Modified tenodesis method for treatment of mallet fractures.

INTRODUCTION: Mallet fractures are avulsions of the terminal extensor tendon from the base of the distal phalangeal bone with a bony fragment. Surgical treatment, which provides accurate anatomical reduction and rigid fixation, is recommended for mallet fractures with involvement of more than one third of the base of the distal phalangeal bone. Various surgical methods have been reported, but there is still no standard treatment modality. The purpose of this investigation was to assess the results of our modified tenodesis method for mallet fractures. MATERIALS AND METHODS: Using our method, the dorsal fracture fragment was reduced and fixed to the main part of the distal phalangeal bone by 2 stitches of "figure-of-eight" 4-0 Prolene sutures. We reviewed 12 consecutive patients with 13 mallet fractures treated with our modified tenodesis method between January 2009 and March 2012. This retrospective study was composed of 7 male and 5 female patients, with a mean age of 35.7 years (range, 25-56 years). All patients underwent surgical treatment and sequent 3-week finger splinting. Patient follow-up lasted 3 to 6 months, with a mean period of 5.2 months. RESULTS: The modified tenodesis method allowed accurate anatomical reconstruction of the injured extensor mechanism. Grading by Crawford criteria showed that the outcome was "excellent" in 8 of 13 digits and "good" in 5 of 13 digits. The follow-up hand x-rays also revealed congruent joint surfaces of distal interphalangeal joints with no evidence of joint space narrowing. No wound complications were encountered, and all the patients returned to normal activities without any disability. CONCLUSIONS: The modified tenodesis method is simple and effective to provide accurate anatomical reduction and fixation for treatment of type I mallet fractures. No device penetration of the small bony fragment or pinning through the distal interphalangeal joint is required, and the surgical complication rate is low. We recommend this treatment modality for all but chronic cases.

Facial necrotizing fasciitis secondary to accidental bite of the upper lip.

We describe a case with facial wounds over the left upper lip that became contaminated with saliva. A facial necrotizing fasciitis developed 2 days after injury. This produced a serious and almost fatal infection.

Epiglottis reconstruction with free radial forearm flap after supraglottic laryngectomy.

A bilobed free radial forearm flap was designed to reconstruct a defect in the epiglottis and tongue base in 2 patients who underwent supraglottic laryngectomy. The flap was initially sutured in the shape of the epiglottis to prevent aspiration during deglutition. Six months after surgery, after a full course of radiation therapy, the flap had flattened and underwent atrophy, but the patients still had good voice production and were able to swallow well without any aspiration. Regardless of the final shape of the reconstructed epiglottis, it will suffice to prevent aspiration if the flap is large enough to occlude the tracheal outlet.

Voice and swallowing after laryngopharyngectomy and free ileocolic flap reconstruction for hypopharyngeal cancer.

Sixteen patients with hypopharyngeal carcinoma who underwent laryngopharyngectomy had immediate reconstruction with a free ileocolic flap to restore voice and swallowing. All patients had satisfactory voice production and swallowing in the early postoperative stage. Maintaining adequate tension and decreasing redundancy of the transferred colon prevented food pooling and provided smooth, rapid swallowing. A wedge resection of the subserosa of the ileocecal valve to increase the intraluminal pressure helped prevent food reflux and provide good phonation. Although this modified technique yielded good initial results, both voice and swallowing deteriorated after concurrent chemoradiotherapy, possibly because of radiation injury to the transferred bowel.

Eccentric mastectomy and zigzag periareolar incision for gynecomastia.

BACKGROUND: Gynecomastia is enlargement of the male breast caused by gland proliferation. Surgery is performed for symptom relief or for cosmetic reasons. The authors used a modified operative procedure, then evaluated the results and safety. METHODS: Between 2001 and 2005, 22 men (median age, 26 years; range, 13-63 years) with gynecomastia underwent surgery. The operative procedure included a zigzag periareolar skin incision, eccentric subcutaneous mastectomy, and liposuction, with postoperative compression. RESULTS: All the patients were satisfied with the results of the surgery, which produced a chest contour resembling a normal male chest rather than simply a smaller breast. The only complication was a hematoma. One patient was found to have breast cancer. CONCLUSIONS: The normal male chest contour can be restored by the described method of eccentric subcutaneous mastectomy.

Functional outcome following free ileocolic flap in total pharyngolaryngectomy.

CONCLUSION: Reconstruction after radical resection for advanced laryngeal and hypopharyngeal cancer can be carried out with low mortality, acceptable morbidity, and a promising functional outcome. OBJECTIVES: To evaluate the functional outcome of reconstruction by a free vascularized ileocolic flap after concurrent chemoradiotherapy (CCRT) and surgery for advanced laryngeal and hypopharyngeal cancer. PATIENTS AND METHODS: Fifteen patients (all male, mean age 49.8 years) with squamous cell carcinoma of larynx (n=1) or hypopharynx (n=14) received a circumferential pharyngolaryngectomy and resection of the proximal esophagus followed by postoperative CCRT (60-65 Gy, cisplatin and 5-fluorouracil). A single-stage reconstruction was performed with a free vascularized ileocolic flap using a microsurgical technique. RESULTS: The course of all operations was uneventful. Eight patients were alive at a follow-up of 24 months after operation, while seven patients died from local recurrence, distant metastasis, and suicide. Relief of dysphagia was achieved in 14 cases. Speech intelligibility was recorded in five patients.

Ileocolic free flap reconstruction, concomitant chemotherapy and radiotherapy and assessment of speech and swallowing function during management of advanced cancer of the larynx and hypopharynx: preliminary report.

CONCLUSION: The new technique of ileocolic free flap reconstruction provides a better quality of life in terms of swallowing and speech for patients who have undergone laryngopharyngectomy with concomitant chemotherapy and radiotherapy (CCRT). OBJECTIVES: To compare and contrast the swallowing and speech outcomes of patients who underwent total laryngopharyngectomy with ileocolic free flap reconstruction and to analyze the survival rate after surgery and CCRT. MATERIAL AND METHODS: This was a follow-up study of 12 patients with advanced (stages III, IVA and IVB) laryngeal and hypopharyngeal cancer who underwent major surgery, CCRT (with one exception) and ileocolic free flap reconstruction. RESULTS: All patients were able to tolerate single-stage combined management comprising total laryngopharyngectomy with or without radical neck dissection plus ileocolic free flap reconstruction and postoperative CCRT (with one exception), without immediate morbidity or mortality. Eleven patients were diagnosed with hypopharyngeal cancer and one with laryngeal cancer. The mean interval between surgery and CCRT was 34.1 days. The mean follow-up period was 16.5 months. Four patients died during the follow-up period as a result of local recurrence (n=2), distant metastasis (n=1) and suicide (n=1). One patient was alive with disease despite neck recurrence.

Combined free vascularized iliac osteocutaneous flap and pedicled pectoralis major myocutaneous flap for reconstruction of anterior chest wall full-thickness defect.

Large defects of the anterior chest wall lead to gross chest instability that can result in paradoxic respiration. Osteoradionecrosis of the lower sternum and multiple left ribs resulted in a huge, full-thickness defect of the left anterior chest wall in a 67-year-old woman. An iliac osteocutaneous flap (bone segment 3 × 14 cm) was harvested for reconstruction of the bone defect. The skin defect was covered by the skin paddle of the iliac osteocutaneous flap and a contralateral rotational pectoralis major muscle flap. Months postoperatively, the patient was physically active, the chest was stable, and the vascularized iliac bone was incorporated into the recipient bone.

Treatment of intractable enterocutaneous fistula with an island pedicled anterolateral thigh flap in Crohn's disease--case report.

Attempts to treat intractable enterocutaneous fistulae secondary to Crohn's disease are challenging and have been associated with long delays. An island pedicled anterolateral thigh (ALT) flap has been shown to achieve adequate coverage of abdominal wall reconstruction. In this case, with the assistance of a well-vascularised flap and adequate medical supportive managements, the intractable enterocutaneous fistula was closed; it then healed progressively.

Comparison of radiotherapy strategies for locally advanced hypopharyngeal cancer after resection and ileocolic flap reconstruction.

CONCLUSION: IMRT provided better conformity, less toxicity and better function restoration for advanced hypopharyngeal carcinoma after major surgery with ileocolic flap reconstruction. OBJECTIVES: To compare the results of adjuvant conventional radiotherapy (2DRT) with intensity modulated radiation therapy (IMRT) for locally advanced hypopharyngeal cancer after resection and ileocolic free flap reconstruction and to design treatment plans for those two modalities plus 3D conformal radiotherapy (3DCRT) for dose distribution comparison. METHODS: 13 locally advanced hypopharyngeal cancer patients were enrolled, 8 treated with 2DRT and 5 with IMRT. Different plans were planned for 3 IMRT-treated patients for comparing dose distribution. RESULTS: After major surgery, patients treated with IMRT had less toxicity and better functional restoration than those with 2DRT. IMRT and 3DCRT both showed lower dose to the spinal cord than did 2DRT. Only IMRT showed reduced dose to ileocolic flap.

Radial forearm versus anterolateral thigh flap reconstruction after hemiglossectomy: functional assessment of swallowing and speech.

The authors retrospectively compared the results of postoperative speech and swallowing in patients who had undergone hemiglossectomy for carcinoma of the anterior tongue. Immediate reconstruction in 16 patients was with a free radial forearm flap and in another 16 with an anterolateral thigh flap. Clinical speech pathology evaluation included the Fletcher time-to-time maximum syllable repetition rate, multiple rhyme test, and overall quality and intelligibility of the patients' speech. Evaluation of swallowing included deglutition duration, bolus volume, and ingestion rate. The functional results with both flaps were adequate, and the two groups did not differ significantly between each other for either speech or swallowing.

Salvage of free second toe with venous thrombosis by shunting retrograde arterial flow of second dorsal metatarsal artery.

Although there are case reports about salvaging amputated digits without venous return by shunting retrograde blood flow from a distal digital artery to a proximal vein (Smith et al., Plast Reconstr Surg 71:52, 1983), successful salvage of a congested free toe with efferent arteriovenous (AV) shunting retrograde arterial flow from the second dorsal metatarsal artery (SDMA) has never been reported. In this paper, we describe the possible factors for venous thrombosis, the errors we committed in the operation, and how the free toe can survive without venous drainage.

Tongue reconstruction with free radial forearm flap after hemiglossectomy: a functional assessment.

Thirty-three patients with squamous cell carcinoma of the anteriolateral part of the tongue underwent a 50 percent resection of the tongue. The surgical defect was reconstructed with a microvascular radial forearm flap. All the flaps were especially designed to have a narrow waist, shaped like an omega in cross-section, thus allowing for a free tongue tip, and avoiding suturing the edge of the flap to the soft palate and tongue base. Sixteen patients were evaluated for swallowing and speech function at least 6 months following reconstruction. With this technique, the majority of the patients had nearly normal deglutition, although their speech was still unsatisfactory. However, the speech function in this series was better than that in other reported series.

Primary closure versus radial forearm flap reconstruction after hemiglossectomy: functional assessment of swallowing and speech.

The authors compared the postoperative speech and swallowing function of six patients who underwent free radial forearm flap reconstruction after hemiglossectomy with that of six control patients who underwent primary closure of the defect. Clinical speech pathologic evaluations included the Fletcher time-to-time maximum repetition rate of syllables, multiple rhyme test, and overall quality and intelligibility of the patients' speech. Evaluation of swallowing included the duration of deglutition, bolus volume, and ingestion rate. Speech quality, including intelligibility and articulation, was better in patients with primary closure. However, the bolus volume and ingestion rate in deglutition were better in those with flap reconstruction. These results suggest that the flap adds bulk, thus improving pharyngeal clearance by maintaining the tongue-to-mouth roof contact that is necessary in the swallowing process. The nonfunctional flap, however, hinders articulation by restricting the mobility of the remaining portion of the normal tongue.

Late hematoma after aesthetic breast augmentation with saline-filled, textured silicone prosthesis.

Late, progressive enlargement of the breast after augmentation mammaplasty is an extremely rare complication. We present two cases of late capsular hematoma after augmentation mammaplasty with saline-filled, textured silicone implants. The MRI and C-T scan both clearly showed fluid accumulated within the capsule in one case. In this patient, we examined the interior of the fibrous capsule endoscopically, finding no persistent bleeding source. However, the inner lining had granulated tissue with new capillary ingrowth. After replacement with smooth-surface prostheses, neither patient had recurrence of the complication. No identifiable etiology could be demonstrated, however, the breakdown of an eroded capsular artery is suspected, caused by friction between the rough surface of the textured prosthesis and the fibrous capsule.

Swallowing function in patients who underwent hemiglossectomy: comparison of primary closure and free radial forearm flap reconstruction with videofluoroscopy.

The swallowing function of patients who had undergone hemiglossectomy with either primary closure of the defect or radial forearm flap reconstruction was studied with videofluoroscopy. Patients with primary closure were unable to lift the tongue tip, had poor tongue-to-palate contact on initiating swallowing, had premature spilling of the bolus into the pharynx, had a large amount of barium stasis on the floor of the mouth, and had prolonged oral transit time. With flap reconstruction, patients easily could lift the tongue and make good contact with the entire palate. They were able to seal the posterior pharyngeal sphincter by elevation of the reconstructed tongue, approximating it to the soft palate, so that premature spilling of the bolus rarely happened. Their swallowing pattern was nearly normal. Although the reconstructed flap is nonfunctional, it provides bulk and helps the remaining tongue to complete the swallow. Compared with primary closure of the tongue defect, the authors suggest it is better to reconstruct it with a free radial forearm flap when more than 50% of the tongue is resected.