摘要:

The mortality rate for poststernotomy infection, which occurs in as many as 5% of median sternotomy incisions after cardiovascular surgery, was 37.5% until sternal debridement with muscle or omental flap reconstruction became the standard treatment for this postoperative complication and lowered the mortality rate to just more than 5%. There are few reports in the literature of physical functional deficits and long-term outcome resulting from such reconstruction. The authors evaluated two groups of patients who had undergone coronary bypass surgery at least 6 months earlier. One group had no postoperative complications; the other group had developed marked sternal wound infections that required debridement and pectoralis major or rectus abdominis muscle reconstruction. Both groups underwent pectoralis and rectus muscle strength testing, evaluation of pain and ability to perform those activities of daily living that are dependent on pectoral and rectus muscle function, and completed self-assessment questionnaires. Differences between the two groups were significant (p < 0.05) with regard to pain and patient satisfaction with appearance and general functional capacity. Pectoral muscle function and strength were significantly different in patients in whom that muscle was transposed. Rectus muscle strength was not affected by the transposition of a single rectus muscle. Physical morbidity and loss of strength seemed to be related directly to loss of sternal stability stemming from marked infection and debridement rather than from loss of the muscles used in reconstruction.

ISSN:0148-7043    

出版商:OVID    

年代:2003

数据来源: OVID

ISSN:0148-7043    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

Defects after extirpation of either sacral or rectal tumors often present a reconstructive challenge to plastics surgeons. Because of their relative infrequency, management guidelines, in the authors’ opinion, have been overlooked. They think that successful, comprehensive treatment lends itself to an integrated team approach. They review their experience with immediate reconstruction after total sacrectomy for sacral malignancies performed between 1996 and 2001. Medical records were reviewed retrospectively for the surgical procedure, postoperative complications, and eventual outcome. A total of 9 patients underwent sacrectomy with a gluteus maximus flap for reconstruction. Six patients had a simultaneous omental flap for complete obliteration of the surgical defect. The authors’ experience suggests that this combination of techniques is a reliable approach for reconstruction of these extensive surgical defects.

ISSN:0148-7043    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

The authors describe the results of fat thickness patterning of the abdominal sites in 50 patients, all of whom required breast reconstruction with a transverse rectus abdominis musculocutaneous flap. The thickness of the abdominal fat was measured at 12 anatomic locations with an ultrasonic instrument. The highest value of the subcutaneous fat thickness was 29.0 ± 10.0 mm at a site 2 cm below the umbilicus at the center of the rectus abdominis muscle. The lowest value of the subcutaneous fat thickness was 17.8 ± 7.6 mm at a site 2 cm above the umbilicus on the anterior superior iliac spine. Average subcutaneous fat thickness over the abdomen of 50 patients was 24.0 ± 9.4 mm. There were 13 patients (group 1) who had an abdominal fat thickness of more than 30 mm, 19 patients (group 2) with an abdominal fat thickness less than 30 mm and more than 20 mm, and 18 patients (group 3) with an abdominal fat thickness less than 20 mm. Complications occurred in 12 of 50 flaps (24%). Among groups 1, 2, and 3 there was no significant difference (p < 0.01) in the overall flap complications (15.4: 36.8: 16.7). In summary, subcutaneous fat thickness showed the higher value at the center of the abdomen and the lower value at the lateral site. Abdominal fat thickness is not a risk factor for necrosis of pedicled transverse rectus abdominis musculocutaneous flaps in patients who are thin, average, or mildly obese. Preoperative examination of the abdominal subcutaneous fat thickness should provide useful information for detailed simulation of a reconstructive operation.

ISSN:0148-7043    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

Improved microsurgical technique has resulted in a high percentage of successful free tissue transfers. When a tissue transfer fails in the head and neck, however, the results are orocutaneous fistulas, carotid artery exposure, and deformity that adds morbidity, expense, and may delay adjuvant therapy. Postoperative monitoring of tissue perfusion can detect early problems in free tissue transfer that may allow for early intervention and salvage. The authors have demonstrated that reflectance photoplethysmography can detect perfusion changes in free tissue transfer within 5 minutes of a pedicle “insult” intraoperatively. Normative data for viable flaps from various donor sites have been established. The authors now report their initial experience with a newly developed reflectance photoplethysmograph based on a hand-held computer for routine clinical use. Their results are compared with a conventional surveillance protocol that included observation, bleeding to pin prick, and bedside duplex scanning of the vascular pedicle. In a series of 30 free tissue transfers (29 patients), there was one ischemic event (skin paddle loss only), which was detected by the monitor. The monitor was able to predict correctly (one flap) survival of a free tissue transfer even when duplex ultrasonic data were indicative of an absence of perfusion. Personal digital assistant-based photoplethysmography appears to be a promising device for bedside diagnosis of free tissue transfer viability or ischemia.

ISSN:0148-7043    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

The purpose of this study was to determine the important prognostic factors for recovery of tendon function as measured by total active movement (TAM) in patients undergoing digital replantation. More important, the authors wanted to establish which factors may be manipulated to maximize motion. A retrospective review of 48 patients (103 digital rays) who underwent replantation was performed. Average TAM for all digits was 129 deg. Zone 1 and zone 5 injuries had better TAM than injuries in zones 2, 3, and 4, which had TAM values not significantly different from one another. Avulsion injuries fared significantly worse than other mechanisms of injury. TAM values were not affected by age, type of bone fixation, number of arteries repaired, or number of digits injured. Digits with both the profundus and the superficialis tendons repaired had significantly better TAM values relative to one-tendon fingers. Similarly, fingers treated with an “early” mobilization regime also exhibited better movement. Small numbers of injured digits in some groups may have limited our ability to detect significant differences.

ISSN:0148-7043    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

Surgical treatment of severe, necrotizing infections frequently leave compound defects that require complex reconstructive procedures. In the upper extremity, local flap coverage is limited because of the size of the lesions. Regarding the results of early microsurgical coverage of complex postinfectious defects of the lower extremity, the goal of this study was to evaluate the role of free tissue transfer in the treatment of severe infections in the upper extremity. Between 1994 and 1999, 24 patients with major defects as a result of severe necrotizing infections in the upper extremity underwent free tissue transfer. Parameters assessed included the success of infection control, flap survival rate, salvage of the extremity, and an outcome analysis by the Disability of Arm–Shoulder–Hand score and a visual analog scale. Patient age ranged from 17 to 75 years (average age, 50.8 years). Previous treatment of 11 patients in outlying hospitals included 4.2 operative procedures and a delay of admission to the authors’ unit of 89 days. The average defect size after debridement was 10.0 × 14.4 cm. Twenty-four free flaps including 16 muscle or musculocutaneous flaps, 4 chimeric flaps from the subscapular system, and 4 osteocutaneous flaps were performed for reconstruction. The overall flap survival was 95.8%. One temporalis fascia flap (TPF) was lost as a result of vascular thrombosis, and three flaps underwent successful revision of the anastomoses. Eight patients required further minor surgical treatment. The Disability of Arm–Shoulder–Hand score yielded an average of 41.5 points, which represents a moderate impairment of activities of daily living. Visual analog scale assessment demonstrated an overall high satisfaction (9.5 points; range, 1–10 points). The data demonstrate that even in severe necrotizing infections resulting in complex acute or chronic defects, limb salvage and infection control can be achieved successfully with radical debridement and early free tissue transfer.

ISSN:0148-7043    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

Wide excision of extramammary Paget's disease of the penoscrotal region may leave large defects that cannot be closed easily. The authors describe their experience with a series of 6 patients in whom reconstruction of the scrotal defect was undertaken using the scrotal remnant raised as a stretchable musculocutaneous flap. It was observed that as little as a third of the residual scrotum could be expanded to resurface the entire scrotum. All flaps survived completely. Severe scrotal edema and ecchymosis were observed in 1 patient but the symptoms resolved completely with Trendelenburg positioning. The penile defects were resurfaced individually with thick skin grafts. Good-quality take with no chordee was observed in all patients after initial reconstruction. One patient developed penile contracture after reexcision of recurrent disease. Mean follow-up was 22 months (range, 3–60 months). Large defects of as much as two thirds of the scrotum may be reconstructed successfully using the tissue-expanding scrotal musculocutaneous flap.

ISSN:0148-7043    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

Hemifacial microsomia is a craniofacial disorder involving structures derived from the first and second brachial arches. Bony structures, soft tissue, and the facial nerve can all be hypoplastic or absent. In this retrospective study of 70 patients at the Children's Hospital Los Angeles, craniofacial dysmorphology, temporal bone computed tomography, and audiological evaluations were examined. The purpose of this study was to identify further relationships between clinical findings, temporal bone anatomy, and audiological findings in these patients. Significant relationships were identified between total radiographic score and overall clinical findings (p< 0.001). Clinical measurements of mandibular hypoplasia were also predictive of temporal computed tomographic findings (p< 0.001), whereas clinical ear findings were related specifically to specific temporal bone abnormalities such as hypoplasia of the middle ear (p= 0.008) and fusion or absence of ossicles (p< 0.001). Interestingly, neither clinical findings nor temporal bone computed tomographic findings were related to either hearing loss type or degree. Audiology should not be deferred on the basis of relatively mild clinical findings.

ISSN:0148-7043    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

Children with metopic synostosis have a well-described clinical picture of trigonocephaly, often with hypotelorbitism. The craniofacial disorder itself is well recognized; however, objective prognostic factors for predicting the risk of reoperation are not well known. In 39 children with metopic synostosis, measurements of the cranial length, cranial width, anterior intercoronal distance, anterior interorbital distance (intercanthal distance), lateral orbital distance, and interzygomatic buttress distance were taken from preoperative computed tomographic (CT) scans and were normalized relative to each child's age. To separate overall facial hypoplasia from regional hypoplasia, a ratio of intercanthal distance to interzygomatic buttress distance was determined. These prognostic factors were analyzed with respect to reoperation rate. A stepwise logistic regression analysis was used to determine the interrelationships between the prognostic factors. Twenty-eight percent of the children underwent reoperation (N = 11, 1 total reoperation and 10 minor recontouring). All of the reoperations occurred in children with a decreased intercanthal distance (p= 0.30). The ratio of intercanthal distance to midfacial width was related to reoperation rate, with those children who had a ratio ≤ 0.80 having a reoperation rate of 44% (8 of 18 total children with an intercanthal-to-zygomatic ratio ≤ 0.8,p= 0.07). This relationship was significant in children younger than the age of 12 months (6 of 13 total children with an intercanthal-to-zygomatic ratio ≤ 0.8, 46% reoperation rate,p= 0.006). This study suggests that preoperative CT measurements can be used as a means of risk stratification in outcome analyses of the surgical treatment of craniosynostosis. In children treated for metopic suture synostosis, a foreshortened intercanthal distance compared with the interzygomatic buttress distance was related to reoperation rate, especially in children younger than 12 months of age.

ISSN:0148-7043    

出版商:OVID    

年代:2003

数据来源: OVID