Search

Objective: To evaluate the incidence and severity of obstructive sleep apnea syndrome (OSAS) in patients with cleft palate having a Furlow palatoplasty or pharyngeal flap for correction of velopharyngeal insufficiency (VPI)., Patients: A total of 48 nonsyndromic children with repaired cleft palate with VPI were enrolled in the study. Twenty of the children had a Furlow palatoplasty (F group) and 28 children had a pharyngeal flap (P group) for correction of VPI., Interventions: An overnight polysomnography evaluation was done to evaluate the incidence and severity of OSAS 6 months or more postoperatively., Main Outcome Measures: Symptoms of OSAS, respiratory disturbance index (RDI), oxyhemoglobin desaturation index (DI), and sleep stages were measured., Results: In the P group, the mean percentage of stage 2 sleep was lower than the F group (p <.05). The mean RDI and DI were larger in the P group, compared with the F group (p <.001). The incidence and severity of OSAS were higher in the P group, compared with the F group (p <.001 and p = 0.05, respectively)., Conclusions: A Furlow palatoplasty should be used in deference to a pharyngeal flap whenever possible on the basis of the preoperative evaluation of VPI because of the decreased incidence and severity of OSAS.

Many patients throughout the world have had breast augmentation using injectable materials. In the Far East, an adulterated impure silicone has been used by non-medical persons and unlicensed 'cosmetic surgeons' as well as by licensed physicians. The injected material usually causes a granulomatous reaction, tenderness, erythema, pain or discomfort and even skin necrosis. Eventually, the injected breast becomes very hard and develops a distorted contour. Previous treatment was by subcutaneous mastectomy with immediate or delayed reconstruction using a silicone prosthesis. The results of this were often unsatisfactory. We obtained more satisfactory results in 11 patients who had the siliconoma removed by subcutaneous mastectomy and the breast reconstructed with a de-epithelialised TRAM flap., (Copyright 2001 The British Association of Plastic Surgeons.)

Background: Cross-leg free flaps have been described for reconstruction of leg defects in cases of trauma with no suitable recipient vessels in the vicinity of the defect. The pitfalls, however, have not been well documented in the literature. The technique of transfer and the length of time required before pedicle division depend on the nature of the flap and the contact surface., Methods: Eight cross-leg free flap reconstructions were performed on seven patients between 1986 and 1993. These included three latissimus dorsi muscle flaps, three fibula osteomyocutaneous flaps, one tensor fascia lata myocutaneous flap, and one posterolateral thigh flap. The important technical considerations are outlined., Results: One latissimus dorsi flap failed, whereas the rest of the flaps completely survived. The morbidity of the recipient and donor sites are listed., Conclusion: We conclude that the technique offers the possibility of salvaging limbs that are, otherwise, nonreconstructable. It is useful for young patients. When the flap is long, it can function as a nutrient flap for the distal limb even though the pedicle has been divided. It is a backup procedure in an urgent situation of re-exploration in which reestablishment of circulation should take place as soon as possible.

The posterior interosseous flap has been used as a pedicled flap for coverage of hand wounds. However, the pedicled flap is associated with partial or even complete loss when there is venous congestion. This happens because it depends on retrograde venous drainage. Another pitfall of the pedicled posterior interosseous flap is the undetected damage to the communicating vessels between the anterior and posterior interosseous arteries before surgery. This would result in failure if the flap is used as a distally based flap. Thirty-four patients had been reconstructed with the microvascular free posterior interosseous flap. The free flap has a large draining vein. Flap survival rate was 97%. There was no venous congestion and no partial loss of the flap. It is thin, sensate, and reliable. The free posterior interosseous flap is indicated for coverage of the following wounds: (1) first web space and thumb, (2) radial side of the index and ulnar side of the small finger if a cross-finger flap cannot be used, and (3) defects at the dorsum of multiple fingers. It can also be used as a free fascial flap. The free posterior interosseous flap provides a reliable option for coverage of hand wounds. Previously, another 14 patients with hand wounds had been reconstructed with a pedicled posterior interosseous flap. The results of pedicled and free posterior interosseous flaps are compared.

Seven patients with extensive loss of soft tissue, extensor tendon, and exposure of bone and joint of dorsum of hand and foot were treated with free composite flaps from the groin area. To retard the adhesion by scarring, membrane interposition between tendon and bone was recommended. The groin flap, based on superficial circumflex iliac vessels, was combined with a well-vascularized external oblique aponeurosis. The groin skin flap provided skin coverage, and the aponeurosis was used simultaneously to create a gliding surface for reconstructed tendons in a single one-stage procedure. All composite free-tissue transfers were successful. The advantages of this technique are: (1) a single, one-stage procedure; (2) fewer adhesions of reconstructed tendons, and no need of secondary tenolysis; and (3) good cosmesis and minimal morbidity at donor site.

One rectus abdominis muscle flap, when based on superior and inferior pedicles, can be transferred simultaneously as two free-muscle flaps in two different configurations during the same operation. The two free flaps based on either pedicle are safe, reliable, and extremely well vascularized. Excellent functional and cosmetic results have been achieved in five patients with minimal donor-site morbidity. It has been our flap of choice for reconstructing the moderate- to large-sized defects at two separate sites of the upper and lower extremities.

Deficiency of the free border of the lip is frequently encountered in secondary cleft lip deformities. The free border of the lip consists of the orbicularis oris marginalis muscle and its overlying subcutaneous tissue, vermilion, and mucosa. The pathology may involve any or all of these components. When there is an absolute shortage of subcutaneous tissue or orbicularis oris marginalis muscle, extra tissue from another source must be used for augmentation. A temporoparietal fascial graft is a simple and reliable method to increase the fullness of the free border of the lip. The tissue is soft in consistency and displays minimal resorption. Most important, more complicated procedures such as an Abbé flap or tongue flap may be avoided. From July of 1988 until June of 1992, the temporoparietal fascial graft was used successfully to correct deficiencies of the free border of the lip in 20 patients with cleft lip deformities. There were two graft exposures that healed with conservative treatment. The procedure is a useful method of augmenting both lateral lip and central lip deficiencies in secondary and tertiary cleft lip deformities.

To avoid the serious complications of pharyngeal flap surgery, a Furlow palatoplasty was used to correct velopharyngeal insufficiency after primary palatoplasty in 18 Chinese cleft palate patients (3 to 23 years old) from 1988 to 1992. The follow-up duration was 1 to 4 years. These patients were selected after a complete study for velopharyngeal insufficiency, including intraoral examination, perceptual speech assessment, videonasopharyngoscopy, and/or multiview videofluoroscopy. The criteria for selection included age, pattern of velopharyngeal closure, size of the velopharyngeal gap, extent of lateral pharyngeal wall movement, existence of a Passavant's ridge, and abnormal levator veli palatini muscle insertion. Complete velopharyngeal closure was achieved for 16 patients after surgery. The majority of these patients (15) had a velopharyngeal gap less than 5 mm. The 2 patients who still had velopharyngeal insufficiency after the surgery had a velopharyngeal gap larger than 10 mm before the surgery. The most important factor seemed to be the size of the velopharyngeal gap. Pattern of velopharyngeal closure or age of the patient also might play an important role. The results showed that a Furlow palatoplasty can satisfactorily correct velopharyngeal insufficiency in carefully selected patients. Although the criteria for the selection of this operation need further study, present results are encouraging.

The number of donor nerves available for nerve transfer in the reconstruction of total root avulsion injuries of the brachial plexus is always insufficient. Use of the contralateral normal C7 cervical nerve as a donor nerve is a new approach to obtain more nerve fibers but also is a controversial procedure. Fifteen patients with total root avulsion of the brachial plexus received cross-chest C7 nerve grafting as the first stage of reconstruction. Eight of these patients, after an interval of 11 to 20 months, had free muscle transplantations (one to three muscles transferred per individual) to the affected limb. A long period of rehabilitation (at least 2 years) is required. The donor limbs of the 15 patients showed negligible deficits of motor and sensory function. Although independent movement of the transferred muscles from the contralateral limb has not been achieved, useful function of the reconstructed limb is possible. The preliminary results are encouraging.

Avulsion injury of the leg may result in exposure of the anterior surface of the tibia in addition to skin loss. This exposed bone should be covered by a soft tissue flap to facilitate healing and provide durability. The split anterior tibial muscle flap is ideal in this situation because of its adjacent location, reliability, and simplicity. A cadaveric study demonstrated rich intramuscle vascular anastomoses between the segmental branches from the anterior tibial artery that provide safety in partial transfer. The technique of split anterior tibial muscle flap was applied successfully in 4 patients with leg avulsion injury associated with tibial bone exposure. The cosmetic result was good and the function of the muscle was preserved.

The adipofascial flap is a useful method for treating deep electrical burn wounds requiring early definitive wound closure to preserve vital structures and function. In the past 2 years, 14 deep electrical burns of the upper extremities involving exposure of tendon, nerve, bone, or blood vessels requiring immediate vessel reconstruction were covered with an adipofascial flap. The latter was a local random turnover flap of the fascia and its overlying subcutaneous fat. All flaps were successfully elevated and applied to severe wounds in order to preserve underlying structures. There were no serious complications. Tendon gliding under the flap was found to be excellent during second reconstructive surgical procedures. The reconstructed limbs had satisfactory preservation of function.

There were four patients with palatal clefts who had been operated on many times previously but who still had large oronasal defects due to wound disruption. Moreover, there was considerable scar in the residual palatal tissue, which was contracted in the anteroposterior dimension. These patients were treated with a radial forearm flap transfer. The technical aspects of this reconstruction are emphasized, especially methods to enhance primary healing and to facilitate in setting the flap. Three of the patients were successfully reconstructed with one operation. The fourth had a small area of dehiscence anteriorly that was later closed with advancement of the flap tissue. There were no other complications. With the replacement of healthy tissue, the palate could be pushed further back to achieve better repair of the muscle. This would contribute to better speech function. In every patient, nasal regurgitation was eliminated, and speech quality improved significantly. The radial forearm flap is ideal for intraoral use, providing thin, hairless skin with a long, large-caliber vascular pedicle. It can reconstruct defects in one stage with well-vascularized tissue and minimal dissection of the palate. In a select group of cleft palate patients, this free-tissue transfer should be considered to achieve closure of large oronasal fistulas in patients with dense scar.

Focal stricture of the cervical esophagus can be caused by corrosive injury or irradiation or following esophageal reconstruction. For severe stricture that cannot be relieved by bougie dilatation, surgical correction should be done. Among the operations performed, the myocutaneous flap is considered the first choice. Patch esophagoplasty with a free flap is indicated in the following situations: (1) when the patient is a young woman, (2) when the patient is obese, and (3) following irradiation that renders myocutaneous flaps unreliable. For correction of focal stricture of the cervical esophagus, six patients underwent esophagoplasty with a patch of free forearm flap. In comparison with other methods, this approach is associated with less morbidity and a better aesthetic result. The patients started oral intake at 1 month. Only one patient had minor leakage, and this healed after conservative treatment. The skin patch inserted in the esophageal wall caused no problem in motility, and the patients could eat smoothly after surgery.

Nine patients with complex extremity injuries were treated with emergency free-flap transfers over a 3 1/2-year period. The transferred emergency free flaps were performed to cover exposed vital structures. All flaps survived without infection. Complete and careful assessment of the systemic condition of the patient and the nature of the injured extremity is mandatory. Emergency free-flap transfers may salvage the limb or finger and may improve the functional and aesthetic results with the shortest possible hospital stay.

The functioning free-muscle transfer is a microneurovascular technique that has proven effective for patients who have a major muscle or muscle group loss for which no other less complicated procedures are available. A new functioning muscle (lateral half of the soleus) transfer was used for forearm reconstruction. This functioning muscle can be transferred alone, or it can be used with overlying skin or nearby fibular bone or both. It was used in a selective complicated case in which not only were major functional muscles lost, but a bone deficiency and skin loss also were seen. The operation was done in one stage with the composite flap (muscle plus bone plus skin). The recovered transferred muscle provided adequate strength and excursion for a functional hand and forearm.

An open tip rhinoplasty was used to correct moderate to severe secondary cleft lip nasal deformities in 122 patients from January 1986 to January 1988. The results of the surgery on 92 patients who were followed for 1 year or more were evaluated. When the surgery was performed after the age of 3 years, 60% of the patients had a satisfactory result. The pathology of the deformity included 32% with deficiencies of the nasal lining, 35% needed framework support such as a columellar strut, and 45% required correction of columellar deficiencies. Patients using a postoperative nasal stent had a 71% satisfactory result compared with a 37% satisfactory result when the stent was not used. The pathology and techniques to correct the nasal deformity are described.

Three patients presented who needed reconstruction of the entire esophagus. Because the stomach and colon were not available in these patients, a posterior tibial artery flap was employed for reconstruction. In the first stage, the long and wide skin flap was elaborated into a skin tube to create the major portion of esophagus in the subcutaneous tunnel. In the second stage, the lower end of the skin tube was joined to the jejunum in Roux-en-Y fashion. This method resulted in smooth passage of food and early rehabilitation for these patients. However, this procedure has the disadvantage of a scar over the leg. In addition, this procedure has the following limitations: (1) a well-vascularized leg is necessary, and (2) a hairless leg is necessary. Although this would not be a procedure of first choice, it remains a worthwhile backup procedure in esophageal reconstruction.

Intraosseous infusion of fluid had been used in traumatology. Here we describe a clinical situation in which bone marrow is first used for drainage of venous blood in a free osteocutaneous flap. Two factors account for the survival of the large osteocutaneous flap in which venous anastomosis was impossible. (1) In the design of the arterial circuit and the major route of venous drainage, there were two ends of the peroneal artery of the osteocutaneous flap. Both its upper and lower ends were anastomosed to the anterior tibial artery of the recipient site to constitute an uninterrupted arterial circulation. This prevented stagnation of arterial flow and thrombosis of the arterial anastomosis. (2) The major route of venous drainage was through bone marrow. The initial congestion was finally overcome by the development of neovascularization. Bone scan showed good survival of bone with increased uptake of radioactivity. At 3 years follow-up, roentgenogram showed bone union, and the patient had no trouble walking. The continuity of the anterior tibial artery, which had been interrupted by trauma, was restored by this flap.

Venous flaps were used for coverage of hand wounds over exposed bones, joints, and tendons in 28 patients. Four types of operations were performed. Among them type IV was the best. It included the advantages of perfusion in types I and III, but excluded their disadvantages. The viability of venous flaps was confirmed. Clinical observation showed that a venous flap is not merely a composite graft. The presence of a vascular network in the flap helps to ensure initial survival before the establishment of neovascularization between the venous flap and the recipient site. Partial loss of a flap was observed in two cases and complete failure was seen in one case. Viability versus flap size and modality of perfusion are analyzed. With total venous perfusion, small venous flaps usually survive better than large ones. For large venous flaps, arterialized venous perfusion is better than total venous perfusion. Venous flaps are useful for wound coverage of fingers and hand, but they do not replace cross-finger flaps or other conventional flaps when these simpler flaps are available.

The perception theory has been recently used in aesthetic reconstructive surgery. Using on the principles of the theory, we have successfully reconstructed an ear with a middle-third defect utilizing local flap and secondary revision procedures.

It should be emphasized that most cases of chest empyema can be successfully treated with conventional thoracic surgery procedures. For chronic empyema with a bronchopleural fistula complicated by previous division of major local muscles following repeated thoracotomies, free muscle flaps are employed. Five such cases treated with this method resulted in successful closure of the airway fistula, as well as complete obliteration of the empyema cavity in a single operation. This method is very effective in eradicating infection and achieves prompt wound healing, decreased morbidity, and gradual improvement of pulmonary function after surgery. Analysis of roentgen ray and computed tomographic scans before and after surgery shows lung expansion when the transferred muscles atrophy. The results are satisfactory. The method described here is not the only solution to this problem, but it is a new approach that has advantages not seen in conventional methods. It is indicated only in patients who have been operated on many times and who have no remaining available local muscles.

A method of reconstructing the entire esophagus by a chain of free forearm flaps connecting pharynx to jejunum is presented. This was indicated because all other means of reconstruction were not possible. It solved a difficult problem with good result, and the patient was satisfied.

In the absence of proper recipient vessels, a large microvascular composite-tissue flap was transferred successfully for reconstruction of a leg with an extensive crush injury. This was accomplished by using vessels of the normal leg. The microvascular flap containing skin, muscle, and 15 cm of fibula survived well after division of the pedicle. To achieve good bone healing, the leg was protected by a brace while gradually increasing weight bearing. The functional result is satisfactory.

Satisfactory coverage of some deep burn wounds is very difficult. During the past year, 20 de-epithelialized turn-over flaps have been used to cover deep burn wounds in 17 patients. Most of the wounds resulted from electrical injuries which caused exposure of tendons, nerves, bone or joint space. A turn-over flap is a convenient local flap for covering deep burn wounds and reducing morbidity. They adhere well, cause less contracture, and make a good bed for the overlying graft. One disadvantage is that healthy tissue around the wound is not always available; another is questionable tendon gliding. Complications consisted of partial flap necrosis, osteomyelitis and an epithelial cyst. Overall results for the reconstruction of difficult burn wounds were considered exceptionally good.

Eight patients had reconstructive surgery for soft-tissue, associated Achilles tendon, and calcaneus defects on the posterior aspect of the ankle. In group A, those patients with skin, soft-tissue, and Achilles tendon loss were treated with free groin flaps that included sheets of the external oblique aponeurosis based on the superficial circumflex iliac vessel. The groin flap provided skin coverage, and the aponeurosis was rolled to form a tendon-like structure to replace the Achilles tendon. In group B, those patients with an additional calcaneus bone loss were treated with free iliac osteocutaneous flaps, together with the external oblique aponeurosis based on the deep circumflex iliac vessel. The iliac bone was then utilized to reconstruct the calcaneus defect. All composite free tissue transfers were successful, except in two group B patients who suffered partial skin loss. The advantages of this technique are (1) a single, one-stage procedure, (2) faster wound healing with fewer adhesions of the reconstructed Achilles tendon, and (3) good cosmesis and minimal morbidity at the donor site.

A musculocutaneous flap is a simple and effective treatment for the complications which can follow esophageal reconstruction at the cervical portion, such as stricture, fistula, and infection of costal cartilages. After the strictured segment is opened or resected, the resultant esophageal defect can be replaced with the skin patch of a musculocutaneous flap. Then the muscle component of the musculocutaneous flap can be used to form a seal around the previously infected lesion site, an area with the potential for recurrent infection and leakage in subsequent operations. Seven patients were treated this way with satisfactory results.

Severe cranial trauma caused by an industrial accident resulted in loss of scalp, skull, dura, and brain tissue in the left frontal region of a 55-year-old man. Successful one-stage total reconstruction of the defect was accomplished using a patch of fascia lata, autogenous split rib graft, and a free forearm flap on an emergency basis. A ten-month follow-up showed uneventful recovery and a good cosmetic result.

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)

A large free flap from an amputated lower extremity based on popliteal vessels was used for coverage of three extensive decubitus ulcers in a single operative procedure. The procedure was easy, reliable, and actually time- and cost-saving. It provided a quick solution and early rehabilitation for a difficult problem.