisters. Funeral services will be held 11:00 a.m. Monday, March 21, 2011 at the Tranquility Full Gospel Tabernacle near Seaman. Gary Ferguson will officiate with the assistance of Daniel McCann. Burial will follow in the Sugar Tree Ridge Cemetery. Visitation will be held on Sunday, March 20, from 3:00 p.m. until 8:00 p.m. at the Tranquility Full Gospel Tabernacle. Memorial donations may be made to the Tranquility Full Gospel Tabernacle, 182 Rankin Brothers Road, Seaman, Ohio 45679. The Turner & Son Funeral Home, Hillsboro, is serving the family. For more information and to sign our on-line register, please visit www.turnerfuneralhomes.cc
Last Updated on Thursday, 24 March 2011 13:56
Last Updated on Thursday, 24 March 2011 13:54
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