Management of perineal wounds following abdominoperineal resection with inferior gluteal flaps.

Our experience treating perineal wounds secondary to abdominoperineal resection, either for inflammatory bowel disease or cancer, is presented. A total of 16 patients were treated either on a delayed basis or at the same time as the abdominoperineal resection. All wounds were closed using the inferior gluteal myocutaneous flap. Fifteen of 16 patients have achieved healing, eight of whom had no complications. Only minor revisions or local wound care were required in the remaining patients, with only one patient failing to heal. Our results compare favorably with previous reports of treatment of this difficult problem.

Single-stage complete muscle flap closure of the postpneumonectomy empyema space: a new method and possible solution to a disturbing complication.

The management of postpneumonectomy empyema remains a disturbing and controversial area in the field of thoracic surgery. Many methods have been described and have had varying degrees of success. We present a series of 5 consecutive patients who underwent single-stage complete muscle flap closure of the pneumonectomy space with extrathoracic muscle flaps and omental grafts between October, 1981, and April, 1983. Two men and three women ranging from 37 years to 64 years old underwent such a closure from 3 to 13 months after original resection. Two patients had associated bronchopleural fistula. Prior to closure, 3 patients were managed with chest tubes and 2 with a modified Eloesser procedure. All operations were single-stage procedures, and all wounds closed primarily, with no permanent tubes or chest wall openings. There was no morbidity or mortality, and no subsequent operation has been required. Single-stage complete muscle flap closure of the postpneumonectomy empyema space has not been described previously, and we think it offers a possible solution to this potentially fatal complication.

Use of free latissimus dorsi musculocutaneous flaps in various neurosurgical disorders.

Musculocutaneous (skin-muscle) flaps have been used predominantly by plastic surgeons for a variety of reconstructive purposes. With the advent of microvascular techniques, the area to be reconstructed is no longer limited to the arc of rotation of the vascular pedicle of the muscle. Instead, the muscle and overlying skin that is best suited for the reconstructive procedure may be dissected out as a free flap, with microvascular anastomosis of an arterial supply and venous drainage to locally existing vessels. This report demonstrates the usefulness of musculocutaneous free flaps in the repair of large defects of the scalp, cranium, and dura after trauma or resection of invasive neoplasms. The authors describe the use of a latissimus dorsi free musculocutaneous flap in eight patients who would have required multiple operations to provide coverage by other techniques. There have been no major complications, and adequate repair has been accomplished, even in cases involving exposed brain.

The use of greater omentum vascularized free flaps for neurosurgical disorders requiring reconstruction.

The heterotopic transfer of composite tissue, with microvascular anastomosis of an arterial supply and venous drainage to locally existing vessels, has received considerable attention in the plastic surgical literature. The use of latissimus dorsi musculocutaneous free flaps has been reported in the repair of large defects of the scalp, cranium, and dura following resection of invasive neoplasms or trauma. When the defect involves primarily subcutaneous tissue loss resulting in abnormal contour, omental free flaps provide effective coverage and restoration of contour. In addition, the inherent capability of the omentum to combat infection and form an ideal bed for the establishment of skin or bone grafts provides further indications for its use. The authors have used omental free flaps in nine cases to reconstruct gunshot wounds of the head, orbit, and face, heal chronic cavitating frontal sinus infections, form a base over exposed dura for reconstruction of the skull with rib grafts, and cover large defects after resection of invasive tumors or infected scalp. These wounds of neurosurgical interest were reconstructed with acceptable structural and aesthetic results. The indications, surgical techniques, results, alternative procedures, and potential complications of this procedure are discussed. The authors believe that omental free flaps should be considered an option in the armamentarium of reconstructive approaches for skull, dural, scalp, orbital, and facial wounds.

Pathways linking the olfactory bulbs with the medial preoptic anterior hypothalamus are important for intermale aggression in mice.

Manipulations affecting olfaction, as well as bilateral lesions of the medial preoptic anterior hypothalamic (MPAH) continuum, decrease intermale aggression in mice. In the present study, unilateral removal of an olfactory bulb was combined with a contralateral lesion of the MPAH. This surgery, like bulbectomy and bilateral lesions of the MPAH, substantially decreased aggressive behavior. This surgery bilaterally destroys the ipsilateral links between the olfactory bulbs and the MPAH, and it is this disruption that presumably causes the decrease in aggression. The effect is not due to removal of an olfactory bulb combined with hypothalamic damage per se, because ipsilaterally lesioned/bulbectomized males continued to fight without decrement after surgery. These results provide compelling evidence that multisynaptic neural pathways linking the chemosensory systems of the olfactory bulbs with the rostral hypothalamus are involved in the regulation of intermale aggression in mice.

Persistent tracheostomy stoma.

Prolonged presence of a tracheostomy tube or prolonged tracheostomy stoma can result in a failure of spontaneous closure. The stoma may remain open until surgically closed. Muscle flaps as well as skin flaps can be used to close the persistent tracheostomy stoma. These flaps seal the stoma, provide soft tissue between the trachea and the skin, and allow a satisfactory cosmetic result. The sternohyoid muscle is readily accessible for this purpose. This procedure was used in five patients with a satisfactory result in each.

Platysma musculocutaneous flap: clinical and anatomic considerations in head and neck reconstruction.

The platysma musculocutaneous flap was used in 14 patients for reconstruction of the oral lining and external skin coverage in the head and neck area. Complications occurred in five patients. Only one patient, however, required further surgery and this was for correction of a poor cosmetic result. The skin and subjacent muscle are supplied by a major vascular pedicle from the facial artery and vein and a minor pedicle from the transverse cervical artery and vein. Either pedicle can be used as the pivot for the flap's arc of rotation. The donor defect can be closed primarily and did not present any problems. The flap can be raised with both its motor and sensory supply intact. The thinness and pliability, color match, and proximity make this flap a useful adjunct in head and neck surgery.

Ten years experience with the free jejunal autograft.

Retrospective analysis by chart review, personal interview, and physical examination identified 88 patients who received 96 jejunal free flaps over a 10 year period. Seventy-nine of these patients had cancer. There were 13 operative failures (13.5 percent) in 10 patients. Failures were attributed to arterial thrombosis in four instances, venous anastomotic problems in four instances, fistula and infection in the neck in one instance, carotid blowout in one instance, psychosis with avulsion in one instance, and an unknown cause in two instances. Seven second attempts at salvage of jejunal flaps were performed with five successes. There were five deaths in the perioperative period (6 percent). Of these, one was directly attributed to graft failure. The following eight abdominal complications required operation: wound dehiscence (four instances), small bowel obstruction (one instance), Mallory-Weiss tear (one instance), gastrostomy tube leak (one instance), and acute gastric dilatation (one instance). Complications in the neck included infection (six instances), infection requiring operation (three instances), hematoma (three instances), and suture line dehiscence (one instance). Fistulas developed in 28 patients (32 percent), 12 of whom required operative closure (43 percent). Significant stenosis developed in six patients, two of whom required operative revision. Of 79 patients treated for cancer, 34 died from progression of disease which recurred an average of 9.7 months postoperatively. Death ensued an average of 16.7 months postoperatively. Ten patients died with no evidence of disease. At last follow-up, 28 patients were alive without apparent disease. Twenty-six of these patients have good swallowing function. Significant palliation and a high rate of restoration of function are possible with the free jejunal autograft. Careful patient selection should markedly decrease operative morbidity and mortality.

Repair of the dehisced median sternotomy incision.

Mediastinitis after open-heart surgery is a potentially disabling, even lethal, condition. The utilization of muscle flaps in treatment has lowered the mortality rate from 40 to 5 per cent and decreased the hospitalization time to 12 days. The authors recommend a single reverse turnover pectoralis major flap based on the internal mammary perforators as the procedure of choice in these cases.

Factors involved in disruption of intestinal anastomoses.

Bowel anastomoses, as performed on 181 dogs, were studied: (1) by interposing segments of colon into small bowel and vice versa, (2) by comparing clean anastomoses to those contaminated by feces before and after suturing, (3) with and without parenteral preoperative antibiotic, and (4) with and without coaptation of an inverted serosa. All animals with a timed sacrifice as well as an unexplained death had careful autopsy. Results demonstrated no difference in the healing capacity of large (91%) versus small (92%) intestine under identical circumstances. Intraluminal bacteria were of importance only if spillage caused contamination during operation and thereby subsequent infection of the peritoneal surface of the suture line. Peritonitis preceded all 28 leaks, yet the converse never occurred. Likelihood of a complicating peritonitis (67%) and thus an anastomotic leak (24%) was significantly reduced through the preoperative administration of prophylactic cefazolin (19 and 4%, respectively). A "serosal seal" also appeared important in obviating suture line disruption. Our data emphasize the value of an inverted and serosal lined anastomosis, bowel preparatory measures, prophylactic antibiotic, and the disruptive action of local bacterial peritonitis.

Objective determinations of sensibility in the upper extremity. Part I. Median nerve sensory conduction velocities.

Distal sensory conduction velocities were determined in 109 normal median nerves. A significant decrease in sensory conduction velocity was noted with increasing age. Latencies increased with age but this relationship was not significant in men. Variables which contribute to the wide range of normal conduction velocities are discussed, and the need for each clinician to establish his own testing procedure is stressed. An additional method for assessing sensory function is suggested.

Objective determinations of sensibility in the upper extremity. Part II. Application of cutaneous stimuli in control subjects.

Sensitization statements were read to two groups of normal subjects to determine whether quantifiable thresholds for pressure, electrical, or tactile stimuli could be altered. Significant reductions in perception thresholds were observed for pressure and digital pulsed stimulation, but not for stimulation to the discomfort threshold, or two point discrimination. These data seem to suggest that increased sensitization is related to the ease of stimulus applications and the comparative simplicity of sensory processing.

Objective determinations of sensibility in the upper extremity. Part III. Application of cutaneous stimuli in patients with peripheral nerve lesions.

Quantitative values for pressure, electrical, and two-point touch stimulation were examined in five patients with peripheral nerve injuries of the ulnar or median nerves. Analyses of profiles generated for each stimulus application in each patient participating in this preliminary study suggest that, following the reading of a sensitization statement, pressure and electrical shock threshold values are clearly reduced compared to similar measurements in the unaffected limb. Values obtained prior to the statement indicated progressively reduced thresholds, however. Changes in sensation appear to precede significant improvements in sensory nerve conduction velocity. Limitations in the sensory testing techniques as well as suggestions for improving its validity are discussed.

Positioning for ultrasound-assisted lipoplasty.

Although the positioning facilitates UAL and SAL, it is essential to pad the patient appropriately, especially on the pressure points. Equally important is the maintenance of fluid balance and body temperature during these procedures.

Equipment and instrumentation for ultrasound-assisted lipoplasty.

Ultrasound energy has been applied in many areas of medicine for some time, but ultrasound energy, equipment, and instrumentation for liposuction are new to plastic surgeons. The technique and equipment differ in many ways from suction-assisted lipoplasty and practitioners of ultrasound-assisted lipoplasty must gain a thorough understanding of the physical principles, the equipment, the limits, and the potential problems before using this technique. Basic components of all systems include a generator, connecting cable, vacuum pump, and activation control. Some units also require the use of a skin protection.

Inferior gluteal free flap breast reconstruction.

This article discusses the indications for and anatomy, technique, and results of breast reconstruction with the inferior gluteal free flap. The authors also present the results of their 25 inferior gluteal flap operations performed in the last decade.

Suction lipectomy in the management of limb lymphedema.

We have been pleased overall with the results achieved using suction lipectomy in lymphedema patients. In appropriately selected patients, it is predictable and well-tolerated. It is, however, only palliative and temporary. It may be performed on a periodic basis. Compressive stockings are essential for success. Based on our experiences, we recommend suction lipectomy for mild temporary cases, specifically involving the upper extremity, and liposuction plus excisional debulking for more severe cases and for the lower extremity.

The gluteal free flap breast reconstruction. Making it work.

The inferior gluteal flap represents our second choice for free autologous tissue breast reconstruction when the TRAM is unavailable. The safety and reliability of the inferior gluteal flap has been demonstrated in 25 consecutive flaps. To make the free gluteal flap work, careful elevation and preparation of recipient vessels with the liberal use of vein grafts, and proper insetting are important factors.

Bony reconstruction in the lower extremity.

The reconstructions of large debridement defects of the tibia are difficult and, at times, discouraging. To maximize the potential for limb salvage, a rigorous patient selection algorithm is essential. Each therapeutic option must consider various host factors, anatomic restraints, physician skills, and institutional resources. In this article, the cost effectiveness and morbidity of two distinct methodologies are compared to bring the guidelines for patient selection to perspective.