Long-term results of total penile reconstruction with a prefabricated lateral arm free flap

Trifluoroethanol (TFE) is often used to increase the helicity of peptides to make them usable as models of helices in proteins. We have measured helix propensities for all 20 amino acids in water and two concentrations of trifluoroethanol, 15 and 40% (v/v) using, as a model system, a peptide derived from the sequence of the alpha-helix of ribonuclease T1. There are three main conclusions from our studies. (1) TFE alters electrostatic interactions in the ribonuclease T1 helical peptide such that the dependence of the helical content on pH is lost in 40% TFE. (2) Helix propensities measured in 15% TFE correlate well with propensities measured in water, however, the correlation with propensities measured in 40% TFE is significantly worse. (3) Propensities measured in alanine-based peptides and the ribonuclease T1 peptide in TFE show very poor agreement, revealing that TFE greatly increases the effect of sequence context.     

Second free flaps in head and neck reconstruction

Over the past decade, free-tissue transfer has greatly improved the quality of oncology-related head and neck reconstruction. As this technique has developed, second free flaps have been performed for aesthetic improvement of the reconstructed site. This study evaluated the indications for and the success of second free flaps. Medical files for patients who underwent second free flaps for head and neck reconstruction at the University of Texas M.D. Anderson Cancer Center, from May 1, 1988 to November 30, 1996, were reviewed. The flaps were classified as being either immediate (done within 72 hr) or delayed (done within 2 years) reconstructions. Indications, risk factors, recipient vessels, outcome, and complications were analyzed. Of the 28 patients included in this study, 12 had immediate (nine as salvage after primary free flap failure, and three for reconstruction of a soft-tissue defect), and 16 had delayed second free flaps (two for reconstruction of a defect resulting from excision of recurrent tumors, and 14 for aesthetic improvement). Reconstruction sites included the oral cavity in 18 patients; the midface in six; the skull base in two; and the scalp in two. The success rate for the second free flaps was 96 percent. Five patients had significant wound complications. In a substantial number of cases, identical recipient vessels were used for both the first and second free flaps. The authors conclude that second free flaps can play an important role in salvaging or improving head and neck reconstruction in selected patients. In many cases, the same recipient vessels can be used for both the first and second flaps.     

Microsurgical elimination of foot soft tissue defects with free vascularized flaps]

The results of 40 microsurgical transplantations of complex flaps in 37 patients with cicatricial-ulcerous foot deformations are analysed. The surgery was indicated in cicatricial soft tissues defects, unhealing trophic ulcers, inability to use local tissues for plastic surgery. The scapular flap was used in 34 cases, thoraco-dorsal flap in 5 cases, deltoid flap in 1 case. It was necessary to increase the square of the scapular flap in case of a vast cicatricial soft tissue defect of the talocrural joint and dorsal surface of the foot and the sole. A special expander was used for this purpose. The importance of ultrasound methods for evaluation of the vessels supplying the sole, as well as the state of the microvascular anastomoses in postoperative period is stressed. The long-term results were followed up for 1.5 to 5 years in 29 of 37 patients. The good results was noted in 18 patients, satisfactory in 7 patients, complications (unhealed trophic ulcers) in 4 patients. The complications were caused by calcanel tuber deformation with osteophyte, osteomyelitis, inradically removed scars.     

Application of different types of free foot flaps in hand surgery

From 1987, nine types of free vascularized flaps or combined flaps from the foot were used to treat 26 cases of hand injury with tissue loss. They were: (1) combined flap of 4 toe dorsums, big toe pulp, first toe web, and dorsalis pedis flap with long extensor tendons of the toes, (2) composite skin flap with the second metatarsophalangeal joint, (3) wrap-around flap from the great toe, (4) first toe web flap, (5) toe pulp flap with only an artery and a nerve, (6) wrap-around flap of the great toe with a dorsalis pedis flap, (7) second toe with dorsalis pedis flap, (8) dorsalis pedis flap, and (9) first toe web flap with second metatarsal bone. All flaps survived. All the patients have used their reconstructed hand. Of the final motor functions of the reconstructed hands, 68.8% are excellent, 27.3% are good, 3.9% are fair. Of the final cosmetic results of the reconstructed hands, 76.9% are excellent, 15.3% are good, 7.8% are acceptable. Of the patients, 64.9% are satisfied with the final results of the donor sites, 31.2% feel it is acceptable, and 3.9% feel it is unsatisfactory. The selection, indication, merits and demerits of vascularized foot flaps and attentive points in the operations are discussed in this paper.     

Bilateral breast reconstruction in very thin patients with extended free TRAM flaps

High dose therapy and stem cell transplantation is increasingly being used for treatment of CLL. The present article summarizes available results reported in literature on the use of high dose therapy followed by allogeneic or autologous hemopoietic precursor infusion. Transplant procedures seem a feasible approach, especially autografts, while allogeneic transplant has been associated with a higher mortality rate. Interesting clinical/biological results have been reported for both allogeneic and autologous transplants but prospective large clinical trials are needed to establish their real value. We consider important issues of stem cell transplantation in CLL patients, such as the kind of transplant (allogeneic vs autologous), the optimum timing, the selection of patients, the value and type of purging and, above all, impact on survival.     

Acute reconstruction of massive cervicofacial necrotizing fasciitis with Estlander and free scapular/parascapular flaps

Previous studies have demonstrated exercise-induced heat shock protein 70 (HSP70) in animals. The purpose of this study was to investigate human skeletal muscle HSP70 response to rowing training. Ten male rowers trained for 4 wk with different forms, durations, and intensities of exercise. Biopsy was performed in the right musculus vastus lateralis before training and at the end of each week. HSP70 in 5 microg of total protein from the muscle sample was determined by using Western blot and immunodetection with chemiluminescence technique, by means of laser densitometer referring to a series of known standard HSP70. Compared with pretraining (100%), HSP70 increased during training (181, 405, 456, and 363% from the first to fourth training week, respectively) with the maximum HSP70 production at the end of second training week. Thus HSP70 is induced in highly trained human muscle by long-term training.     

A comparison of resource costs for head and neck reconstruction with free and pectoralis major flaps

A series of 178 immediate reconstructions with regional or distant tissue for repair of oropharyngeal defects caused by treatment of head and neck cancer was reviewed to determine whether reconstruction with free flaps was more or less expensive than reconstruction with regional myocutaneous flaps. In this series, three types of flaps were used: the radial forearm free flap (n = 89), the rectus abdominis free flap (n = 56), and the pectoralis major myocutaneous flap (n = 33). Resource costs were determined by adding all costs to the institution of providing each service studied using salaried employees (including physicians). The two free-flap groups were combined to compare free flaps with the pectoralis major myocutaneous flap, a regional myocutaneous flap. Failure rates in the two groups were similar (3.0 percent for pectoralis major myocutaneous flap, 3.4 percent for free flaps). The mean costs of surgery were slightly higher for the free flaps, but the subsequent hospital stay costs were lower. Therefore, the total mean resource cost for the free-flap group ($28,460) was lower than the cost for the myocutaneous flap group ($40,992). The pectoralis major myocutaneous flap may have been selected for more patients with advanced disease and systemic medical problems, contributing to longer hospitalization and added cost. Nevertheless, this study suggests that free flaps are not more expensive than other methods and may provide cost savings for selected patients.     

Simultaneous transfer of free fibula and radial forearm flaps for complex oromandibular reconstruction

In the present investigation Actinomyces pyogenes specific antigens caused an antibody response in the host. This could be determined by two enzyme-linked immunosorbent assays (ELISA) using cell extracts and a haemolysin preparation as antigens. An increased antibody titre was detectable in the sera of cows vaccinated with culture supernatants of A. pyogenes and Peptococcus indolicus, in the sera of cows infected with live cells of A. pyogenes and P. indolicus, in the sera of cows suffering from 'summer mastitis', and in part of the sera of nonvaccinated, apparently healthy cows. However, the titre of the cows that were vaccinated with culture supernatants decreased 8-9 months after inoculation. Because of the wide variation in antibody titre the determination of A. pyogenes specific antibodies seems to be only of limited use for the control of this infection.     

Sensory recovery in noninnervated radial forearm free flaps in oral and oropharyngeal reconstruction

BACKGROUND: Reinnerveration of free flaps used in oral and oropharyngeal reconstruction may provide a high level of sensory return. Spontaneous recovery of sensation in noninnervated flaps may also occur. OBJECTIVE: To evaluate the extent of spontaneous sensory return among patients who underwent radial forearm free flap reconstruction in the oral cavity and oropharynx. METHODS: A total of 40 patients were evaluated by 2 independent examiners. The median patient age was 60 years, and the median time from surgery was 47 months. A total of 29 patients had received postoperative radiotherapy. The mean flap size was 25 cm2. The following sensory modalities were tested: light touch, pinprick, hot and cold, and moving and static 2-point discrimination. RESULTS: Recovery of sensation of at least 1 modality was noted in 32 patients (80%), however, only 5 patients (13%) had return of all 5 modalities. Eight patients (20%) had no sensory return. There was a trend to improved sensory recovery in flaps placed in the alveolar and retromolar trigone areas; however, on multivariate analysis, sensory return could not be predicted by any of the following factors: patient age, flap site, flap size, length of follow-up, and use of postoperative radiotherapy. CONCLUSIONS: Complete sensory recovery was uncommon, unpredictable, and variable, although some recovery of sensation occurred in 80% of patients. It is not valid to rely on spontaneous sensory recovery for sensory innervation of free flaps. Correlation of sensory return with function is still needed.     

The management of unsalvageable free flaps

The loss of vascular flow in the early postoperative period will generally lead to free flap failure. When attempts at flap salvage are unsuccessful, conservative management with delayed flap debridement may be indicated. Seven unsalvageable free flaps were managed with observation and flap debridement 4 to 14 days following loss of vascular signals. At the time of debridement, six of the seven wounds had viable granulation tissue and were successfully closed with skin grafts. The seventh patient had loss of vascular flow to the free flap within 12 hr of surgery and, at the time of delayed debridement, had no evidence of granulation ingrowth. Local revascularization of flaps is known to occur and offers an explanation for these findings. Delayed debridement of unsalvageable free flaps is indicated for noncritical wounds, and may obviate the need for a second free-tissue transfer to obtain wound closure.     

应用游离腓骨复合组织瓣行功能性重建上颌骨缺损

上颌骨是面部中份的基石,是面部中份外形和功能最重要的骨骼结构,参与眼眶、颧上颌复合体、鼻腔、口腔等各种面部中份重要结构的组成.由于肿瘤切除、外伤、炎症及先天畸形所致的上颌骨缺损不仅严重影响外形,而且直接影响语言、咀嚼、吞咽等多项生理功能.由于上颌骨及面部中份解剖结构和功能的复杂性,使上颌骨缺损的修复与重建成为临床医师面临的挑战性难题.     

The use of platysmal myocutaneous flaps in laryngeal reconstruction

Vertical frontal subtotal laryngectomy, a procedure that can remove as much as 90% of the larynx, was used to produce a functionally acceptable neolarynx with platysmal myocutaneous flaps. Thirty-two patients with laryngeal carcinoma underwent this operation. All flaps survived and there was no necrosis after operation. With the exception of one patient who require nasal feeding because of an irritating cough when swallowing food, all the other patients regain breathing, swallowing and phonating of laryngeal function. The operative methods, advantages and experiences are discussed in this paper.     

Long-term results of visually guided left ventricular reconstruction as single therapy to treat ventricular tachycardia associated with postinfarction anteroseptal aneurysm

INTRODUCTION: Postinfarction ventricular tachycardia (VT), anteroseptal aneurysm, and ventricular dysfunction are commonly associated and predict a poor long-term prognosis. Surgical left ventricular reconstruction, which includes double plication of the anterior and septal wall, can improve ventricular function. This article analyzes the long-term efficacy of such a procedure to control recurrence of VT in a group of 50 consecutive patients. METHODS AND RESULTS: The study group consisted of 50 consecutive patients operated on between December 1986 and December 1994. The group comprised 44 men and 6 women. The mean age was 56+/-11 years. All patients had spontaneous VT following an anterior myocardial infarction. Twenty-five patients had two or more episodes of VT (eight presented as cardiac arrest, nine as syncope). Coronary artery disease was limited to the left anterior descending artery in 27 patients. An anteroseptal aneurysm was present in 49 patients. All patients had VT induced by programmed ventricular stimulation before surgery, and left ventricular reconstruction was performed without intraoperative mapping in all cases. Total mortality, VT recurrence, and sudden death rate were the endpoints of the study. In-hospital mortality was 8%. Postoperative left ventricular ejection fraction improved from 0.38 to 0.50 (P<0.05). Only two patients had postoperative inducible VT. Overall survival, VT recurrence rate, and sudden death rate were 73%, 12%, and 10%, respectively, after a median follow-up period of 6.25 years (0 to 8 years). CONCLUSION: Visually guided left ventricular reconstruction with septal and anterior wall plicature can be utilized effectively to treat recurrent VT associated with postinfarction anteroseptal aneurysm.     

Long-term results of femorotibial bypass with vein or polytetrafluoroethylene

OBJECTIVE: The purpose of this study was to determine predictors of posttraumatic stress disorder (PTSD) in health care workers exposed to a disaster, in order to facilitate early case identification and prevention of subsequent morbidity. METHOD: Following an air disaster, 355 military medical health care workers were studied over an 18-month follow-up period. Measures included assessment of peritraumatic reactions associated with the disaster, the frequency of other stressful events after the disaster, and standard PTSD rating scales at 6, 12, and 18 months. RESULTS: Multivariate logistic regression of data on health care workers who cared for victims of the air disaster showed that PTSD was more likely to develop in those who had not completed college, those who had worked with burn victims, those who had experienced more stressful life events in a period of approximately 6 months following the disaster, and those who experienced emotional numbness immediately after the disaster. CONCLUSIONS: Results suggest that lower levels of education, exposure to grotesque burn injuries, stressful life events following exposure, and feelings of numbness following exposure are useful predictors of subsequent development of PTSD.     

Functional and histologic effects of a free nonvascularised muscle graft implanted into a reinnervated muscle after prolonged denervation

Striated muscle atrophy and degeneration, which increase with the delay of denervation, represent two of the main causes for poor recovery following delayed nerve repair. The present study, using a rat model, tests the hypothesis that an adjunction of small, free, nonvascularised muscle grafts of contralateral healthy triceps into a chronically denervated triceps improves muscle regeneration and recovery following sciatic nerve repair delayed for 3 months. Our experiments seem to show a relative increase in mechanical properties in animals in which free muscle graft into the triceps was performed 3 weeks following nerve repair. The improvement of the regenerative process of muscles which have suffered a long period of denervation should be considered as an additional therapeutic procedure in the case of late nerve repair.