One-stage total penile reconstruction with a free sensate osteocutaneous fibula flap

This is the first series of total penile reconstructions with the free sensate osteocutaneous fibula flap. The main advantages of this flap lie in its intrinsic rigidity, its superior donor-site location, and its long vascular pedicle. The fibula flap provides better bone volume than does the radial forearm flap, which commonly results in a floppy phallus in the absence of bone. Penile prostheses in other flaps have enjoyed limited success. Forearm donor-site complications can be avoided. The donor site in the lower extremity can be readily covered with a sock. The vascular pedicle of the fibula flap is of sufficient length to allow end-to-side anastomosis of the flap to the femoral artery. Interpositional vein grafts are unnecessary, and dissection of the inferior epigastric artery system to serve as a donor artery may be avoided. The appearance of the neophallus is excellent. We present only the first four continuous cases of the six we have performed because sufficient follow-up data are available only for these four. The advantages and disadvantages of fibula and forearm donor sites, the long-term fate of the bony component, the importance of sensation, and the vascularized urethral reconstruction are discussed. High patient satisfaction and the advantages of the technique convince us that the fibula osteocutaneous flap is superior for total penile reconstruction.     

Functional alveolar ridge reconstruction with prefabricated iliac crest free flap and osseointegrated implants after hemimaxillectomy

We achieved functional alveolar ridge reconstruction after hemimaxillectomy using a prefabricated iliac crest flap. The iliac crest was vascularized secondarily by a long rectus abdominis muscle flap with its inferior epigastric vessels intact to obtain an ideal anatomic location between the maxillary defect and microvascular anastomosis site. The iliac crest was tightly resurfaced with a split-thickness skin graft as well. After a bony surgical delay, the prefabricated iliac crest flap was microsurgically transferred to the face. Three osseointegrated implants were placed in the prefabricated iliac crest, and a dental prosthesis was worn with immobilization and stability. Our procedure enabled recovery of a satisfactory facial appearance and excellent masticatory function.     

Long-term results of weight-bearing foot reconstruction with non-innervated and reinnervated free flaps

PURPOSE: The author outlines the care of patients receiving intravenous amphotericin B, with emphasis on the prevention and/or management of nephrotoxicity. OVERVIEW: The immunocompromised patient remains at risk for systemic fungal infections; however, therapeutic options are limited. Although amphotericin B has remained the drug of choice for more than 30 years, its toxic effects, particularly nephrotoxicity, warrant careful attention. Nephrotoxicity is the most serious and dose-limiting effect of amphotericin B therapy. Appropriate assessment before, during, and after therapy in patients receiving intravenous amphotericin B may help to minimize the potential for nephrotoxicity. CLINICAL IMPLICATIONS: To provide optimal patient care, it is imperative that the clinician understand the etiology of and the signs and symptoms associated with nephrotoxicity, as well as interventions to prevent nephrotoxicity, in the patient receiving amphotericin B.     

Pelvic reconstruction with a free fillet lower leg flap

Orthostatic tremor (OT) is a rare movement disorder that consists of involuntary shaking of the legs and trunk present only on standing. Although the origin and the mechanism of this condition are not well understood, the neurophysiologic abnormalities and PET studies suggest a central origin. We describe the clinical and radiologic features of two patients with symptomatic OT and associated pontine lesions, and conclude that OT may arise from dysfunction of the cerebellum or related pontine structures.     

Facial reconstruction using a retroauricular-temporal free flap

Large and deep soft-tissue defects of the face usually require resurfacing by free-tissue transfer. An appropriate free flap for facial reconstruction may be harvested from the retroauricular and temporal region utilizing two arterial pedicles (superficial temporal artery and posterior auricular artery). This flap provides normal color, texture, and thickness and thus is an optimal anatomic and aesthetic reconstruction with minimal donor-site morbidity.     

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.     

Resurfacing of the donor defect after wrap-around toe transfer with a free lateral forearm flap

BACKGROUND: One-week proton pump inhibitor-based triple therapies are very popular in the US despite limited US data documenting efficacy. We assessed 1-week proton pump inhibitor triple therapies for Helicobacter pylori, and compared them to dual antibiotic therapies (to assess benefit of omeprazole) and to omeprazole-amoxycillin (to assess benefit of clarithromycin) in a large, randomized, US multicentre study. METHODS: Healthy subjects who were H. pylori-positive by rapid serological test and 13C-urea breath test were randomly assigned to (i) omeprazole (O) 20 mg b.d. + amoxycillin (A) 1 g t.d.s. for 14 days (OA); (ii) A 1 g b.d. + clarithromycin (C) 500 mg b.d. for 7 days (AC); (iii) C 250 mg b.d. + metronidazole (M) 500 mg b.d. for 7 days (CM); (iv) O 20 mg b.d. + C 250 mg b.d. + M 500 mg b.d. for 7 days (MOC); or (v) O 20 mg b.d. + C 500 mg b.d. + A 1 g b.d. for 7 days (OAC). Repeat breath tests were done at 6 weeks to assess H. pylori status. RESULTS: Three hundred and two H. pylori-positive subjects at 25 centres received medication. Intention-to-treat cure rate was significantly higher for OAC (82%) than for MOC (67%), CM (59%), AC (18%) or OA (58%), Per-protocol cure rates were 85% for OAC and 75% for MOC. Discontinuation of therapy due to a side-effect occurred in 0-3% of each study group. CONCLUSIONS: One-week twice-daily triple therapy with omeprazole, amoxycillin and clarithromycin provides the best rate of eradication of the five regimens studied. However, treatment in the US for 7 days may be unable to achieve eradication rates of > or = 90% with proton pump inhibitor-based triple therapy.     

Pulp reconstruction of fingers with very small sensate medial plantar free flap

The essence in dealing with the pulp deficit accompanying fingertip injuries lies in functional restitution of the inherent skin texture and characteristics unique to that area and sufficient preservation of digital length, along with successful restoration of fine tactile sensation indispensable to delicate and skillful maneuvers. Among various techniques used to meet such demands, the very small sensate medial plantar free flap can be considered an excellent method in view of the skin texture that allows firm grasping, durability to friction rub, a cushion effect, and adequate sensation. Six cases of finger pulp reconstruction with the very small sensate medial plantar free flap are presented. At follow-up examination (an average follow-up of 24.3 months), the patients were evaluated clinically and neurologically. The operative procedures, advantages, and results in clinical cases are presented. Satisfactory results were obtained with sufficient preservation of digital length and good sensory recovery. No functional deficit was found at the donor site.     

Pharyngoesophageal reconstruction using the tubed free radial forearm flap

Patients undergoing laryngopharyngectomy require the restoration of both deglutition and voice. We believe the tubed radial free flap offers the combined advantages of a rapid harvest with minimal morbidity, a long flap pedicle, extraordinary reliability, and the possibility of customization to fit virtually any size of defect. This flap does have a somewhat higher leakage rate; however, such leaks are relatively minor and nearly all will resolve with a brief period of conservative treatment. Postoperatively, this flap tolerates radiation therapy very well. Most importantly, it maximizes the functional rehabilitation of the patient by providing the best speech and swallowing results available. For these reasons we consider the tubed radial forearm free flap to be the flap of choice for circumferential pharyngoesophageal reconstruction.     

Superior gluteal artery perforator free flap for breast reconstruction

The purpose of this paper is to present a new method of breast reconstruction utilizing skin and fat from the buttock without muscle sacrifice. Cadaver dissections were done to study the musculocutaneous perforators of the superior gluteal artery and vein. Eleven breasts were reconstructed successfully with skin/fat flaps based on the superior gluteal artery with its proximal perforators. Long flap vascular pedicles allow the internal mammary or thoracodorsal vessels to be used as recipient vessels. This new technique has several advantages over the previously described gluteus maximus myocutaneous flaps, including long vascular pedicle and no muscle sacrifice.     

Combined saphenous vein with free flap reconstruction in the treatment of carotid stenosis

Revascularization for arterial stenosis in varied anatomic sites exposed to therapeutic radiation has been well described. In most circumstances, symptomatic end organ ischemia has been the indication for surgical intervention. We report the case of a patient who had symptomatic carotid stenosis 40 years after having ipsilateral neck dissection with radiation therapy. We did a saphenous vein graft interposition and free flap reconstruction of the overlying damaged skin.     

Auricular reconstruction with a postauricular myocutaneous island flap: flip-flop flap

Surgical defects of the concha-helix part of the ear larger than 2 cm may pose a reconstructive challenge. Split- or full-thickness skin grafts or local flaps may be used, and a number of these have been described. Yet cosmetic results are often unsatisfactory. Our experience with a postauricular myocutaneous island flap is described. Eleven patients (12 ears), aged 48 to 89 years, underwent the procedure under local anesthesia following excision of conchal bowl malignant tumors that included the cartilage underlying the skin. The surgical technique is described in detail. Few complications were encountered, and cosmetic results were excellent. In four ears, resection margins extended into the ear canal, and that portion was allowed to heal satisfactorily by secondary intention. We recommend the use of this flap for practical, safe, and early good cosmetic results.     

Results after resection of intraoral cancer and reconstruction with the free radial forearm flap

OBJECTIVE: Prospectively evaluate the effect on the nutritional status of a glucose polymer as energy supplementation alone in chronic hemodialysis patients with moderate and severe malnutrition. MATERIAL AND METHODS: The nutritional status of 55 hemodialysis patients was assessed by using a score that included Iron binding capacity, albumin, cholesterol, body mass index, mid brachial circumference, arm muscle area, triceps skinfold, and clinical impression. Twenty-two of 27 patients (14 men and 8 women, mean age 43 +/- 15 years, time on dialysis 65 +/- 49 months) were classified as moderately or severely malnourished and were supplemented for 6 months with 100 g of glucose polymers per day (equivalent to 380 kcal or 1590 kJ) added to the usual food intake. The patients were reevaluated at 3 and 6 months. RESULTS: Only body weight, body mass index, triceps skinfold, and brachial circumference and clinical impression increased significantly at the end of the third month (P < .05) in the 22 patients. These results were confirmed at 6 months in 18 patients that completed the study. Mean body weight increase was 2.4 kg (range, .2 to 6.3 kg). The nutritional status, evaluated through the score, improved in only 4 patients at the end of the study. Few gastrointestinal side effects were observed. Triglycerides increased from 136 +/- 40 mg/dL to 235 +/- 120 mg/dL. Follow-up of the patients showed that fat mass (assessed by anthropometry) was maintained for 6 months after supplementation was discontinued. CONCLUSION: Energy supplementation alone in patients with moderate and severe malnutrition on chronic hemodialysis resulted in an increase in body weight, owing to an increase in body fat, but the nutritional status did not improve.     

Thumb reconstruction with a free neurovascular wrap-around flap from the big toe: long-term follow-up of thirty cases

From March 1982 to December 1992, 30 cases of thumb reconstruction with a free neurovascular wrap-around flap from the big toe were performed at Korea University Hospital. Twenty-nine of a total of 30 cases were successful and obtained excellent functional and cosmetic results. Postoperative complications included 1 case of graft failure, 6 partial skin necroses, 1 malunion, and 15 cases of resorption of iliac bone graft including 1 case of fatigue fracture of grafted bone. Even for the first metacarpal neck amputations, thumb reconstruction with a free neurovascular wrap-around flap was possible; however, limitation of motion of the reconstructed thumb and resorption of the grafted bone occurred. Thumb reconstruction with a wrap-around free flap from the big toe gives excellent cosmetic and functional results and causes minimal morbidity on the donor site.     

Superior gluteal vessel as recipient for free flap reconstruction of lumbosacral defect

When the lumbosacral soft-tissue defect cannot be closed with a local flap, the option of a free flap should be considered. However, very few cases of free flaps have been reported, the reason being mainly difficulties in finding a suitable recipient vessel. Several vessels, such as inferior gluteal vessel, extension of thoracodorsal vessel with vein graft were reported as recipient vessels, but each one had its own drawbacks. The superior gluteal vessel has been used as a donor vessel in breast reconstruction after mastectomy but is thought to be undesirable as a recipient for microvascular anastomosis, mainly because of technical difficulty. From May of 1993 to March of 1997, five patients (one man and four women) received microvascular transfer of latissimus dorsi myocutaneous flaps using the superior gluteal vessel as a recipient. Their ages ranged from 11 to 64 years (mean 44 years of age). The causes of lumbosacral defects were tumor (1), trauma (1), radiation (2), and pressure sore (1). Before free flap transfer, the patients received an average of 2.8 operations for sacral lesions. Mean follow-up period was 12.4 months (2 to 40 months). A lateral approach was used to the superior gluteal vessel after elevation and retraction of gluteus maximus muscle. A thoracodorsal artery and vein were anastomosed to superior gluteal artery and vein in three cases, whereas in two cases, one artery and two veins could be anastomosed. All the flaps survived with complete recovery from sacral lesions. During the follow-up period, one case of partial skin graft necrosis and one case of a small superficial pressure sore developed, but there was neither dehiscence nor recurrence. The superior gluteal vessel is large in caliber, constant, with numerous branches, lying in proximity to the lesion, and relatively unaffected despite previous radiation. The technical difficulties with the deep location and short pedicle length can be overcome with some modifications in approach to the vascular pedicle. The superior gluteal artery and vein can be used as a recipient for the free tissue transfer when the lumbosacral defects cannot be covered with a conventional method.     

Tracheal reconstruction with a vascularized cartilage flap in rabbits

Contribution of 42 patients, aged 57 to 69 (mean age 58) with infiltrant vesical neoplasia who underwent radical cystoprostatectomy according to the technique described by P.C. Walsh (38/42) or radical cystectomy with hysterectomy (4/42). Neoplasia stages were as follows: 7 T2G-III; 13 T3aGII: 15 T3aG-III and 7 T3bG-III. Ten (10) patients, aged between 48 and 70 (mean age 57), with prostate neoplasia who were performed radical prostatectomy using the technique described by the above author, were also ascribed to the last group. Prostate neoplasias were at the following stages: 4 T2c; 5 T3a and 1T3b. T3 stages had been given hormonal therapy prior to the procedure. No patient received radiotherapy. Rectal injury occurred in 2 of the 52 (2/52) patients described. One was a female patient who was being performed cystectomy and hysterectomy plus double adnexectomy. Urinary by-pass in this case was C.F.C. detubulized ureterosigmoidostomy. The second case was a male patient undergoing radical prostatectomy. In both cases pre- and post-operative discharge colostomy was performed. Suture of rectal injury was also done in the patient where colostomy was performed during the procedure. The authors emphasise that no rectal injury that may take place during radical prostatectomy or cystoprostatectomy should be disregarded. They raise and answer questions of great practical interest such as: Is simple suture of the rectum enough? Should the omentum be used in rectal repair? Is it indispensable to perform discharge colostomy? and, is prognosis more serious when the gut is not prepared?