Showing papers in "Plastic and Reconstructive Surgery in 1986"

Early microsurgical reconstruction of complex trauma of the extremities.

Abstract: Five hundred and thirty-two patients underwent microsurgical reconstruction following trauma to their extremities. They were divided into three groups for the purpose of review. Group 1 underwent free-flap transfer within 72 hours of the injury, group 2 between 72 hours and 3 months of the injury, and group 3 between 3 months and 12.6 years, with a mean of 3.4 years. The results were analyzed with respect to flap failure, infection, bone-healing time, length of hospital stay, and number of operative procedures. The flap failure rate was 0.75 percent in group 1, 12 percent in group 2, and 9.5 percent in group 3 (p less than 0.0005 early versus delayed; p less than 0.0025 early versus late). Postoperative infection occurred in 1.5 percent of group 1, 17.5 percent of group 2, and 6 percent of group 3. Bone-healing time was 6.8 months in group 1, 12.3 months in group 2, and 29 months in group 3. The average length of total hospital stay was 27 days for group 1, 130 days for group 2, and 256 days for group 3. The number of operations averaged 1.3 for group 1, 4.1 for group 2, and 7.8 for group 3.

The osteocutaneous scapular flap for mandibular and maxillary reconstruction.

Abstract: Microfil injections in 8 cadavers and clinical experience with 26 patients have demonstrated a reliable blood supply to the lateral border of the scapula based on branches of the circumflex scapular artery. This tissue has been used successfully for reconstruction of a variety of defects resulting from maxillectomy and mandibular defects from cancer and benign tumor excisions. Advantages of this tissue over previous reconstructive methods include the ability to design multiple cutaneous panels on a separate vascular pedicle from the bone flap allowing improvement in three-dimensional spatial relationships for complex mandibular and maxillary reconstructions. The lateral border of the scapula provides up to 14 cm of thick, straight corticocancellous bone that can be osteotomized where desired. The thin blade of the scapula provides optimum tissues for palate and orbital floor reconstruction. There have been no flap failures and minimal donor-site complications.

The radial forearm flap in intraoral reconstruction: the experience of 60 consecutive cases.

Abstract: Sixty consecutive patients in whom a free radial forearm flap was used to reconstruct an intraoral defect have been reviewed. The ages ranged from 54 to 85 years, the majority of patients presenting with intraoral carcinoma. There were 6 microvascular failures, and the remaining 54 patients (90 percent) healed uneventfully, with no incidence of fistula. Intraoral healing time was reduced to 11 days on average, and hospitalization was similarly reduced to 17.8 days. A slower postoperative recovery did not appear to be related to age or to the site of the defect within the oral cavity but closely paralleled the extent of excisional surgery. The postoperative mortality was less than 2 percent, but the overall prognosis remained poor, with a 21.6 percent mortality at follow-up (minimum 15 months). Thirty-nine patients (72 percent) underwent early postoperative radical radiotherapy without any evidence of intraoral wound breakdown or problems with flap viability. The results demonstrate the effectiveness of this method of intraoral reconstruction and indicate that such complicated and prolonged surgical techniques do not increase the risks associated with major head and neck surgery.

Fibular osteoseptocutaneous flap: anatomic study and clinical application.

Abstract: The vascularized fibular graft has been expanded to an osteoseptocutaneous flap by including a cutaneous flap on the lateral aspect of the lower leg. The cutaneous flap can serve not only for postoperative monitoring of the grafted fibula, but also as extra skin coverage to replace substantial skin defects or prevent tight closure of the wound. From anatomic studies of 20 cadaver legs and 15 clinical cases, it has been possible to demonstrate adequate circulation to the skin of the lateral aspect of the lower leg from the septocutaneous branches of the peroneal artery alone. This finding has allowed the development of a new concept and technique to elevate the fibula as an osteoseptocutaneous flap for reconstruction which provides the following advantages: Elevation of the fibular osteoseptocutaneous unit is easy and fast. The cutaneous flap of the fibular osteoseptocutaneous unit can slide almost freely while attached to the paper-thin posterior crural septum without being tethered by a bulky muscle cuff, facilitating the setting of the fibular osteocutaneous flap when the bone and skin are widely separated. Intraoperatively, in a situation in which it is necessary to change from originally selected recipient vessels to ones more suitable, the thin posterior crural septum can be folded around the fibula allowing more flexibility in choice of recipient vessels. The fibular osteoseptocutaneous flap meets the criteria outlined for composite tissue reconstruction of defects of the extremities.(ABSTRACT TRUNCATED AT 250 WORDS)

Three-dimensional computer-assisted design of craniofacial surgical procedures: optimization and interaction with cephalometric and CT-based models.

Abstract: A computer program is described which aids the clinician in planning craniofacial surgical procedures. It operates on a three-dimensional landmark data base derived by combining posteroanterior and lateral cephalograins from the patient and from the Bolton normative standards. A three-dimensional su

Surgical anatomy and blood supply of the fascial layers of the temporal region.

Abstract: In 15 fresh cadavers (30 sides), we studied the two layers of fascia in the temporal region, with particular regard to their blood supply and to their usefulness--together or separately--as microvascular free-tissue autografts. The superficial temporal fascia (temporoparietal fascia, epicranial aponeurosis) lies immediately deep to the hair follicles. It is part of the subcutaneous musculoaponeurotic system and is continuous in all directions with other structures belonging to that layer--including the galea above and the SMAS layer of the face below. The deep temporal fascia (temporalis fascia, investing fascia of temporalis) is separated from the superficial fascia by an avascular plane of loose areolar tissue. It completely invests the superficial aspect of the temporalis muscle down to (but not beyond) the zygomatic arch. It is firmly attached to periosteum all around the margin of the muscles. Below it is attached to the upper border of the zygomatic arch. We found the deep temporal fascia to be supplied solely by the middle temporal artery, a constant branch of the superficial temporal. The middle temporal artery arises 1 to 3 cm below the upper border of the zygomatic arch, runs always superficial to the arch, and enters the deep temporal fascia immediately above that layer's attachment to the zygomatic arch. If the middle temporal vessels are protected, the two layers of temporal fascia can be raised together as a fully vascularized tissue island. This island can be fashioned as a bilobed or a double-layered flap, depending on the manner of dissection. The potential surgical usefulness of these findings is discussed.

Treatment of the painful neuroma by neuroma resection and muscle implantation.

Abstract: The successful treatment of the painful neuroma remains an elusive surgical goal. This report evaluates one approach to the management of this problem which entails neuroma excision and placement of the proximal end of the nerve away from denervated skin, away from tension, and into a well-vascularized environment: muscle. Seventy-eight neuromas in 60 patients with a mean follow-up of 31 months (range 18 to 43 months) were evaluated. Sixty-seven percent of these patients involved Workmen's Compensation and 57 percent had had at least one previous operation to treat their pain. The results demonstrated good to excellent results in 82 percent of the treated nerves in the entire group. Factors that were predictive of a poorer outcome were (1) digital neuroma (p less than 0.0005), (2) Workmen's Compensation (p less than 0.01), and (3) three or more previous operations for pain (p less than 0.01). Transposition of nerves into small superficial muscles or muscles with significant excursion resulted in treatment failures. The etiology and histopathology of treatment failures are reviewed. Treatment of radial sensory neuromas by transposition of the radial sensory nerve into the brachioradialis muscle when any associated injury to the lateral antebrachial cutaneous nerve was also treated, gave good to excellent relief of pain, and improved hand function in 88 percent of the patients.

Atypical hyperplastic lesions of the female breast: A long-term follow-up study

Abstract: A total of 10,542 breast biopsy specimens obtained between 1950 and 1968 were studied. Examples of atypical \"ductal\" (ADH) and atypical lobular hyperplasia (ALH), defined as having only some features of carcinoma in situ (CIS), were diagnosed in 3.6% of these specimens. In the same series, CIS was diagnosed in 1.7% of biopsy specimens excluding those with invasive cancer. The subsequent risk of invasive breast carcinoma after ALH or ADH was 4-5 times that of the general population. Follow-up was 90% successful and extended 17 years after biopsy. History of breast cancer in a mother, sister, or daughter doubled the risk of subsequent invasive carcinoma development (to 8 times for ALH and 10 times for ADH). The authors conclude that among the epithelial hyperplastic lesions of the human breast, a minority may be recognized by their resemblance to CIS which have a clinically significant elevation of subsequent breast cancer risk. This risk is one-half that of CIS.

Comparison of the effect of bacterial inoculation in musculocutaneous and fasciocutaneous flaps.

Abstract: The skin fascial flap is now recognized as a reliable flap for use in reconstructive surgery. The fasciocutaneous flap has been advocated for coverage of chronic infected wounds after debridement as an alternative to the musculocutaneous flap. Previous experimental and clinical studies have demonstrated the superior resistance of the musculocutaneous flap as compared to the random-pattern flap to bacterial inoculation. A canine model is presented for comparison of the effect of bacterial inoculation in fasciocutaneous and musculocutaneous flaps of similar dimensions. The area of skin necrosis secondary to bacterial inoculation was similar in these two flap types despite greater blood flow and skin oxygen in the fasciocutaneous flap. In a study of closed wound spaces formed by the deep surface of these two flap types, a greater degree of inhibition and elimination of bacterial growth and more collagen deposition are observed in the musculocutaneous wound space than in the fasciocutaneous flap.

Mechanisms of global support and posttraumatic enophthalmos: I. The anatomy of the ligament sling and its relation to intramuscular cone orbital fat.

Abstract: The mechanisms of posttraumatic enophthalmos were evaluated to determine the interrelation between fat and ligaments in globe support. Anatomic studies demonstrate that the ligaments form an essential "sling" framework for the globe but are alone insufficient to maintain the globe's full forward position. Removal of extramuscular fat in cadavers and in patients undergoing blepharoplasty did not significantly change globe position. Loss of intramuscular cone fat (atrophy or displacement) in cadavers and patients produced enophthalmos. Fat atrophy is not a prominent feature in most patients with posttraumatic enophthalmos. Some loss of intramuscular cone fat from displacement outside the muscle cone is frequently present. The principal mechanism, however, of posttraumatic enophthalmos involves a displacement and change in the shape of orbital soft tissue. Loss of bone and ligament support permits posterior displacement and a reshaping of orbital soft tissue under the influence of gravity and the remodeling forces of fibrous scar contracture. The shape of the retrobulbar orbital contents changes from a modified cone to a sphere, and the globe sinks backward and downward. Given that the volume of orbital soft tissue is constant following trauma, procedures to restore the shape and position of the orbital soft tissue by mobilization and bone reconstruction will correct or significantly improve enophthalmos.

Bony ankylosis of the temporomandibular joint: follow-up of 70 patients treated with arthroplasty and acrylic spacer interposition

Abstract: This paper presents the author's experience with interpositional arthroplasty using an acrylic cylinder in 70 cases of bony ankylosis of the temporomandibular joint. Ankylosis followed trauma in all but one patient. The diagnosis was established when restriction of mouth opening was associated with roentgenologic evidence of deformation of the condyle, obliteration of the joint space, and abnormal bone formation in and around the joint. The pathologic changes were classified into four types depending on severity, and each type influenced the treatment. Surgical treatment included creation of a transversely elliptical gap between the two bony components of the joint using a neurosurgical burr and perforator and a chisel through a preauricular approach and interposition of an acrylic cylinder. This maintained the gap, facilitated movement, and encouraged nonunion. The results following a long follow-up of 2 to 10 years showed uniformly good results with a range of mouth opening varying from 2 to 5 cm. Only three bilateral cases recurred and two others had a limited range of mouth opening, with interincisor distance varying from 2 to 2.5 cm.

Frontal Cranioplasty: Risk Factors and Choice of Cranial Vault Reconstructive Material

Abstract: A study of patients with large cranial defects involving the frontal bone, frontal sinus, nose, and orbit does not support the contention that there is a clear superiority of reconstructive material despite a history of previous bone infection. No patient with an isolated cranial reconstruction experienced an infection despite location in the area of the frontal sinus or the use of acrylic material. All patients experiencing infection underwent simultaneous reconstruction of the frontal cranium and nose and three- or four-wall reconstruction of the orbit, where the frontal sinus had previously been eliminated and where a previous bone infection had been present. Risk factors associated with cranioplasty were timing (p = 0.001) and cranial vault reconstruction in communication with previously infected ethmoid sinuses and the nose (p = 0.03). A history of previous bone infection suggests increased risk (p = 0.15). The choice of reconstructive material was not significant, although acrylic cranioplasties did not experience the complications expected from a review of the literature.

Capsular contracture: a prospective study of the effect of local antibacterial agents.

Abstract: In a prospective, random, double-blind, and concurrently controlled clinical study of 124 patients having augmentation mammaplasty, using multiple independent subjective judges as well as objective compressibility measurements, the use of a variety of local antibacterials in or around inflatable retromammary prosthetic implants reduced the early postoperative onset of class III to IV capsular contracture by sevenfold (85 percent) and the final incidence by more than half (50 percent) (p less than 0.01). We believe this study provides the most unequivocal evidence to date that the cause of capsular contracture in retromammary augmentation is periprosthetic bacterial contamination. Irrigation with a 5 percent povidone-iodine (50 percent Betadine) solution was as effective as other techniques and is currently our procedure of choice.

Effect of dietary enrichment with eicosapentaenoic and docosahexaenoic acids on in vitro neutrophil and monocyte leukotriene generation and neutrophil function

Abstract: The effects of dietary fish-oil fatty acids on the function of the 5-lipoxygenase pathway of peripheral-blood polymorphonuclear leukocytes and monocytes were determined in seven normal subjects who supplemented their usual diet for six weeks with daily doses of triglycerides containing 3.2 g of eicosapentaenoic acid and 2.2 g of docosahexaenoic acid. The diet increased the eicosapentaenoic acid content in neutrophils and monocytes more than sevenfold, without changing the quantities of arachidonic acid and docosahexaenoic acid. When the neutrophils were activated, the release of [3H]arachidonic acid and its labeled metabolites was reduced by a mean of 37 per cent, and the maximum generation of three products of the 5-lipoxygenase pathway was reduced by more than 48 per cent. The ionophore-induced release of [3H]arachidonic acid and its labeled metabolites from monocytes in monolayers was reduced by a mean of 39 per cent, and the generation of leukotriene B4 by 58 per cent. The adherence of neutrophils to bovine endothelial-cell monolayers pretreated with leukotriene B4 was inhibited completely, and their average chemotactic response to leukotriene B4 was inhibited by 70 per cent, as compared with values determined before the diet was begun and six weeks after its discontinuation. We conclude that diets enriched with fish-oil-derived fatty acids may have antiinflammatory effects by inhibiting the 5-lipoxygenase pathway in neutrophils and monocytes and inhibiting the leukotriene B4-mediated functions of neutrophils.

A simplified lead oxide cadaver injection technique.

Abstract: A simple, inexpensive injectable substance is reported for analysis of the arterial circulation in fresh human or animal cadavers. The technique is a modification of that reported by Salmon in 1936 and utilizes lead oxide and gelatin. This combination is highly radiopaque; it perfuses the small radicles of the vascular tree and sets to a firm rubbery consistency to fascilitate dissection.

The incidence of malignant melanoma (0 to 15 years of age) arising in "large" congenital nevocellular nevi.

Abstract: While the association between large congenital nevocellular nevi and malignant melanoma has been established beyond reasonable doubt, its magnitude is the subject of” wide controversy. In this study an attempt is made to estimate the risk of malignant transformation during the first 15 years of life in a sample of 39 congenital nevocellular nevi occupying a mean of 17 percent of the total body surface area collected from plastic surgical centers in England and Wales. During the period of observation, which totaled 337 years, two patients developed and died of metastatic malignant melanoma. A melanoma risk of 8.52 percent during the first 15 years ol life is calculated. Although a high risk ol melanoma must weigh heavily in favor of early prophylactic excision, the management of large congenital nevocellular nevi is considered to be too complicated to permit the invariable adoption of a wholesale excisional policy

Complex maxillary fractures: role of buttress reconstruction and immediate bone grafts

Abstract: Between 1978 and 1984, 558 patients with complex facial fractures have been treated. One hundred and seventy-one of these patients have had complex Le Fort fractures of the maxilla. In this group of patients, the importance of direct anatomic reconstruction of the anterior maxillary buttresses has been assessed. Complete exposure of the injured buttresses will facilitate assessment of the exact fracture pattern. Direct fixation of the medial and lateral maxillary buttresses on each side, in combination with immediate bone-graft reinforcement or replacement of comminuted or missing buttresses, will facilitate the reconstruction of even the most severely injured maxilla in one stage. This approach is combined with similar reconstructive techniques in other areas of the craniofacial skeleton. Associated mandibular fractures are managed with rigid internal fixation utilizing A-O techniques. The use of these techniques dramatically facilitates airway management and simplifies the treatment of the edentulous patient, the patient with bilateral condylar neck fractures, and those patients with sagittal splitting of the maxilla and palate. The use of both internal craniofacial suspension wires and external craniofacial suspension devices has become largely unnecessary, and reconstruction of even the most complex injuries in one stage with minimal complications and secondary deformities is made possible.

Primary correction of the unilateral cleft lip nose: a 15-year experience.

Abstract: This paper reviews a 15-year personal experience based on 400 unilateral cleft nasal deformities that were reconstructed using a method that repositions the alar cartilage by freeing it from the skin and lining and shifts it to a new position. The rotation-advancement lip procedure facilitates the exposure and approach to the nasal reconstruction. The nasal soft tissues are transected from the skeletal base, reshaped, repositioned, and secured by using temporary stent sutures that readapt the alar cartilage, skin, and lining. The nasal floor is closed and the ala base is positioned to match the normal side. Good subsequent growth with maintenance of the reconstruction has been noted in this series. The repair does not directly expose or suture the alar cartilage. Improvement in the cleft nasal deformity is noted in 80 percent of the cases. Twenty percent require additional techniques to achieve the desired symmetry. This method has been used by the author as his primary unilateral cleft nasal repair and has been taught to residents and fellows under his direction with good results. This technique eliminates the severe cleft nasal deformity seen in many secondary cases.

Functional evaluation of latissimus dorsi donor site.

Abstract: A study was undertaken to determine the cosmetic and functional problems associated with the latissimus dorsi muscle donor site. Twenty-four patients undergoing both free and pedicle muscle and myocutaneous flap procedures for a wide variety of reconstructive problems were studied. All patients had a contour defect at the donor site, a scar which varied with the patient's age and whether overlying skin had been taken with the muscle flap. Mild to moderate shoulder weakness and some loss of motion were noted in most patients which improved over the course of several months. An upper extremity disability in strength and shoulder motion should be anticipated following latissimus dorsi transfer, which in most cases is minimized by the recruitment of synergistic muscle units. Vigorous range-of-motion exercises following surgery should be encouraged to minimize adhesions and joint capsule stiffness. Social changes in occupation and daily living activities were noted which were not a problem for most patients. Twenty-three of 24 patients were pleased with the overall outcome of their surgery and would recommend the procedure to others. A prospective study before and after latissimus dorsi transfer followed by a second evaluation 2 to 3 years postoperatively would help to clarify the role synergistic muscle units play in "taking over" latissimus dorsi function.

Nasal reconstruction: seeking a fourth dimension.

Abstract: A method of nasal reconstruction emphasizing the use of thin but highly vascular local lining and cover flaps to allow successful primary placement of delicate cartilage grafts is presented. The cartilage fabrication provides projection in space, airway patency, and, when visible through conforming skin cover, the delicate contour of the normal nose. Because tissue is replaced in kind and quantity, the need for multiple revisions to sculpt and debulk is decreased. Techniques and four case reports describe its applications to tip, heminose, subtotal, and total nasal defects.

Laser photoradiation therapy of cancer

Abstract: We conducted a trial of photoradiation therapy of cancer at the University of California at Irvine. The basis of this technique is a photochemical reaction between an i.v.-injected material, hematoporphyrin derivative, and red light (wavelength, 630 nm). Hematoporphyrin derivative localized in malignant tissue, resulting in selective destruction of cancer cells upon illumination with red light. One hundred twenty-eight sites of recurrent cancer or premalignant lesions were treated in 37 patients. Of this group, 35 patients had recurrent cancer refractory to conventional therapy, and two had premalignant lesions. Favorable responses were achieved in 67% of the sites treated. The dose of hematoporphyrin derivative used in this study ranged from 2 to 5 mg/kg with the majority of patients receiving 3 mg/kg. Total light dose administered appeared to be the most critical parameter evaluated. Light doses in excess of 20 J/sq cm generally resulted in blistering and necrosis of intact skin, while no appreciable increase in response was observed. Photoradiation therapy has demonstrable efficacy in cancer therapy and avoids much of the morbidity of current conventional techniques.

The vascular basis of the radial forearm flap.

Abstract: The radial forearm flap is one of several valuable fasciocutaneous flaps. Therefore, its arterial and venous supply has been studied by dissection of 56 cadavers using various techniques, such as ink, latex, and barium sulfate injections. The relevant arterial branches tend to be in three groups with three associated and anastomosing perfusion zones. The blood supply of the distal radius is shown by latex injections. The vessels to tendons and nerves are briefly discussed. The flap is drained by superficial veins or radial artery venae comitantes or both. Each arterial perforator has one or two associated veins through which blood can pass into the venae comitantes. It is confirmed that the veins have valves, through which reverse flow has to occur in the pedicle of distally based island flaps. An explanation of how this is possible is given. The relevance of the findings to fasciocutaneous flaps in general is discussed.

Breast volume and anthropomorphic measurements: normal values.

Abstract: Fifty-five consecutive female volunteers were evaluated. Linear measurements of the breast and nipple position were determined to fixed points on the chest wall. Volume determination was done by a standard chest-wall casting technique. A highly significant difference was found between left and right breasts in the axilla-to-nipple distance and nipple-to-midline measurements. A significant difference was also found in the distance from the lowest point of the breast (patient upright) to the nipple. Analysis of the volumetric difference between right and left breasts did not achieve statistical significance.

Use of the galeal frontalis myofascial flap in craniofacial surgery.

Abstract: The anatomy and the technique of raising the galeal frontalis myofascial flap is described. In 38 patients with various pathologies, congenital anomalies, tumors, and trauma, this technique was employed. There were no extradural infections. The applications and complications of the flap are discussed. It is highly recommended wherever there is a possibility of direct intracranial nasopharyngeal communication.

Management and timing of cleft palate fistula repair.

Abstract: This study reviewed 199 cleft palate repairs resulting in 22 percent fistula formation. Of these, 49 percent were judged to be symptomatic. Of 44 fistulas, 21 required treatment, of which 14 had conventional type surgical closure with an overall success rate of 35 percent. Good surgical technique and good surgical judgment were felt to be important factors both in preventing postoperative fistula and in the success of their repair. Conventional methods of surgical repair of hard palate fistulas were seen to result in a very poor success rate. Orthodontic movement of maxillary segments was seen to contribute to late postoperative fistula formation. Therefore, orthodontic movement should be completed before undertaking surgical repair of anterior palatal fistulas. Finally, the success rate of anterior fistula repair has been dramatically improved by the addition of free periosteal grafts and cancellous bone grafts.

The relationship between breast cancer and augmentation mammaplasty: an epidemiologic study.

Abstract: Surgical implantation of breast prostheses for cosmetic purposes has become increasingly popular, and by 1981, it was estimated that three-quarters of a million women had had such an operation. The long-term potential risks, particularly of breast cancer, of such procedures have not been properly investigated. To evaluate the potential breast cancer risk, we have conducted a retrospective cohort study of 3111 women followed through various public and medical records for a total of 18,476 person-years, with a median of 6.2 years per person. The cases of breast cancer were detected by means of a computerized match with the Los Angeles County Cancer Surveillance Program, a population-based cancer registry. Overall, 15.7 breast cancer cases were expected and 9 were observed, a nonsignificant deficit [standardized incidence ratio (SIR) = 57 percent, 95 percent confidence limits: 26 percent, 109 percent]. The cancers were generally diagnosed at an early stage. Among the 573 women aged 40 or older at implantation, 7.1 cases were expected and 8 were observed (SIR = 113 percent). In women whose implants were performed before the age of 40, only 1 case was observed whereas 8.6 cases were expected (SIR = 12 percent, 95 percent confidence limits: 0.3 percent, 65 percent), a significant difference. These data do not support an increased risk of breast cancer following augmentation mammaplasty. The low breast cancer rate in women having augmentation mammaplasty at a young age suggests that many such women may have a reduced amount of breast tissue, but data on this are unavailable.