RESUMO

Closure of the radial forearm flap donor site has been achieved by triangulating the defect and using a full-thickness skin graft from the adjacent volar forearm. Coverage of the flexor carpi radialis tendon has been more robust, and the aesthetic results have been superior to split-thickness skin-graft coverage of the forearm flap donor site.

Assuntos

RESUMO

Free tissue transfer of a jejunal segment was undertaken for laryngopharyngoesophageal reconstruction in 20 patients who received postoperative irradiation therapy. Treatment consisted of 1.8- to 2-Gy-fractions, the average total dose was 55.57 Gy (range, 40 to 66 Gy). Anastomotic strictures (six) were encountered early in the series and associated with stapled anastomoses. Hand-sewing the jejunoesophagostomy eliminated the problem. Enteric cutaneous fistula, bowel necrosis, and hemorrhagic enteritis were not observed. We conclude that the application of postoperative irradiation therapy to patients requiring jejunal interposition grafts is feasible.

Assuntos

RESUMO

Fifty consecutive patients with acute and chronic ischemia of the hand were investigated by Allen testing, Doppler ultrasound, digital plethysmography, and angiography over a 4-year period. The pathophysiologic mechanism responsible for the ischemia was determined to be emboli in 6%, vasospasm in 10%, thrombosis or "sludging" in 28%, occlusive disease in 26%, and occlusive disease associated with either vasospasm or external compression in 30%. Ten patients required emergency medical treatment with intraarterial streptokinase, intravenous heparin, or dextran 40 and continuous stellate ganglion blocks, and three patients required emergency microsurgical revascularization because of radial artery thrombosis. Patients with chronic ischemia of the hand were maintained on nifedipine, 30 to 60 mg daily, and pentoxifylline, 1200 mg daily. Seven patients underwent digital sympathectomy and 14 patients underwent microsurgical revascularization as prophylactic procedures for chronic digital ischemia. Amputations were required in 18 patients because of end-stage gangrene. Long-term follow-up revealed a 20% incidence of recurrent digital ulcerations. There have been six deaths during follow-up, five of them due to myocardial infarction; this reflects the underlying systemic arteriopathy in many of these patients.

Assuntos

RESUMO

During the 5-year period from July of 1984 to July of 1989, we performed 94 free-tissue transfers in 92 patients over the age of 50 whom we arbitrarily defined as "elderly." There were 32 patients in the age range between 50 and 59 years, 40 patients aged between 60 and 69 years, and 20 patients aged between 70 and 79 years. Seventy-one flaps were utilized for head and neck reconstruction, and 23 flaps were used in reconstruction of the trunk and extremities. There was 1 total flap loss, for a flap viability rate of 99 percent (93 of 94). Postoperative complications were classified into surgical (technical) and medical categories. There were 14 major surgical complications (15 percent) and 13 significant postoperative medical problems (14 percent). The majority of these complications occurred in head and neck cancer patients in the age group between 60 and 69 years, who had significant underlying medical problems and were preoperatively classified as ASA 3. There were 5 postoperative deaths, for a mortality rate of 5.4 percent (5 of 92 patients).

Assuntos

RESUMO

Nine patients with extensive wounds of the hip joint due to chronic infection following total hip arthroplasty or internal fixation of fractures of the femoral head and neck have been treated by serial radical debridements to remove infected bone, contaminated remnants of bone cement, and the surrounding fibrotic soft tissues. The resultant deep cavity extending down to the acetabulum has then been obliterated with either pedicled muscle flaps or free muscle flaps. Subcutaneous or transpelvic transposition of rectus abdominis muscle flaps is preferred for smaller defects, but only the free latissimus dorsi muscle flap provides sufficient volume of tissue to obliterate the more extensive hip defects. Systemic antibiotics have been continued only for a short-term course of 14 days postoperatively. There has been no recurrence of infection, with follow-up ranging between 6 months and 3 1/4 years. One patient has undergone reimplantation of a second custom hip prosthesis into the vascularized bed of a free latissimus dorsi muscle flap.

Assuntos

RESUMO

Gastric pull-up or free jejunal interposition was used for reconstruction after total laryngopharyngectomy in 31 patients. Complications and functional outcomes of the two methods are compared. Primary swallowing was achieved in 86% of patients after gastric pull-up and in 82% of patients after jejunal interposition. Patients who underwent jejunal interposition were able to swallow sooner and had a shorter hospital stay than patients who underwent gastric pull-up. Esophageal tumor recurrence after jejunal interposition was not observed. Hepatic failure occurred in two gastric pull-up patients, leading to perioperative death in one. Flap necrosis occurred in two jejunal interposition patients and one gastric pull-up patient. Two additional fistulas occurred in jejunal interposition patients as a result of microvascular complications. Stricture developed in four jejunal interposition patients, requiring revision surgery in two. Minor complications were more common in the gastric pull-up group. Long-term speech and swallowing function are compared. Our current choice of jejunal interposition or gastric pull-up for reconstruction after total laryngopharyngectomy primarily depends on the location of the tumor.

Assuntos

RESUMO

Twenty-one patients with gigantic defects of the scalp and middle third of the face and palate following excision of neglected or recurrent tumors, burns, and infections have undergone microsurgical reconstruction. Wide resection of the middle third of the face, orbit, and palate requires "complex" three-dimensional volume reconstruction, whereas extensive defects of the scalp and skull (exceeding 80 cm2) require coverage of the larger surface area soft-tissue defect and the exposed brain and dura. The latissimus dorsi free-muscle flap and split-thickness skin graft have become our methods of choice for extensive scalp and skull defects. The latissimus dorsi musculocutaneous free flap is preferable for reconstruction of complex palatal and external skin and orbital defects of the middle third of the face. Microsurgical free-tissue transfer reliably frees the oncologic surgeon from the constraints imposed by conventional reconstructive techniques and may therefore allow improved curative or at least palliative resection of these extensive tumors.

Assuntos

RESUMO

Teratoma is the most common nasopharyngeal tumor in neonates. The tumor is usually limited to the oropharynx and is manifest by stridor and respiratory distress. Complete excision affects a cure. An unusual case of nasopharyngeal teratoma extending into the temporal bone, causing facial paralysis and conductive hearing loss, in addition to stridor, is presented. Stridor was relieved by transoral partial excision shortly after birth. Complete removal of the tumor by way of a subtemporal and infratemporal fossa approach was performed at 14 months of age. The defect was filled with a rectus abdominis muscle graft with microvascular anastomoses. The facial nerve was reconstructed secondarily with a sural nerve graft. The patient has no recurrence tumor and has good facial function at 30 months. This case demonstrates the first known case of facial paralysis due to nasopharyngeal teratoma. The surgical approach for tumor removal: lateral infratemporal fossa dissection, and the method of reconstruction: free rectus abdominis muscle flap with microvascular anastomoses, had so far not been described in a patient this young.

Assuntos

Assuntos

RESUMO

An epidemiologic survey of 24 members of a three-generation family revealed an unusually high incidence of mallet fingers. Twenty mallet fingers were found in seven family members by clinical examination, suggesting a familial predisposition to develop this deformity. Multiple mallet fingers (range, two to six) occurred in four individuals. Classification of these mallet fingers based on the mechanism of injury demonstrated a high incidence (85%) resulting from minimal trauma or occurring spontaneously. Symptoms and signs of bilateral carpal tunnel syndrome were documented in five family members with mallet fingers (71%), and three individuals with mallet finger deformities also had associated trigger fingers (43%).

Assuntos