Overview of the rectus abdominis myocutaneous flap in head and neck reconstruction

OBJECTIVES: To examine the current in-patient respite service in terms of the type of patient served, whether their care could be provided satisfactorily outwith hospital and whether hospital resources could be used more efficiently. DESIGN: Multi-disciplinary assessment of subjects and completion of recording form. SETTING: Inverclyde and Renfrew, Scotland (population 288,000). SUBJECTS: All elective respite admissions to Merchiston Hospital during the period 1.1.93 to 31.12.93. RESULTS: Twenty-six patients received respite care in the period studied. Seventy-three per cent had severe/profound handicap, and all had at least one additional problem to their learning disability. We found the majority (73%) would require extra nursing care in hospital. Current social work respite placements do not cater for this level of disability. Respite bed occupancy rates are lower during the week than at the weekend. CONCLUSIONS: Most patients receiving respite care in our hospital are a highly dependent group whose needs cannot be met by local social work services. There is a need for more accurate planning of respite provision to maximise the efficient use of beds.     

Pectoralis major myocutaneous flap for reconstruction of defects following resections in head and neck area

Pectoralis major myocutaneous flap (PMMF) has become the standard for reconstruction of major defects in head and neck area. Eleven cases, operated over a three year period, in which PMMF was used for reconstruction have been reviewed retrospectively. Nine patients had oral squamous cell carcinoma, one had a basal cell carcinoma of the external ear and one had lost skin and soft tissue of neck following synergistic gangrene. Ten of the eleven flaps survived (success rate 91%). One of the three rib grafts used to reconstruct mandible got infected and had to be removed. Three patients developed wound infections and one had a temporary orocutaneous fistula which closed spontaneously. This brief experience confirms the reliability and efficiency of PMMF for head and neck reconstruction.     

Free innervated latissimus dorsi muscle flap for reconstruction of full-thickness abdominal wall defects

The aim of this study was to develop a maturation protocol for immature oocytes and assess the protocol with cryopreserved oocytes. Nuclear maturation (mature spindle and aligned chromosomes) occurred irrespective of the treatment regime: 71-89% of oocytes matured in vitro had a normal spindle and chromosomes compared with 87% matured in vivo. Fertilization rates were not significantly different from those of in-vivo matured oocytes. Of the maturation treatment regimes investigated, the initial treatment producing best development to blastocyst (cytoplasmic maturation) involved a 2 h incubation in standard maturation medium (SMM) containing 7.5 IU follicle stimulating hormone (FSH) followed by 14 h in SMM plus 7.5 IU FSH:luteinizing hormone with follicular cells [62% (range 49-69)]. The addition of 1 ng/ml epidermal growth factor (EGF) in this protocol resulted in development [75% (range 71-81)] that was not significantly different from in-vivo matured oocytes [82% (range 73-90)]. Exposure of the oocytes to 1.5 M dimethylsulphoxide (DMSO) did not affect fertilization or development rates. Following a slow-cool/thaw freezing regime, 81% (range 74-89) of the oocytes were morphologically normal, i.e. had a spherical shape with an intact zona and oolemma; they had, however, lost their previously attached cumulus and corona cells. Maturation of frozen-thawed oocytes in the presence of EGF gave good fertilization rates but poor development rates [80% (range 77-86) and 37% (range 33-40) respectively]. In conclusion, the best maturation, both nuclear and cytoplasmic, occurred in the presence of a combination of gonadotrophins, EGF and follicular cells. Oocytes cryopreserved using a slow-cool/thaw regime can be matured to produce blastocysts after in-vitro fertilization.     

The transversus and rectus abdominis musculoperitoneal (TRAMP) composite flap for vulvovaginal reconstruction

The transversus and rectus abdominis musculoperitoneal (TRAMP) flap, a novel composite flap supplied by the deep inferior epigastric vessels, was used successfully for partial vulvovaginal reconstruction following anterior and posterior exenteration. The full potential of the TRAMP flap in vulvovaginal reconstruction is being investigated further.     

A method that preserves circulation during preparation of the pectoralis major myocutaneous flap in head and neck reconstruction

The present article describes a method that preserves circulation during the preparation of the pectoralis major myocutaneous flap used in head and neck reconstruction. The major disadvantage of this flap is its poor circulation and consequent partial necrosis. To solve this problem, we analyzed the circulation and hemodynamics of the pectoralis major myocutaneous flap (the perforator of the anterior intercostal branch located about 1 to 2 cm medial to the areola in the fourth intercostal space is important), evaluated the safe donor sites in the chest wall for a skin island (the perforator is included on the skin island's central axis), improved the surgical procedure for elevating flaps (for preventing perforator injuries), and devised a means to transfer flaps, thereby increasing the range of the flaps (the transfer route is under the clavicle). Using this technique, head and neck reconstruction was performed on 62 patients. The diagnosis included oral cancer (21), oropharyngeal carcinoma (10), parotid carcinoma (10), hypopharyngeal carcinoma (9), and other head and neck malignant tumors (12). Of these, partial or marginal necrosis of the flap caused by circulatory problems was detected in three patients (5 percent). Using our method, the problems associated with inadequate circulation in the pectoralis major myocutaneous flap were greatly alleviated, thus reconfirming the usefulness of this flap in head and neck reconstruction.     

A modification of the bladder flap of Boari for the management of defects of the distal ureter (author's transl)

The results of the management of defects of the distal ureter of various causes with a bladder flap of Boari including the anti-reflux implantation of the ureter in 65 patients are reported. 50 patients had prior gynaecological operations. The other 15 patients had prior urological operation, inflammations (tuberculosis), tumors or anomalies of the ureter. The follow-up time ranges from a few weeks to five years and 80-90% of the patients were cured. 24 of these patients had prior malignant tumors.     

Expanded unilateral forehead flap (sail flap) for coverage of opposite forehead defect

This report details our experience with five patients who had skin defects of their forehead that were covered with an expanded unilateral forehead flap from the contralateral side that we call the sail flap. Skin expansion provides an ideal thin flap for the forehead aesthetic unit. The viability of the sail flap is sufficient through expansion, and it is available in suitable size and shape for the defect. The donor site is minimal and well accepted because the scar coincides with the hairline.     

Three-dimensional reconstruction of types IV and V midfacial defects by free rectus abdominis myocutaneous (RAM) flap

A 25-year old woman with rapid HIV disease progression had been receiving zidovudine (ZDV) for two years, when she became pregnant. She had a high viral load and carried out zidovudine-resistant viral strains. For these reasons, and with the main objective to maximally reduce viremia, the association of DDI to ZDV was introduced a few weeks before delivery. The virological follow-up for one year has confirmed the lack of HIV infection in the child. Combined antiretroviral therapy during the last weeks of pregnancy might be considered for the prevention of vertical transmission of HIV in cases of high risk of newborn infection, without adding relevant toxicity.     

Rectus abdominis muscle flap (RAMF) technique for the management of bladder exstrophies: late clinical outcome and urodynamic findings

OBJECTIVE: To investigate the efficacy of the rectus abdominis muscle flap (RAMF) technique for the closure and augmentation of small, non-compliant bladder exstrophies. PATIENTS AND METHODS: The RAMF technique was used in two girls and two boys (mean age at operation, 31.7 months, range 3-72) with bladder exstrophy. The clinical outcome and urodynamics were assessed during a follow-up of 29 months to 6 years (mean 49.2 months) and included imaging, cystoscopy, biochemical and microbiological studies. RESULTS: There were no urinary tract infections, metabolic problems or electrolyte disturbances and kidney function remained normal in all patients. Radiography confirmed intact function and anatomy of the urinary tract and cystoscopy showed complete coverage of the inner peritoneal layer of RAMF with uroepithelium. No stone formation or mucus production were detected. Currently, three patients void using clean intermittent catheterization through the native urethra and the fourth through an appendiceal Mitrofanoff valve. However, the bladder volume was insufficient at the late follow-up and three patients required bladder augmentation. CONCLUSIONS: The RAMF technique is a good alternative for closing bladder exstrophies and achieves an increase in bladder capacity; however, although there is a mild improvement in bladder capacity and compliance. RAMF should not be used as a bladder augmentation procedure. The technique is indicated in the closure of large bladder defects, bladder exstrophies with small, inelastic, non-compliant bladder remnants and failed primary closures.     

Circumferential forearm fasciocutaneous free flap reconstruction of forequarter amputation/chest wall resection using simultaneous extra-anatomic revascularization (SEAR)

In recent years, many cytokines have been defined and some of them used clinically. In hematological malignancies, cytokines, including granulocyte colony-stimulating factor (G-CSF), have been widely used for leukopenia after chemotherapy. However, in acute myelogenous leukemia (AML), some leukemic cells may be induced to proliferate by these cytokines and they must be used with care. In this study, we have investigated cell reactivity and proliferation with G-CSF, granulocyte-macrophage colony-stimulating factor (GM-CMF), macrophage colony-stimulating factor (M-CSF), stem cell factor (SCF) and thrombopoietin (TPO) in cases of AML. We have also investigated the reactivity of some myeloid leukemia cell lines to TPO. G-CSF, GM-CSF, M-CSF, SCF and TPO caused proliferation of leukemic cells in 25%, 58.3%, 8.3%, 21.1% and 0% of cases, respectively. Because of this result, the use of G-CSF in AML should be regarded as potentially hazardous. TPO did not cause proliferation of leukemic cells in any case of AML, or in cell lines except MO7E, which is a megakaryocytic cell line. This result suggests that TPO might cause proliferation of some megakaryocytic leukemia cells. We cannot conclude that TPO does not cause proliferation of other AML cells, as the number of cases was small and it has been reported elsewhere that leukemia cells may proliferate when exposed to TPO in 50% of AML cases. Reactivity of AM L cells to TPO is an important factor when deciding the indications of TPO in AML and myelodysplastic syndrome.     

The amino acid sequences of two acylphosphatase isoforms from fish muscle (Lamna nasus)

Two acylphosphatase isoenzymes have been purified from Lamna nasus muscle, and their complete amino acid sequences have been determined. The former (E1) consists of 99 amino acid residues, while the latter (E2) consists of 102 residues. Both are acetylated at their N termini. E1 has the FFRK active site motif characteristic of all common-type acylphosphatase isoenzymes, whereas E2 contains the CFRM active site motif characteristic of all muscle-type acylphosphatase isoenzymes. They have quite similar kinetic properties. The comparison of sequences of fish E1 and E2 isoenzymes with other known mammalian and bird acylphosphatases reveals that the E2 isoenzyme has an N terminus tail, four residues long, similar to those previously found in all known bird species muscle-type isoenzymes. Among organ-common-type acylphosphatases about 50% of residues are completely conserved, whereas about 60% of muscle-type acylphosphatase residues are completely conserved, indicating that the latter type of isoenzyme has a slower evolutionary rate than the former. The sequences of E1 and E2 acylphosphatases from L. nasus represent the first primary structures of this kind of enzyme determined among fish species.     

Age dependent possibilities for healing in cartilage injuries (experimental investigations with animals) (author's transl)

Regenerative and degenerative changes of cartilage were studied in animals by micromorphological methods and autoradiography. Cartilage lesions of defined size were set in the femoral condyle of rabbits of variing age by means of an electrical drill developed by us. We used juvenile animals, 3 months old, and senile animals 4 years old. The lesions were studied by lightmicroscopy, electronmicroscopy and scanning electron microscopy. In young animals we were able to demonstrate prevailing reparative changes after injury and the potency for genuine regeneration originating from cartilage. Isolated chondral lesions develop reactive tissue originating mainly from superficial parts of the cartilage. When subchondral bone is exposed we see granulation tissue filling up the defect and change by metaplasia. The replacing tissue originating from superficial cartilage as well as from subchondral bone is able to fill the defect within 3 months. In the replacing tissue originating from cartilage we find fibroblasts and fibrocytes with many mitoses. Consecutively the cells are rounding increasingly. Finally chondrocytes are developing. At the same time as these reparative changes occur we see degenerative changes with decreased mucopolysaccharide synthesis, cell necroses with consecutive decrease in number of cells and singular small cluster. In old animals we could not demonstrate any reparative or regenerative changes after injuries; the artificial defect in cartilage persists. Instead, degenerative changes with signs of arthrosis are developing rapidly: chondroitin sulfate synthesis is decreased, there is ample cluster formation, cell necrosis, decrease in number of cells, and incorporation of paraplasmatic substances in cartilage. We could not demonstrate any mitoses. The causes for the inability of cartilage of aged individuals for reparative changes are discussed.     

Tissue preparation in combined scapula flap for microsurgical reconstruction of defects of the oromaxillofacial area]

Nowadays, in congenital or acquired large oro-maxillofacial defects microsurgical reconstruction is mainly performed by revascularized osseous, osteocutaneous, or osteomyocutaneous distant flaps. The aim of reconstruction includes not only restoration of stable continuity and esthetic contour, but also the restoration of a functioning "chewing organ". For reconstruction in maxillary and midface defects, we prefer the scapular flap for a single-step reconstruction. Tissue prefabrication results in osseointegrated implants and thin mucosal linings with stable soft tissue conditions at the time of microsurgical reconstruction. Following dental restoration, full oral function is given. This single-stage procedure improves the psychosocial situation of the patient considerably when compared with conventional multi-stage reconstruction.     

Anatomical basis of the variable aspects of injuries of the axillary nerve (excluding the terminal branches in the deltoid muscle)

The course of the axillary n. is complex with three points of angulation that may be used to delineate four segments and a fifth segment that corresponds to the intramuscular ending of the nerve in the deltoid m. The purpose of this study was to determine the precise anatomy of the nerve and of its branches, and some morphologic features for each segment. Thirty-two shoulders from embalmed adult cadavers have been studied. The axillary n. was divided in five segments: 1) from its origin to the inferior border of the subscapularis m., 2) from the subscapularis m. to the anterolateral border of the tendon of the long head of the triceps brachii m., 3) from the triceps to the posteromedial part of the surgical neck of the humerus, 4) from the humerus to the entry into the deltoid m., 5) the intramuscular distribution of the nerve in the deltoid m. In each segment from 1 to 4 were noted the origins of the branches to the subscapularis and teres minor mm. and to the scapulohumeral joint, and the origins of the lateral cutaneous branchial n. and of the terminal motor branches to the deltoid m. The length and the diameter of the nerve in the segments and the distance from the segment S1 to the musculotendinous junction of the subscapularis m. were measured. The results showed that the mean diameters were about 4.1 mm in segment 1, 4.1 mm in segment 2 and 3.4 mm in segment 3. The mean distance to the musculotendinous junction was 7.7 mm. Many variations in the levels of origin of the different muscular, articular or cutaneous branches were found without symmetry between the right and left sides. The lateral cutaneous brachial n. was absent in four cases. The results are compared with those in the literature. The division into five segments is proposed to radiologists and surgeons for evaluation or operative procedures on the axillary n., and to provide a hypothesis about the variable aspects of injuries of the nerve.