Reconstruction of total maxillectomy defects with preservation of the orbital contents

Reconstruction after total maxillectomy with preservation of the orbital contents is technically more challenging than when the maxillectomy is combined with orbital exenteration. Reconstruction of such defects should (1) provide support to the orbital contents, (2) obliterate any communication between the orbit and nasopharynx, (3) reconstruct the palatal surface, and (4) achieve facial symmetry and a good aesthetic result. We report our experience in performing reconstructive surgery on 14 patients who had a total maxillectomy and preservation of the orbital contents using nonvascularized bone grafts for reconstruction of the orbital floor and maxilla, in conjunction with a soft-tissue free flap or pedicled muscle flap. The orbital floor was reconstructed using split ribs in six cases (42.9 percent), split calvaria in six cases (42.9 percent), and iliac crest graft in two cases (14.3 percent). A myocutaneous rectus abdominis free flap was used for soft-tissue reconstruction and resurfacing of the palatal mucosa in twelve patients (85.7 percent), and a temporalis muscle transposition was used in two elderly patients (14.3 percent). One patient died 2 days after surgery. Mean follow-up and aesthetic and functional results were assessed in the remaining 13 patients a minimum of 6 months postoperatively. In 9 of these 13 patients (69.2 percent), postoperative radiotherapy was administered. No reexplorations or free flap failures were observed. One rectus flap developed partial necrosis of the skin island intraorally without affecting the final result. All patients had adequate functional vision. One patient had a mild vertical dystopia; there were no cases of enophthalmos. Ectropion was the most common undesirable result and was present in 10 of 13 cases (76.9 percent). It was graded as mild in four cases (40.0 percent), moderate in four cases (40.0 percent), and severe in the remaining two cases (20.0 percent). Speech was considered normal in six cases (46.2 percent), near normal in six cases (46.2 percent), and intelligible in one case (7.7 percent). Chewing function was considered good (soft to unrestricted diet) in all cases except for one patient who was only able to eat a pureed diet. Aesthetic results after immediate reconstruction were considered good in nine cases (69.2 percent) and fair in four cases (30.8 percent). Primary reconstruction of total maxillectomy defects with orbital content preservation remains a complex problem without a perfect solution. The combination of nonvascularized bone grafts for orbital/maxillary reconstruction with a soft-tissue free flap is a safe, reliable, and effective method of maximizing postoperative functional and aesthetic results.     

The use of free rectus abdominis myocutaneous flap to close the empyema space with alveolar fistula--a case report

A 59-year-old man, who had had right middle and lower lobectomy for pulmonary tuberculosis, admitted for the treatment of empyema with fistula. Closure of empyema space with free rectus abdominis myocutaneous flap was performed following open window thoracotomy and thoracoplasty. As he previously underwent two major operation, lobectomy by posterolateral approach and gastrectomy for gastric ulcer, free rectus abdominis flap was chosen instead of omental flap or latissimus dorsi myocutaneous flap. Postoperative CT film showed that this flap was filled up in all interstices of the empyema cavity. The pedicle vessels to this flap are large enough to provide long stalks, so microsurgical anastomosis can be accomplished safely. The use of free rectus abdominis myocutaneous flap is one of a useful maneuver for chronic empyema with fistula.     

Hepatic Kupffer cell blockade reduces mortality of acute hemorrhagic pancreatitis in mice

BACKGROUND: Recovery of upper aerodigestive tract function after reconstruction of segmental oromandiblectomy defects is frequently incomplete. The purpose of this study was to quantitate postreconstruction function and define variables that predict functional outcome in this population. METHODS: A prospective study of 21 patients who underwent microvascular free tissue transfer reconstruction of segmental oromandibular defects was performed. Measures of swallowing, speech, bite, and oral intake were performed preoperatively and at 1, 3, 6, and 12 months postoperatively or until plateau. Preoperative versus maximal postoperative measures were compared and correlated with nine potentially predictive variables. Univariate and multivariate analyses were performed to determine the most significant predictive factors. RESULTS: Baseline function in the study population was abnormal. Postoperative bite force improved, but swallowing, speech, and oral intake were worse than preoperative. Significant (univariate) predictors of outcome included diagnosis of cancer, tongue resection, pharynx resection, and flap skin paddle area. Only tongue resection remained significant in multivariate analysis. CONCLUSIONS: Increasing need for oropharyngeal lining replacement, especially after tongue resection, is the most important predictor of functional outcome in reconstruction of segmental mandible defects.     

A review of 716 consecutive free flaps for oncologic surgical defects: refinement in donor-site selection and technique

Free-tissue transfer has become an important method for reconstructing complex oncologic surgical defects. This study is a retrospective review of a 10-year experience with 716 consecutive free flaps in 698 patients. Regional applications included the head and neck (69 percent), trunk and breast (14 percent), lower extremity (12 percent), and upper extremity (5 percent). Donor sites included the rectus abdominis (195), fibula (193), forearm (133), latissimus dorsi (69),jejunum (55), gluteus (28), scapula (26), and seven others (17). Microvascular anastomoses were performed to large-caliber recipient vessels using a continuous suture technique; end-to-end anastomoses were preferred (75 percent). Flaps were designed to avoid the need for vein grafts. Conventional postoperative flap monitoring methods were used. These included clinical observation supplemented by Doppler ultrasonography, surface temperature probes, and pin prick testing. Buried flaps were either evaluated with Doppler ultrasonography or not monitored. The overall success rate for free-flap reconstruction of oncologic surgical defects was 98 percent. Fifty-seven flaps (8 percent) were reexplored for either anastomotic or infectious problems. Reexplored flaps were salvaged in 40 cases (70 percent). Surviving flaps resulted in a healed wound and did not delay postoperative radiation or chemotherapy. The incidence of major and minor postoperative complications was 34 percent. The mean duration of hospitalization was 20 days, and the average cost was $40,224. The results of this study support the need for only seven donor sites to solve the majority (98 percent) of oncologic problems requiring microsurgical expertise. The evolution of preferred donor sites for specific regional applications is illustrated in this 10-year experience. Technical refinements have simplified performing the microsurgical anastomoses and essentially eliminated the need for vein grafts. Conventional monitoring has led to the rapid identification of vascular compromise and subsequent flap salvage in the majority of non-buried free flaps.     

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.     

Evaluation of optimal measuring site and index by QDR4500A for postmenopausal bone loss]

Adjuvant therapy and microsurgery have allowed advances in surgical extirpation of lower extremity neoplasms. This retrospective study was designed to evaluate the microvascular transfer for lower extremity reconstruction in patients receiving pre- or post-operative irradiation and chemotherapy alone and in combination. Over a 5-year period, 24 free tissue transfers were performed in 22 patients undergoing surgical resection with adjuvant therapy for lower extremity neoplasms. There were 13 male and 9 female patients with an average age of 51 years. The latissimus dorsi muscle was most commonly transferred (N = 15). Eighteen tumors received pre- and three received postoperative radiotherapy. Two tumors received a combination of radiotherapy and brachytherapy. Pre- and/or postoperative chemotherapy was used in 14 patients. Twelve of these patients had both chemo- and radiation therapy. A total of six complications occurred, with no flap loss. Complications were evenly distributed among adjuvant regimens. All patients who underwent attempted limb salvage were able to ambulate postoperatively, except for 1 patients who had local recurrence. In conclusion, adjuvant therapy did not increase the complication rate for free tissue transfer in the lower extremity. Adjuvant therapy did not require alterations in the free tissue transfer and, similarly, free tissue transfer did not alter adjuvant therapy. We believe that free tissue transfer in complicated wounds allows for better wound healing with adjuvant therapy rather than local or primary wound closure alone.     

ACL reconstruction in children with open physes

Flap reconstruction of the vulva and vagina following gynecological ablative procedures has become an integral part of the management of gynecological oncology patients. The benefits of flap reconstruction, including early primary healing, improved cosmesis over skin grafting, and prolonged secondary wound healing, have been well accepted. Additionally, the creation of a neovagina or neovulva often restores the sexual function and positive body image of the patient lost to radical procedures. The gracilis musculocutaneous flap has been used extensively in flap reconstruction but reports of partial flap necrosis and the need for extensive dissection of both thighs have led to alternative flap choices. The rectus musculocutaneous flap, with its hardier cutaneous blood supply, is often too bulky and difficult to inset delicately around the preserved urethral and vaginal cuff. The umbilicus has the required soft tissue, and its conically contoured depression allows for delicate insetting of the rectus abdominis musculocutaneous flap around the urethral cuff. We present 2 patients who underwent vertical rectus musculocutaneous flaps with umbilical soft tissue to restore urinary function and to create a cosmetic nonfunctional vagina.     

Cabin 1, a negative regulator for calcineurin signaling in T lymphocytes

Rectus femoris surgery was performed on 70 patients with cerebral palsy and stiff-knee gait. Fifty-three patients underwent distal rectus transfer, and 17 patients had distal rectus release with complete muscle mobilization. Gait analysis was performed preoperatively and postoperatively at a minimum of 1 year. Swing-phase peak knee flexion (PKF) was improved in the transfer group, allowing improved foot clearance and more efficient gait (p = 0.04). PKF in swing deteriorated slightly in the release group (p = 0.04). The presence of abnormal swing-phase electromyogram (EMG) activity in the rectus alone or abnormal combined rectus and vastus lateralis activity did not influence the PKF results in either surgery (p < 0.05). The Ely test had no predictive value in identifying patients with abnormal EMG activity (p > 0.05). Preoperative knee range of motion was not a significant variable in determining relative success of rectus surgery. No deleterious effects were observed in stance phase in either group (p > 0.05).     

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.     

Combined radiochemotherapy for organ preservation in head and neck cancer: review of literature and personal experience

Combined radiochemotherapy is the most common method aimed at improving the rate of clinical response in advanced head and neck cancer. Complete clinical remission may correspond to a significant percentage in organ and/or function preservation. In 1992 a protocol of concomitant radiochemotherapy with continuous infusion of carboplatin for 14 consecutive days at the daily dose of 30 mg/m2 and concomitant radiotherapy with conventional fractionation (1.8 Gy to a total 65-70Gy) was started. Over a 3-year period, 56 patients with advanced head and neck cancer, were treated. In view of organ preservation, 26 patients of this series, though with considerable extent of the disease at diagnosis, were considered candidates for radical surgery: oral cavity 9 patients; oropharynx 9 patients; larynx/hypopharynx 8 patients. A single patient was stage I (hypopharynx); most patients were stage III (7) and IV (17 = 65%); T4 20%, N3 23%. 17/20 patients (70%) showed complete clinical response, 6 partial clinical response with a single non responder (overall response 95%). A patient underwent total glossectomy followed by local recurrence and another patient underwent pharyngolaryngectomy also followed by recurrence. After a mean follow-up from 22 to 60 months, 9 patients were still free of disease (37.5%). Median duration of complete response was 25.6 months. Overall median survival was 26.7 months: 38 months in responders. 2-year survival of patients with complete response was 59%. As for organ preservation, at present 6 over 18 patients (33%) with tumor of the oral cavity or oropharynx and 3 patients with tumors of larynx/hypopharynx have preserved organ and function. As for complete responders, 54.5% of those with tumors of oral cavity or oropharynx and 50% of those with tumors of larynx/hypopharynx, have preserved anatomy and function after at least 2-year follow-up. To-date, in follow-up controls relevant late toxicity has not been observed, showing that to the positive anatomical result corresponds the functional preservation of single structures.     

Effect of estradiol on behavioral reactions of female non-mature rats

A recent series of 25 patients who underwent reconstruction of Gustilo IIIB lower extremity wounds with rectus abdominis muscle transplants is presented. Complications include one flap loss and one donor site skin incision dehiscence. At follow-up, a majority of patients were ambulatory and a third employed in some fashion. Comparison with a historical group of patients demonstrates continued improvement in surgical results.     

Reconstruction of pelvic exenterative wounds with transpelvic rectus abdominis flaps: a case series

Exenterative pelvic surgery is commonly performed for advanced carcinoma of the cervix and selected cases of locally advanced colorectal cancers. Low-lying lesions that are locally invasive in contiguous organs require resection of the perineal body en bloc with the resected specimen. The resulting defect, both in the pelvis and the perineum, creates a difficult management problem. Dead space in the pelvis, especially with adjunctive irradiation, leads to delayed wound healing and prolapse of small bowel into the pelvis. Small bowel obstruction and/or fistula formation are the greatest sources of morbidity in the operative group. Fifteen patients underwent exenterative pelvic procedures (total exenteration, 1 patient; posterior exenteration, 8 patients; abdominoperineal resection, 6 patients). All patients were reconstructed by transpelvic placement of the rectus abdominis muscle (muscle only, 4 patients; muscle with skin grafting, 8 patients; musculocutaneous, 3 patients). Eighty-seven percent received radiation therapy. One patient had Crohn's disease and all others had carcinoma. Healing was complete in 12 of 15 patients at discharge. There were no complications related to pelvic dead space (i.e., bowel obstruction, perineal fistula), with a mean follow-up time of 24.3 months. Small bowel was effectively excluded from the pelvis to the level of the acetabular roof by computerized axial tomography scan. The transpelvic rectus abdominis muscle flap is effective in preventing major morbidity after exenterative pelvic surgery.     

Cranioplasty with neovascularized autogenous calvarial bone

We have presented two cases of cranioplasty with neovascularized autogenous calvarial bone. A surgical procedure applying the principle of flap prefabrication has been applied to the preservation of autogenous calvarial bone obtained during external cranial decompression. The rectus abdominis muscle flap was elevated. A subcutaneous pocket was prepared for preservation of calvarial bone integrated with the rectus abdominis muscle. The outer cortex of calvarial bone was removed partially by bone chiseling. The muscle flap was attached to the bone graft by means of two holes on the bone by suture. The calvarial bone, grafted onto the rectus abdominis muscle flap, was inserted into the subcutaneous pocket. Several weeks later, the neovascularized calvarial bone flap was dissected along with inferior epigastric pedicle. Cranioplasty was performed using the bone element of the flap. Revascularization was achieved by anastomosing the inferior epigastric vessels to the temporal vessels. The postoperative films demonstrated marked radiolucency at the borders of the flap, although bone scan documented that the flap was vascularized. We speculate that the transferred bony segment was not completely vascularized.     

Microsurgical treatment of intramedullary spinal cord tumors

Eighty patients with intramedullary spinal cord tumors were treated by microsurgical methods between 1988 and 1996. Twenty-nine patients were diagnosed with astrocytoma, 36 with ependymoma, five with metastasis, four with lipoma, three with dermoid or epidermoid tumor, two with neurofibroma, and one with neuroma. Vascular and infectious lesions (such as abscesses and hemangioblastomas) were excluded. After laminectomy, total removal of the lesion was achieved in 68 of 80 patients and subtotal removal in 12. Postoperative radiation therapy was performed in 13 of 80 patients. The follow-up period ranged from 12 to 92 months (mean 42.2 months). All patients underwent preoperative and postoperative magnetic resonance imaging at intervals ranging from 3 months to 5 years postoperatively. Four patients showed clinical and radiological evidence of local tumor recurrence during the follow-up period. Four patients died 5 months to 15 months postoperatively from the re-expansion of their primary metastatic disease. The operative results at long term (after the 6th postoperative month) were better than the results at short term (before the 6th postoperative month) and revealed clinical improvement in 63, no change in 10, and deterioration in seven patients. We recommend early radical surgery, whenever possible, to be performed when the patient's neurological status is still good. Subtotal removal and irradiation are better for malignant or metastatic tumors. Partial decompressive removal is best for large intramedullary lipomas. Plastic laminotomy with preservation of the intervertebral joints is especially recommended in young or middle-aged patients.     

Use of ultrasonography to evaluate muscle thickness and blood flow in free flaps

The purpose of this study was to investigate the common belief that a microvascular transfer of a non-innervated free muscle flap loses muscle bulk over time. Sixteen patients (latissimus dorsi = 8, rectus abdominis = 7, and gracilis muscle = 1) were evaluated an average of 41 months after free flap transfer. Latissimus dorsi and lower extremity flaps displayed significantly more swelling than the other flaps. Flap bulk was measured by ultrasound. The mean thickness of upper extremity flaps was 10.3 +/- 1.8 mm (control muscles 11.8 +/- 2.8), lower-extremity 14.5 +/- 3.7 mm (control muscles 10.9 +/- 0.7), latissimus dorsi 14.3 +/- 2.2 mm (control muscles 10.3 +/- 0.8, P = 0.018), and rectus abdominis 11.2 +/- 1.2 mm (control muscles 12.4 +/- 1.9). Color Doppler ultrasonography was used to detect the pedicles of the free flaps and also to measure the peak velocity of blood flow intramuscularly and in the pedicles. In the upper extremities (n = 5) the pedicles could be found in only 20% of cases whereas in the lower extremities (n = 11) 91% of pedicles were located. (P = 0.013). Peak flow within the free flaps was significantly higher in the lower extremity (50% of the peak flow of the common femoral artery) than in the upper extremity (5% of the peak flow of the common femoral artery, P = 0.013). This study demonstrated that non-innervated free muscle flaps in the extremities maintain the original muscle thickness, although lower extremity and latissimus dorsi flaps have a trend to be thicker. Most pedicles of free muscle flaps in the upper extremities could not be located by ultrasound. However, flaps in the lower extremities most often have patent pedicles and also more vigorous intramuscular blood flow.     

Free tissue transfer in the management of burns

Although the majority of burn wounds undergoing surgical treatment require only excision with split-skin grafting, the introduction of free microvascular tissue transfer has allowed for the preservation of otherwise unsalvageable deep burn injuries and the resurfacing of burn scars in areas with no available local tissue. A total of 1699 patients with burn injuries were admitted to the Burns Unit in Newcastle upon Tyne in the 5 years 1989-1993. During this period 604 patients (35.5 per cent) required surgical treatment of their burns. Of these patients 582 (96.4 per cent) underwent excision of their burns with split-skin grafting, 13 (2.1 per cent) of the patients required local flap cover and nine patients (1.5 per cent) had free tissue transfer. Free flap loss in this study was 22 per cent in burns patients as compared to only 3 per cent in patients undergoing microsurgical reconstruction for other reasons.     

Dermal autografts for fascial repair after TRAM flap harvest

To find an alternative to synthetic mesh closure of abdominal fascial defects after transverse rectus abdominis musculocutaneous (TRAM) flap harvest, dermal autografts were removed from tissue to be discarded and used for fascial closure. Dermal grafts have been used for herniorrhaphy and fascial repair after TRAM harvest previously, but have never been systematically studied. The dermal autograft technique was used in 24 patients to repair or reinforce anterior rectus sheath or external oblique fascia after TRAM harvest for breast reconstruction. During the same period, 25 other patients underwent TRAM breast reconstruction with abdominal wall closure by other methods. All patients were followed by serial physical examinations given by the operating surgeon. Average follow-up in the dermal autograft group was 12.6 versus 12.0 months in the second group. In the dermal autograft group, two patients complained of bulging of the anterior abdominal wall; one developed a true hernia, away from the location of the dermal autograft. In the second group, two patients experienced bulging. Wounds and infectious complications were similar in both groups. Dermal autografts are a useful alternative to mesh repair or direct closure of fascial defects after TRAM flap harvest.     

Reinnervated lateral antebrachial cutaneous neurosome flaps in oral reconstruction: are we making sense?

Eight patients who underwent a partial glossectomy and associated floor of the mouth resection for squamous cell carcinoma were reconstructed with a sensate radial forearm flap in which the lateral antebrachial cutaneous nerve was anastomosed to the (divided) lingual nerve. The patients were compared prospectively with matched controls who received noninnervated forearm flaps for the same defect. A "blinded" therapist performed detailed sensory testing at least 6 months following surgery. In all modalities examined, the sensate proved superior to the nonsensate flap and not statistically different from the opposite side of the tongue. Two-point discrimination and pressure sensitivity were much greater in the innervated forearm flaps than in the forearms from which they came. The results are discussed with reference to the density of sensory receptors, the degree of cortical representation, and the subcortical anatomy of the neurosensory tracts. It appears that the density of sensory receptors is not directly related to the sensory potential in a given tissue transfer and that this potential is more related to the cortical fidelity of the recipient nerve. A historical matched cohort of 10 patients receiving pectoralis flaps for similar defects also was examined. Although the follow-up was longer, reinnervation was of a very low order--even worse than with noninnervated forearm flaps. This work supports the concept that sensory reinnervation should be attempted whenever possible following ablative oral surgery. This would include suture or grafting of major sensory nerves as well as the reinnervation of flaps.     

Intracerebral hemorrhage more than twice as common as subarachnoid hemorrhage

A review of pre- and postoperative prone knee flexion (PKF) data after isolated hamstring tenotomy for 52 patients with cerebral palsy (CP) at an average follow-up of 3 years 4 months showed the frequency of diminished knee flexion to be 71%. Twenty-three percent of the knees actually had improved flexion, whereas 6% were unchanged. On the average, patients' flexion decreased 14.4 degrees from a preoperative PKF of 131.5 degrees to 117.1 degrees postoperatively (p < 0.0001). Only 11.5% of patients had PKF < 90 degrees at most recent follow-up, however; only 1.9% had PKF < 60 degrees. Thirteen percent of ambulators eventually required a rectus femoris transfer to correct "stiff-legged gait."