Senders CW, Di Mauro SM, et al (Univ of California, Sacramento; Univ of Maryland, Baltimore)
The Efficacy of Perioperative Steroid Therapy in Pediatric Primary Palatoplasty
Cleft Palate Craniofac J 36: 340-344, 1999
The efficacy of steroids to limit airway distress in palatoplasty was investigated in a prospective, double-bind, randomized,
The incidence of postoperative airway distress and fever was significantly lower in the steroid treated group than in the placebo
Perioperative administration of steroid therapy in children undergoing primary palatoplasty significantly lowers the incidence of airway distess and postoperative fever.
Yotsuyanagi T, Nihei Y, Yokoi K, et al (Hirosaki Univ, Japan)
Functional Reconstruction Using a Depressor Anguli Oris Musculocutaneous Flap for Large Lower Lip Defects, Especially for Elderly Patients.
Plast Reconstr Surg 103: 850-856, 1999
The most common lesion of the malignant lesions of oral cavity is lower lip squamous carcinoma
In planning the reconstruction of large excision defect the following factors should be kept in mind.
– Maintenance of sphineteric action
– Retention of sensation
– A large enough opening for the mouth
– Acceptable cosmetic appearance.
In surgical technique described – Nerve supply and Blood supply is well preserved.
Raulin C, Schroeter CA, Weiss RA, et al (Laserklinik, Karlsruhe, Germany; Med Centre, Maastricht, The Netherlands; Johns Hopkins Univ, Baltimore, Md; et al)
Treatment of Port-Wine Stains With a Noncoherent Pulsed Light Source: A Retrospective Study.
Arch Dermatol 135: 679-683, 1999
Thirty-seven patients with 40 port-wine stains between 1994 to 1997, aged 1 to 68 years were treated with intense pulsed light source (IPLS). Before and after treatment, photographs were taken. All side effects recorded. The treatment appears to be safe and effective.
Kuzbari R, Worseg AP, Tairych G, et al [Univ of Vienna, Austria]
Sliding Door Technique for the Repair of Midline incisional Hernias
Plast Reconstr Surg 101: 135-1242, 1998
Sliding door technique that makes it possible to effect a tensionless and autologous repair of large hernias after midline laparotomy.
In this technique the medical border of the rectus sheath is identified on both sides of the hernia. Rectus sheaths are dissected away from the muscles; Rectus sheaths, after being incised at the aponeuroses of the external oblique muscles, slide towards the midline. The posterior rectus sheaths are sutured. The rectus muscles are secured with overlapping sutures, and the released anterior layers of the rectus sheaths are sutured. Releasing the rectus sheaths from the pull of the external oblique muscles eliminates the most unyielding pull.
Davison SP, Sherris DA, Meland NB (Mayo Clinic, Rochester, Minn; Mayo Clinic, Scottsdale, Ariz)
An Algorithm for Maxillectomy Defect Reconstruction.
Laryngoscope 108: 215-219, 1998
One hundred and eight patients over a period of 5 yrs underwent reconstruction of maxillary defects.
The majority can be best reconstructed with a prosthesis, obturator. The guidelines are :-
– First choose a technique that retains greatest residual hard palate without comprising growth excision.
– Second, position the resection in the socket of an extracted tooth, to preserve tooth adjacent to the defect.
– Third, consider a split thickness skin graft.
– Fourth, to avoid the influence with the obturator bulb, remove the inferior turbinate.
– Fifth, if possible, use a feasible preserve palatal disease free mucosa for tissue coverage.
Finally consider the removal of residual adynamic soft palate if 50% or more has to be resected. Preoperative planning of the surgical approach is crucial, and the authors offer an algorithm to assist in this process.
Santler G, Karcher H, Ruda C, et al [Univ Clinic for Dentistry, Graz, Austria]
Fractures of the Condylar Process : Surgical Versus Nonsurgical Treatment
J Oral Maxillofac Surg 57: 392-397, 1999, Pg.150
Improved materials for osteosynthesis, including Kirschner wires, wires, miniplates and lag screws has made open surgical treatment more promising.
Patients treated nonsurgically were treated by maxillomandibular fixation [MMF] or without MMF.
Patients treated surgically or nonsurgically had no significant difference in mobility, joint problems, occlusion,and muscle pain or nerve disorders.
Minimally invasive therapy for condylar process fractures remains the method of choice.
Condylar mandible has a tremendous capability for reparation, self-reconstruction, and remodeling.
Rath T, Millesi W, Lang S, et al (Univ of Vienna)
Mucosal Prelamination of a Radial Forearm Flap for Intraoral Reconstruction.
Eur J Plast Surg 21: 166-170, 1998.
In 5 patients the use of a distal radial forearm flap to which buccal mucosal grafts were meshed in reconstructing oral defects after radical resection of squamous cell carcinoma is described. It was safe, easy to use and successful. Although the time is needed between creation of the flap and its insertion, this time can be used to deliver preoperative radiation and chemotherapy.
Yotsuyanagi T, Yokoi K, et al (Hirosaki Univ, Japan)
A Supportive Technique Using a Splint to Obtain Definite Contour and Desirable Protrusion After Reconstruction of Microtia
Plast Reconstr Surg 101: 1051-1055, 1998
The use of thermoplastic splint is used in 17 patients directly to the newly constructed ear, to prevent deformity resulting from odema and scarring. Patients were monitored for 3 yrs. The splints were used after the first and second stage of costal cartilage grafting.
This technique is worth consideration. G.R. Holt.
Abou Chebel N, Beziat J-L, Torossian J-M (CHU Lyon-Nord, Cedex, France)
Le Lambeau Myo-Muqueux de Buccinateur Pedicule sur les Vaisseaux Faciaux: Interet Dans la Reconstruction du Plancher de la Cavite Buccale: A Propos de 10 Cas.
Ann Chir Plast Esthet 43: 252-257, 1998
Ten patients were given the flap. The musculomucous buccinator flap described provided excellent- functional and esthetic results in the repair of the floor of the mouth. Its flexibility ensures good tongue mobility. However, it requires extraction of the mandibular molars and also must have intact facial artery that can be raised with the flap. The Doppler could also be used to identify the course of the facial artery intraorally. The flap must be placed anterior to the parotid duct and opening. The patient must now chew if the flap crosses alveolar ridge. G.R. Holt.
Smutz WP, Kongsayreepong A, Hughes RE, et al[ Mayo Clinic and Found, Rochester, Minn]
Mechanical Advantage of the Thumb Muscles
J Biomech 31: 565-570, 1998
The moment arms of the thumb muscles at the interphalangeal, metacarpophalangeal, and carpometacarpal joints were measured throughout the range of motion of each joint.
1. At metacarpophalangeal joint –
FPL, FPB, ADPt and ADPo and OPP were the major flexors.
2. At carpometacarpal joint –
FPL, FPB, ADPt, ADPo and OPP were the major flexors.
This knowledge can aid in planning rehabilitation.
Jing Deng, Nina M Newton, Margaret A Hall-Craggs, et al ( Department of Obstetrics and Gynaecology, Reconstructive and Plastic Surgery, Medical Physics and Medical Imaging, University College, London, UK)
Novel technique for three-dimensional visualization and quantification of deformable, moving soft-tissue body parts.
Lancet, vol.356, July 8, 2000, p.127-131.
Three dimensional (3D) imaging of delicate, moving soft tissue body parts is difficult – e.g. understanding of the muscles that control lip movements is based largely on histological and cadaveric studies. The aim of the authors was to develop an innovative scanning technique for imaging and reconstruction of dynamic orofacial morphology by use of 3D and four-dimensional (4D i.e. 3D plus time) ultrasonography.
To avoid deformation of delicate orofacial structures, a water-bath with an accoustic window was devised. The orofacial part was immersed in the bath throughout scanning, and a timer was used to synchronise lip-movements with the 4D scan.
The findings were that, the 4D views showed the functional differences in superficial and deep muscle groups of the lips and clearly showed the changes occurring with movements of the lips and mouth.
The authors have developed a prototype device and with further refinement of the device, this technique may offer a new way of dynamically imaging and quantifying many soft-tissue parts in 3D without deforming structure or disturbing function.
E Gur, A Yeung, M Al-Azzawi, et al (Univ of Toronto)
The Excised Preauricular Sinus in 14 Years of Experience : Is There a Problem ?
Plast Reconstr Surg 102: 1405-1408, 1998.
A few of the patients having a congenital pre-auricular sinus suffer from recurrent infections. In such cases surgical excision of the sinus tracts is required. Recurrence is very likely if the tract is not excised completely.
The authors have reviewed 165 primary preauricular excision procedures in 146 patients over a period of 14 years.
The recurrence rate was higher (15.79%) in patients who had active infection during surgery than in patients who did not have active infection (8.22%). The recurrence rate was higher (16.7%) in patients who had surgical drainage of an abscess before the procedure, and 8.16% in those who did not.
Recurrence rates can be reduced by excising a piece of cartilage at the base of the tract and by demonstrating the sinus with dye injection and/or probing at the time of surgery.
Cleft Lip and Palate
Kirschner RE, Wang P, Jawad AF, et al [ Univ of Pennsylvania, Philadelphia; Children’s Hosp, Philadelphia; Children’s Seashore House, Philadelphia]
Cleft-Palate Repair by Modified Furlow Double-Opposing Z-plasty: The Children’s Hospital of Philadelphia Experience
Plast Reconstr Surg 104: 1998-2010, 1999
390 patients underwent Furlow palatoplasty. 65 were under the age of 5 years at the time of last speech evaluation. Speech scores were not available in 86 patients, but it was available in 181 nonsyndromic patients at 5 years or older. [ Pittsburgh Weighted scales for speech symtpoms associated with Velopharyngeal incompetence].
88.4% showed no or inaudible nasal escape and 97.2% showed no errors in articulation related to velopharyngeal incompetence. Secondary pharyngeal flap surgery was needed in 7.2% of cases. There was a trend towards better results in patients undergoing surgery before the age of 6 months and towards poorer outcome in Veau class I and II clefts.
Furlow palatoplasty provides outstanding speech results.
Millard DR, Latham R, Huifen X, et al [Univ of Miami, Fla]
Cleft Lip and Palate Treated by Presurgical Orthopedics, Gingivoperi-osteoplasty, and Lip Adhesion [POPLA] Compared With Previous Lip Adhesion Method: A Preliminary Study of Serial Dental Casts
Plast Reconstr Surg 103: 1630-1644, 1999
This study compares the result of POPLA [1978 onwards] through an examination of dental casts.
124 patients with complete unilateral or bilateral cleft lip and complete or incomplete clefts of the primary and secondary palate were evaluated.
63 patients treated by POPLA method were evaluated as group I [41 with UCLP and 22 with BCLP]. 15 from UCLP and 4 from BCLP group later received orthodontic treatment. Group 2 [ 61 patients] were treated with surgical closure of soft palate and lip adhesion [ 36 UCLP and 25 BCLP] 25 of UCLP and 17 of BCLP later received orthodontic treatment.
Serial dental casts were made at birth and at 3, 6 and 9 years of age. The alveolar gap, arch width, anteroposterior distance, incisor crossbite and buccal crossbite were compared. Radiographs were used to assess bony bridge. Average at follow up was 8 years 11 months in group I and 22 years 3 months in group II.
Results- Bone grafting to close the alveolar gap was required in 59% of cases in group II but in only 3% of cases in group I. Similarly a velopharyngeal flap procedure was required in 35% of group II cases but in only 16% in group I cases. Multiple tooth anterior crossbite was more frequent in Group I. However multiple tooth buccal crossbite was less common in Group I. Anteroposterior distances were similar in both groups at 6 years of age, but by 9 years of age the maxillary dental arch length had increased in all, but group 2 patients with BCLP. Radiographs revealed bony bridge formation in 63% of UCLP and 83% of BCLP who underwent POPLA procedures.
POPLA method gives very good results.
Mackay D, Mazahari M, Graham WP, et al [ Milton S Hershey Med Ctr, Hershey, Pa; Lancaster Cleft Palate Clinic, Hershey, Pa]
Incidence of Operative Procedures on Cleft Lip and Palate Patients
Ann Plast Surg 42: 445-448, 1999
Charts of 374 cleft lip and palate patients were reviewed for the number of primary and secondary procedures performed. The follow up period was 15 years.
Each patient underwent an average of 3.3 procedures and 1.2 otolaryngologic procedures. Of 51 patients with UCLP [incomplete] 29 had secondary procedures and 10% had rhinoplasties. Of 19 patients with complete UCLP 37% had secondary procedures. 47% had rhinoplasties. Of 110 patients with complete UCLP 36% had secondary procedures, 45% had rhinoplasties and 72% had a 2-stage palate repair – of 51 patients with BCLP, 84% had secondary lip repair, 73% had rhinoplasties and 84% had a 2-stage palate repair.
The authors feel that the true incidence of operative procedures is underestimated. It is clear however that secondary procedures make up a major component of surgical repair.
Gosain AK, Conley SF, Santoro TD, et al [ Med College of Wisconsin, Milwaukee]
A Prospective Evaluation of the Prevalence of Submucous Cleft Palate in Patients with Isolated Cleft Lip Versus Controls
Plast Reconstr Surg 103: 1857-1863, 1999
This study evaluates the relationship between isolated cleft lip and submucous cleft palate.
25 patients with isolated cleft lip without an overt clefting of the secondary palate were compared with 25 controls [ age 3-6 months compared with controls of 8 months to 13 years].
Physical examination and nasoendoscopy were performed to look for submucous cleft palate —- bifid uvula, midline diastasis of the palatal muscles and notching of the posterior border of the hard palate.
Results – 12% had classic and 6% had occult submucous cleft palate as against none in the control group. 36% had nasoendoscopic evidence of flattening or a midline depression of the posterior palate and musculus uvula, and palpable evidence of palatal muscle diastasis. However only 3 patients met all 3 physical criteria, 4 met only one criterion and 2 did not meet any of the criteria. All 9 patients with submucous cleft palate and 8 other patients had an alveolar cleft i.e. 53% of those with an alveolar cleft also had submucous cleft palate.
Conclusion – About 1/3rd of the isolated cleft lip patients had submucous cleft palate. Nasoendoscopy was a more effective procedure as compared to physical examination. It is recommended that all cleft lip patients be subjected to nasoendoscopy
Witt P, Cohen D, Grames LM, et al [ washington Univ, St Louis]
Sphincter Pharyngoplasty for the Surgical Management of Speech Dysfunction Associated with Velocardiofacial Syndrome
Br J Plast Surg 52: 613-618, 1999
This is a retrospective review of sphincter pharyngoplasty in the management of velocardiofacial syndrome.
The patients were identified by a computerized craniofacial anomalies registry. 19 patients who underwent velopharyngeal surgical management based on perceptual speech evaluations and instrumental assessments of inadequate velopharyngeal closure were studied.
All patients received a molecular analysis of velocardiofacial syndrome based on fluorescent in situ hybridization analysis of peripheral blood lymphocytes and independent examination by a geneticist.
The surgical outcome was considered successful if perceptual speech evaluation showed elimination of hypernasality , nasal emission turbulence and instrumental assessment revealed 100% velopharyngeal closure.
Results – 18 of 19 patients were managed successfully by sphincter pharyngoplasty. The one failure had mild persistent hypernasality and mild turbulence. This patient was not compliant with continued speech therapy and the parents did not consent to a post-tightening revision surgery. In 5 patients persistent snoring developed postoperatively. One patient had sleep apnea which resolved after use of nasally administered continuous positive airway pressure.
Conclusion – Sphincter pharyngoplasty is a reasonable alternative to pharyngeal flap surgery for velopharyngeal dysfunction.
David LR, Blalock D, Argenta LC [Wake Forest Univ, Winston-Salem, NC]
Uvular Transposition: A New Method of Cleft Palate Repair
Plast Reconstr Surg 104:897-904, 1999
This is a description of a new method of repair that allows simultaneous lengthening of the palate with a mean increase of greater than 1.0 cm; a reduction in the circumference of the nasopharyngeal aperture; and anatomical reconstruction of the muscles of the palate.
62 patients underwent uvular transposition for repair of isolated cleft palate unilateral cleft lip and palate, and other craniofacial syndromes in 32, 13, 14 and 3 children respectively. The age at surgery was between 4 and 10 months [ mean 7 months]. Their mean age at initial speech assessment was 46 months and the mean age at the most recent speech assessment was 66 months.
Technique – The palate was lengthened by using tissue from the uvula by means of a double opposing A plasty. An intravelar veloplasty was done and two thirds of the mass of the uvula was transposed to the nasal surface of the soft palate. This approach of facilitated velopharyngeal closure by significantly lengthening the palate, anatomically reconstructing the palatal excursion was needed to achieve closure.
Results – Perceptual nasal emission was normal in 95% patients 3% children required pharyngeal flap for velopharyngeal insufficiency.
Lee TJ [Univ of Ulsan, Seoul, Korea]
Upper Lip Measurements at the Time of Surgery and Follow-up After Modified Rotation -Advancement Flap Repair in Unilateral Cleft Lip Patients
Plast Reconstr Surg 104: 911-915, 1999
Caliper measurements of vertical horizontal and nostril still dimensions were compared immediately after surgery and at follow up to determine whether rotation advancement flap repair of a unilateral cleft lip will grow short on the repaired sides.
45 patietns [ 30 boys 15 girls] with nonsyndromic unilateral cleft lip underwent a rotation advancement flap repair in 18 who had incomplete defects. The lip was corrected to the same vertical length as the noncleft side. In 27 who had complete defects because of the difficulties of flap rotation the repaired lip was shorter vertically than on the noncleft side.
Results – There was no change in the growth ratios of the two sides [follow up range 8-84 months]. However the nostril sill became significantly wider on the repaired side.
Lekkas C, Latief BS, ter Rahe SPN, et al [ Univ of Leiden, The Netherlands; Universitas Indonesia, Jakarta; Catholic Univ of Nijmegen, The Netherlands]
The Adult Unoperated Cleft Patient: Absence of Maxillary teeth Outside the Cleft Area
Cleft Palate Craniofac J37: 17-20, 2000
In patients with cleft that is operated on in childhood, absence of one or more teeth is frequently seen. The prevalence of missing permanent teeth outside the cleft region is thought to be more than 24% when the secondary palate is also cleft in bilateral cleft lip and palate the missing teeth may be as high 68.4%. In non cleft population the incidence of missing teeth is estimated as less than 6%.
This study investigates the possible absence of teeth in the postcanine region of the upper jaw in patients who have not undergone surgery to repair cleft.
Dental casts were obtained from 266 adult patients who had not undergone surgery for correction of cleft. The patients were grouped based on the type of cleft, whether unilateral cleft lip and alveolus, unilateral cleft lip and palate, bilateral cleft lip and palate. The majority of patients were younger than 30 year. Casts from 100 controls were studied for comparison.
Results – None of the casts [in all 4 groups] revealed any missing permanent teeth. Numeric tooth anomalies were found only in the area of the cleft.
Brent B (Stanford Univ, Calif)
Technical Advances in Ear Reconstruction With Autogenous Rib Cartilage Grafts: Personal Experience With 1200 Cases
Plast Reconstr Surg 104:319-334, 1999
Twenty-five years of experience with microtia repair are reported, and cartilage-sparing techniques to preserve maximum chest wall integrity while still allowing sufficient cartilage for ear reconstruction are described.
Delaying microtia repair until the child is 7 or 8 years old makes sufficient rib cartilage for the repair available and lets the child be actively involved in postoperative care.
The best material for sculpting the framework is autogenous rib cartilage.
Muscle and connective tissue are removed from the cartilage before framework fabrication, but perichondrium should be preserved to encourage nourishment from the skin cover.
For anyone dealing with congenital auricular deformities, reading this article is a must
Berenguer B, Burrows PE, Zurakowski D, et al (Harvard Med School, Boston)
Sclerotherapy of Craniofacial Venous Malformations: Complications and Results
Plast Reconstr Surg 104:1-15, 1999
Craniofacial venous malformations are often treated by directly injecting the lesion with a sclerosant agent, such as 98% ethanol or 3% sodium tetradecyl sulfate.
The complications of sclerotherapy were acute blistering (50%), hemoglobinuria (28%), deep ulceration and scarring (13%) and infection (7.5%). Two patients developed transient facial paresis, and 1 patient developed permanent unilateral vocal cord paralysis; the sclerosant agent in all 3 cases was ethanol.
Craniofacial venous malformations can be safely and effectively treated by sclerotherapy with 98% ethanol or 3% sodium tetradecyl sulfate. However, multiple sessions may be needed, and extensive perioral malformations may also require resection.
Castanon M, Margarit J, Carrasco R, et al (Universidad de Barcelona)
Long-term Follow-up of Nineteen Cystic Lymphangiomas Treated With Fibrin Sealant
J Pediatr Surg 34:1276-1279, 1999
Surgery remains the treatment of choice for cystic lymphangioma, even though these are complex procedures with a high risk of complications. A new approach that uses injections of Tissucol fibrin sealant is reported.
The treatment was successful after only 1 puncture in 10 of the 19 cases. Two treatments were required in 6 patients, and 3 treatments in 3 patients.
Good results achieved with puncture, aspiration, and Tissucol injection of cystic lymphangiomas. This is a simple and safe procedure that achieved excellent long-term results. Tissucol has recently been approved for use in the United States.
Ekerot L (Malmo Univ, Sweden)
Correction of Syndactyly: Advantages With a Non-grafting Technique and the use of Absorbable Skin Sutures
Scand J Plast Reconstr Hand Surg 33:427-431, 1999
Syndactyly correction without skin grafting is a simple surgical procedure that provides good results. The technique could be made even simpler by the use of absorbable skin sutures, which would avoid the need for anesthetic during suture removal.
Complications occurred in 12 of 32 webs in the skin-grafting group, compared with 2 of 19 webs in the non-skin-grafting /Ethilon group and 0 of 9 webs in the non-skin-grafting/Vicryl rapide group.
This experience supports the use of a non-skin-grafting technique and absorbable sutures for the correction of syndactyly. Omitting skin grafts shortens operating time and reduces the complication rate; the use of absorbable sutures eliminates the need for a second operation to remove the sutures.
Horlock N, Grobbelaar AO, Gault DT (Mount Vernon Hosp, Northwood, Middlesex, England)
Can the Carbon Dioxide Laser Completely Ablate Basal Cell Carcinomas? A Histological Study
Br J Plast Surg 53:286-293, 2000
Despite numerous methods to treat basal cell carcinomas (BCCs), tumor recurrence rates are as high as 30%. Recently, improvements in laser technology have led many physicians to use carbon dioxide laser ablation for BCC.
Before excision tumors are exposed to a carbon dioxide laser combined with a microprocessor-controlled scanner that reduced thermal diffusion. The laser was applied to the tumour until no residual tumour could be seen, and for 2 additional passes thereafter. After excision, the tumor bed was excised and examined histologically to identify residual tumor and to determine the depth of the ablation.
Macroscopically superficial BCCs, irrespective of microscopic findings, can be treated with laser if they are ablated to at least the level of the middle dermis.
Conversely, macroscopically nodular tumors should not be treated with this modality. This is especially true for nodular BCCs of the neck or face because the depth of ablation required can result in delayed healing and poor cosmesis.
Zhao Z, Li S, Yan Y, et al (Chinese Peking Union Med College, Beijing, China)
New Buccinator Myomucosal Island Flap: Anatomic Study and Clinical Application
Plast Reconstr Surg 104:55-64, 1999
A new flap for facial reconstruction is described.
The authors detail their study of the vascular anatomy of the buccinator muscle in a series of fresh cadaver dissections, and describe 2 patterns of buccinator musculomucosal island flaps supplied by buccal arterial branches.
Existence of posterior buccal branch, a few inferior buccal branches, and anterior buccal branches to the posterior, inferior, and anterior portions of the buccinator were consistent findings.
The buccal arterial branches supply the 2 types of buccinator musculomucosal island flaps. This flap is in a location that would be quite useful for the closure of palate defects, and the authors have used it in this fashion successfully.
Maegawa J, Saijo M, Murasawa S (Yokohama City Univ, Japan; Saijo Clinic, Yokohama, Japan)
Muscle Bow Traction Method for Dynamic Facial Reanimation
Ann Plast Surg 43:354-358, 1999
The muscle bow traction method represents a new approach to facial reanimation. The procedure uses the masseter muscle and a fascial sling; the sling around the muscle pulls the oral commissure laterally and backward by the restoring force of the muscle during contraction.
This procedure differs from other techniques of muscle transposition in that the force acts at a right angle to the muscle contraction.
This approach is unique in that it uses the restoring force of the muscle from the relaxed to the contracting position. The technique seems simpler and safer than other muscle transposition procedures.
Yousif NJ, Dzwierzynski WW, Sanger JR, et al (Aesthetic and Reconstructive Surgery Associates, Brookfield Wis; Med College of Wisconsin, Milwaukee)
The Innervated Gracilis Musculocutaneous Flap for Total Tongue Reconstruction
Plast Reconstr Surg 104:916-921, 1999
The gracilis muscle is oriented transversely to form a sling that elevates the tongue with active muscle contraction, thus achieving a functional neotongue. Microsurgery is used to approximate the obturator nerve to the hypoglossal nerve.
This reconstruction can replace tongue bulk with the potential for improved physiologic motion. It may improve the functional recovery and quality of life of patients undergoing total glossectomies.
Delaere P, Vander Poorten V, Guelinckx P, et al (Univ Hosp Gasthuisberg, Leuven, Belgium)
Progress in Larynx-Sparing Surgery for Glottic Cancer Through Tracheal Transplantation
Plast Reconstr Surg 104:1635-1641, 1999
Despite the current emphasis on organ preservation surgery, a total laryngectomy is still the treatment of choice for unilateral, advanced glottic cancer.
However, recent studies have demonstrated the use of autologous trachea tissue to restore extensive laryngeal defects.
The 2-stage surgical procedure used the posterior half of the involved side of the larynx to restore laryngeal function, and transplanted tracheal tissue served as a buttress of apposition for the remaining mobile arytenoid and vocal cord. The tracheal segment was revascularized using a radial forearm fascial flap, which served as the vascular carrier.
Voice quality was good or moderately hoarse. Airway function was also good.
Cordeiro PG, Disa JJ, Hidalgo DA, et al (Mem Sloan-Kettering Cancer Ctr, New York)
Reconstruction of the Mandible With Osseous Free Flaps: A 10-Year Experience With 150 Consecutive Patients
Plast Reconstr Surg 104:1314-1320, 1999
Osseous and osseocutaneous free-tissue transfers are now the standard method for reconstructing segmental mandibular defects. The review included a total of 150 patients undergoing mandibular osseous or osseocutaneous free flap reconstruction.
The most common indications for resections was the presence of squamous cell or other types of malignancies. The fibula was the osseous donor site in 90% of operations; other donor sites included the radius, scapula, and ilium.
Osseous free flaps have a very high success rate for mandibular reconstruction and good functional and aesthetic results at follow-up.
Ono I, Tateshita T, Satou M, et al (Fukushima Med Univ, Japan)
Treatment of Large Complex Cranial Bone Defects by Using Hydroxyapatite Ceramic Implants
Plast Reconstr Surg 104:339-349, 1999
Resin has several disadvantages for use in the reconstruction of large defects of the skull, including low biocompatibility and a frequent need for later removal. Hydroxyapatite ceramic implants are highly biocompatible and are commercially available for the reconstruction of defects up to 5 x 10 cm.
Data from helical volume CT scans were used with a laser lithographic molding method to create high-precision, full-scale models. The models were then used to create an implant of the proper size, shape, and curvature.
None of the implants had to be removed because of infection or other complications.
Combining hydroxyapatite with bone-inducing substances may produce ceramic implants for reconstruction that are ultimately proved to be “as good as” bone itself.
Huang J-L, Duan Z-Q, Yang L, et al (401st Hosp of PLA, Qingdao, People’s Republic of China)
Esophageal Reconstruction by Jejunal Transfer
Ann Plast Surg 42:658-661, 1999
Esophageal reconstruction in the treatment of esophageal stenosis and atresia has remained a difficult procedure. However, better outcomes have been experienced since the advent of microsurgical techniques, which allow the jejunum to be used instead of the colon.
Two surgical teams were used for the operation. One team exposed the proximal jejunum and mesentery by means of an upper median laparotomy, while the other team dissected the cervical segment of the esophagus, along with the adjacent vessels for anastomosis.
The success rate for the reconstruction was 97%.
Netscher DT, Meade RA (Baylor College of Medicine, Houston; Dept of Veterans Affairs Med Ctr, Houston)
Reconstruction of Fingertip Amputations With Full-Thickness Perionychial Grafts From the Retained Part and Local Flaps
Plast Reconstr Surg 104:1705-1712, 1999
When the fingertip has been amputated distal to the interphalangeal joint and the amputated distal to the interphalangeal joint and the amputated part has been saved, both composite grafting and microvascular anastomosis have a high failure rate.
In the approach to reconstruction of fingertip amputations when the amputated part has been saved, the hyponychium, perionychium, and nail matrix from the amputated part are combined with local flaps. The aesthetic and functional results are satisfactory. This technique may be particularly useful for patients with amputations between the midzone of the nail matrix, proximal to the eponychial fold.
Harris PA, Nanchahal J (Charing Cross Hosp, London)
Closed Continuous Irrigation in the Treatment of Hand Infections
J Hand Surg [Br] 24B: 328-333, 1999
A small, perforated infant feeding tube is placed within a larger perforated tube and enclosed within the infected hand space. This setup ensures system patency while permitting hand therapy. The technique was modified to allow tubes to be positioned within the flexor sheath with minimal access. Closed continuos irrigation was applied.
Hand irrigation with normal saline was carried out for a mean of 3.5 days. All regained complete function.
The small-caliber, flexible tubes can be introduced into the flexor sheath without unduly increasing sheath pressure.
The hardest thing for the author has always been to judge the amount of fluid needed to adequately “wash out the infection” and not to increase the pressure, which increases the pain within the hand.
Rettig ME, Raskin KB (New York Univ)
Retrograde Compression Screw Fixation of Acute Proximal Pole Scaphoid Fractures
J Hand Surg [Am] 24A: 1206-1210, 1999
Displaced fractures of the scaphoid usually heal with difficulty because fragment offset, gapping, mobility, and angulation compromise the healing process.
Open reduction and internal fixation were performed in 17 consecutive patients (1 female; aged 16-37 years) with unstable acute proximal pole scaphoid fractures. Operations were performed an average of 15 days after injury.
Patients were evaluated at 12 to 63 months. No postoperative complications occurred. No patients required hardware removal or additional surgical reconstruction.
Retrograde compression screw fixation of acute unstable proximal pole scaphoid fractures achieved 100% healing in an average of 10 weeks.
Watson HK, Weinzweig J, Guidera PM, et al (Connecticut Combined Hand Service, Hartford, New Haven, and Worcester, Mass)
One Thousand Intercarpal Arthrodeses
J Hand Surg [Br] 24B: 307-315, 1999
Limited wrist arthrodesis is a useful treatment for specific carpal disorders, maximizing residual wrist motion and strength while eliminating pain.
One thousand seventy-seven procedures were performed. Seven hundred ninety-eight patients underwent triscaphe arthrodesis because of rotary subluxation of the scaphoid, degenerative joint disease, Kienbock disease, midcarpal instability, traumatic dislocations, and congenital synchondrosis of the triscaphe joint.
Two hundred fifty-two patients underwent scapholunate advanced collapse (SLAC) wrist reconstruction because of chronic rotary subluxation of the scaphoid, established scaphoid nonunion, advanced radioscaphoid SLAC, advanced midcarpal SLAC, distal radial fracture resulting in dislocation or disruption of the scaphoid fossa, congenital preaxial hypoplasia, fracture of the capitatum and Preiser disease.
Twenty-five patients underwent 27 lunatetriquetral (LT) arthrodeses, indicated by LT instability, degenerative arthritis of the LT joint.
All types of intercarpal arthrodeses had low complication rates. Patient satisfaction was high. Because the radial styloidectomy was included with triscaphe arthrodesis, no secondary changes of degenerative arthritis occurred. This series of limited wrist arthrodeses is the largest reported to date.
Watson clearly brings into focus the importance of a full understanding of both the indications of arthrodesis and the technique necessary to provide a successful outcome.
Wright JB, Lam K, Hansen D, et al (Westaim Biomedical Corp, Fort Saskatchewan, Alberta)
Efficacy of Topical Silver Against Fungal Burn Wound Pathogens
Am J Infect Control 27:344-350, 1999
Fungal infections of burn wounds are now an important cause of burn-related morbidity and mortality rates. Fungal inocula were placed in contact with mafenide acetate, silver nitrate, silver sulfadiazine, and a nanocrystalline silver-coated dressing.
The nanocrystalline silver-coated dressing provided the fastest, broadest-spectrum fungicidal activity.
The use of nanocrystalline silver-coated dressings may minimize the potential of fungal infections among patients with burn wounds, decreasing complications that delay wound healing.
This study of a new nanocrystalline silver-based dressing is very promising in vitro against both bacteria and fungi. Fungal infection complicating burns has a high mortality rate, and thus, it would be hoped that in vivo studies will be forthcoming.
As organisms are suppressed or eradicated, a new pathogen fills the now vacant ecologic niche and presents a host of new problems. Thus, ongoing research in antimicrobial agents must be encouraged, because there is no perfect agent and never will be.
Yasuhara S, Kanakubo E, Perez M-E, et al (Harvard Med School, Boston; Univ of Tokyo; Cleveland Clinic Found, Ohio)
Burn Injury Induces Skeletal Muscle Apoptosis and the Activation of Caspase Pathways in Rats
J Burn Care Rehabil 20:462-470, 1999
Patients with burns exhibit altered protein kinetics and muscle weakness, among other metabolic disorders. Apoptosis is a possible cause of loss of muscle mass.
Activation of stress-activated protein kinase was noted in muscle tissue soon after the burn injury, which supports the involvement of ceramide in burn-induced apoptosis. Muscle tissue from burned animals also showed activation of caspase-1, -3, and -9, which are final apoptotic enzymes.
Burn injuries in rats are associated with the occurrence of apoptosis in skeletal muscle.
This excellent basic science study is both disturbing and exciting. It is extremely disturbing, because clinicians have always associated weakness and muscle-wasting post-thermal injury with poor nutrition and negative nitrogen balance, and the deconditioning that occurs in the bed-bound patient, or both.
There was no difference in caloric intake in these groups and, yet there was significant difference in muscle function.
The work is exciting, because once the pathways are understood, there is the potential for therapeutic intervention to eradicate the problem.
Stoner ML, Wood FM, (Princess Margaret Hosp, Perth, Australia; Royal Perth Hosp, Australia)
The Treatment of Hypopigmented Lesions With Cultured Epithelial Autograft
J Burn Care Rehabil 21:50-54, 2000
Hypopigmentation is a frequent occurrence after deep, partial-thickness burns. The technique of cultured epithelial autograft (CEA) has enabled the authors to produce large areas of pigmented epidermis from a small donor site.
Epidermal cells cultured from dark-skinned patients produce pigment within the epidermal cell sheets, indicating the presence of melanocytes.
There are several advantages to the use of CEA to treat hypopigmented lesions. Most important is that the treated area pigments to match the color of the adjacent normal skin. A large quantity of pigmented CEA is easily obtainable from a very small donor site.
The technique is easily performed with minimal patient discomfort. Scar potential is minimal because the dermabrasion is superficial. CEA offers a simple and effective method for treating depigmentation resulting from deep, partial-thickness burns.
Zak AL, Harrington DT, Barillo DJ, et al (US Army Inst of Surgical Research, Fort Sam Houston, Tex)
Acute Respiratory Failure That Complicates the Resuscitation of Pediatric Patients With Scald Injuries
J Burn Care Rehabil 20: 391-399, 1999
Although respiratory distress in children after scald burns is rare, the ability to predict which patients are at risk would facilitate management. Management of pediatric patients needing endotracheal intubation and mechanical ventilation after scald burn injury was examined in an attempt to define an at-risk population for this complication.
Discriminant function analysis determined that larger burn size and younger age were independent predictors of the need for mechanical ventilation.
Scald-induced respiratory failure in younger children may be caused by over-resuscitation that leads to excess edema formation in the upper and lower airways. Edema can exacerbate airway resistance problems in younger children because of the smaller cross-sectional area of their airways. The functionally immature renal tubules of children younger than 2 years also cannot appropriately concentrate urine, which may add to increased fluid requirements.
Children younger than 2 years who have large scald burn areas are at increased risk of respiratory failure.
Urine output should certainly be monitored hourly and fluids titrated accordingly. If oral, nasogastric, and IV fluids are given simultaneously, titration of intake has to be governed by urine output. Daily weights will provide a guide if too much or too little fluid has been given, and the urine sodium remains an excellent indicator for the status of circulating volume.
Antell DE, Taczanowski EM (Columbia Univ, New York)
How Environment and Lifestyle Choices Influence the Aging Process
Ann Plast Surg 43: 585-588, 1999
The mechanism by which aging affects physical appearance has not yet been determined, although several theories exist. Both genetic and environmental influences are suspected to contribute, but it is not known whether one or the other dominates.
To study environmental effects, the impact of which may be controlled, identical twins were chosen, thus eliminating as much as possible the influence of genetics.
The appearances of twins with radically different lifestyles differed most notably, while those with nearly identical lifestyles differed little.
The factors that created the greatest discrepancies were substance or alcohol abuse, sun exposure, and emotional stress.
An acceleration of the aging process, as revealed by physical appearance, can be produced by exposure to environmental and lifestyle factors that take a toll on the skin. This effect is independent of genetic influences.
Exercise, diet, and avoidance of toxins all will lead to a better result.
Shafir R, Cohen M, Gur E (Tel-Aviv Univ, Israel)
Blindness as a Complication of Subcutaneous Nasal Steroid Injection
Plast Reconstr Surg 104: 1180-1182, 1999
Intranasally injected drugs – especially steroids – can cause blindness. Although this complication has been reported in the ophthalmology and otolaryngology literature, it has not been described in the plastic surgery literature.
Permanent blindness resulting from steroid injection into the nasal dorsum is a rare complication caused by microemboli of the injected suspension, resulting in occlusion of retinal or choroidal vessels.
This occurs more often with steroids but has also been reported with injections of any material in the midface from the glabella to the nasolabial fold, as well as the turbinates.
Troilius C (Plastikkirugi Centrum, Malmo, Sweden)
Ultrasound-Assisted Lipoplasty: Is It Really Safe?
Aesthetic Plast Surg 23: 307-311, 1999
US-assisted liposuction (UAL) specifically targets the adipocytes, but the procedure leaves patients tired and sometimes anemic.
Patients who have undergone UAL experience significant blood and albumin loss 1 week postoperatively.
Clearly, there is more blood loss than we have been led to believe, and we need to collect more data on UAL in this regard. Since we do not see the blood, where is it going, is it lost in the third space or does UAL render the cell colorless? Based on these studies, we certainly should treat our patients as iron-deficient and use ferrous sulfate preoperatively and postoperatively.
Talmor M, Fahey TJ II, Wise J, et al (New York Presbyterian Hosp-Cornell Med Ctr)
Large-Volume Liposuction Complicated by Retroperitoneal Hemorrhage: Management Principles and Implications for the Quality Improvement Process
Plast Reconstr Surg 105: 2244-2248, 2000
Liposuction is regarded as a safe and efficacious procedure, particularly when the tumescent technique is used. It is occasionally associated with major medical complications and even death.
A patient was described who underwent large-volume liposuction and had exsanguinating retroperitoneal hemorrhage that caused cardiopulmonary arrest.
Large-volume liposuction is not a minor procedure, and patients need to be monitored carefully. Hemodynamic instability is an otherwise healthy patient may be caused by fluid overload, lidocaine toxicity, or hemorrhagic shock. This must be recognized and treated aggressively.
Gerber B, Krause A, Reimer T, et al (Univ of Rostock, Germany)
Breast Reconstruction With Latissimus Dorsi Flap: Improved Aesthetic Results After Transection of Its Humeral Insertion
Plast Reconstr Surg 103: 1876-1881, 1999
The latissimus dorsi flap usually gives good cosmetic results in breast reconstruction, although some patients report an unpleasant feeling of a bulge in the axillary region.
Among women undergoing immediate latissimus dorsi flap breast reconstruction, cutting the tendinous insertion improves the cosmetic result while avoiding an unpleasant axillary bulge. This is a safe technique that provides for complete mobilization of the latissimus dorsi flap.
Division of the humeral head of the latissimus dorsi increases the surgeon’s flexibility in shaping the reconstructed breast and does, indeed, remove the offending axillary bulge.
Rohrich RJ, Trott SA, Love M, et al (Univ of Texas, Dallas)
Mersilene Suture as a Vehicle for Delivery of Growth Factors in Tendon Repair
Plast Reconstr Surg 104: 1713-1717, 1999
Numerous studies indicate that exogenous growth factors enhance wound healing. An in vitro model was used to investigate the possibility of delivering growth factor to wounds by binding the growth factor to sutures.
None of the tissue samples showed any bacterial infection. Sutures treated with epidermal growth factor showed significant cellular proliferation by day 7. Sutures treated with platelet-derived growth factor also showed significant cellular proliferation, but to a lesser degree.
Epidermal growth factor (which exerts its mitogenic effects on fibroblasts) was more effective in promoting cellular proliferation than was platelet-derived growth factor (which exerts its primary effect on mesenchymal cells). Further research is needed to confirm that these results are applicable to an in vivo model.
This would be particularly useful in areas where growth factors cannot be easily reapplied, such as the deep tissues of the fascia, intestinal tract, or joint structures. Hopefully, the authors are expanding their models and considering human trials.
Brown SA, Mayberry AJ, Mathy JA, et al (Duke Univ, Durham, NC; George Washington Univ, Washington, DC)
The Effect of Muscle Flap Transposition to the Fracture Site on TNFa Levels During Fracture Healing
Plast Reconstr Surg 105: 991-998, 2000
Open fractures in humans are associated with a complex wound-healing process. This process involves the production of various types of cytokines, including tumor necrosis factor a (TNF-a). A dog model of high-energy open fracture was used to study the effects of injury, repair, and infection on levels of TNF-a.
Open tibial fracture in dogs is associated with a significant increase in TNF-a level at the fracture site. The TNF-a level is not further increased by inoculation with S aureus, but muscle flap placement reduces TNF-a level.
The results underscore the importance of measurement of cytokine levels in wound fluid rather than in serum.
The authors show that by closing the wound they are able to decrease TNF-a levels. This article adds to our understanding of how wound closure procedures improve healing.
Greif R, for the Outcomes Research Group (Donauspital, Vienna; et al)
Supplemental Perioperative Oxygen to Reduce the Incidence of Surgical-wound Infection
N Engl J Med 342: 161-167, 2000
One of the factors that influence the incidence of surgical-wound infection is the oxygen tension in the tissue.
A simple way to improve oxygen tension is to increase the concentration of inspired oxygen.
The administration of supplemental oxygen during colorectal surgery and for 2 hours after surgery reduced to half the incidence of surgical-wound infection. The costs and risks of this practice are minimal and may reduce the incidence of this dangerous and expensive complication.
Parr AM, Zoutman ZE, Davidson JSD (Queen’s Univ, Kingston, Ontario)
Antimicrobial Activity of Lidocaine Against Bacteria Associated With Nosocomial Wound Infection
Ann Plast Surg 43: 239-245, 1999
The antimicrobial activity of local anesthetics may have implications for management of postoperative wounds.
The susceptibility to lidocaine of clinical isolates of vancomycin-resistant enterococci (VRE) and methicillin-resistant Staphylococcus aureus (MRSA) was also studied.
Lidocaine inhibited growth in all strains of bacteria tested in a dose-dependent manner. Gram-negative organisms showed the greatest sensitivity to lidocaine, and S aureus was the least-sensitive organism. The addition of epinephrine to the lidocaine had no effect on the susceptibility of the bacteria.
Lidocaine may play a prophylactic role in the treatment of surgical wound infection, particularly in the setting of methicillin-resistant and vancomycin-resistant bacteria.
This work documents that lidocaine is safe and possibly beneficial in the setting of local soft tissue infection.
Van Landuyt K, De Cordier BC, Monstrey SJ, et al (Univ Hosp of Gent, Belgium)
The Antecubital Fasciocutaneous Island Flap for Elbow Coverage
Ann Plast Surg 41: 252-257, 1998
It can be difficult to reconstruct soft tissue defects in the periolecranon area, which are most often related to chronic inflammation of the olecranon bursa.
The defect after excision of the infected bursa cannot usually be closed primarily. The antecubital fasciocutaneous island flap is proposed for use in covering soft tissue defects in the area around the olecranon.
The antecubital fasciocutaneous island flap is a useful technique for resurfacing of small to medium-sized soft tissue defects of the periolecranon area.
It provides thin, pliable, sensitive skin for transfer to the elbow in a single-stage procedure, without additional scarring around the defect. Flap harvest is relatively simple, with little impact on forearm contour.