Reconstruction of the infected median sternotomy wound.

Infection of a median sternotomy incision may result in a large, unsightly, unstable, and potentially fatal wound. We report on a series of 18 patients who were treated during the past six years with muscle flap closure for this difficult wound problem. We describe the evolution of our current preferred techniques and the results we have achieved with them. Patient risk factors and hospital course are discussed. Before definitive flap closure, all patients were treated with aggressive debridement of the bone and cartilage involved. Our first 4 patients were treated with pectoralis major myocutaneous rotation flaps. Since 1982, our procedure of choice has been to use a rectus abdominis muscle flap covered with either chest skin advancement flaps or, for deeper wounds, bilateral pectoralis major myocutaneous advancement flaps. The current technique makes possible an excellent cosmetic result with no functional deficit, and it lends good stability to the chest wall. We continue to use pectoralis flaps if there is reason to believe the blood supply to the rectus has been compromised.

Mandibular reconstruction in irradiated patients utilizing myosseous-cutaneous flaps.

Myosseous-cutaneous flaps were used for mandibular reconstruction in 16 irradiated patients. Three of six sternomastoid-clavicle flaps failed (all in conjunction with a neck dissection), as did one of 10 pectoralis major-anterior-fifth rib flaps. One trapezius-scapular flap was used and it succeeded. We found the blood supply of the sternomastoid-clavicle flap too tenuous for use in conjunction with a neck dissection. The trapezius-scapular flap had too short an arc of rotation to be used for defects other than those in the horizontal ramus. In addition, this flap required a change of position and created an undesirable functional deformity. The pectoralis major-fifth rib flap, in contrast, could be used for a variety of defects, in conjunction with a neck dissection, and did not require a change of position during operation. We found it to be the most versatile and dependable of the flaps employed in this series.

Trigonocephaly: refinements in reconstruction. Experience with 33 patients.

Thirty-three consecutive patients with metopic synostosis treated between January of 1980 and June of 1984 are presented. All patients underwent craniofacial reconstruction by an interdisciplinary team utilizing a detailed remodeling of the supraorbital rims and forehead. Advantages of the current modifications are discussed, as well as an analysis of the results. We believe this represents a significant advance over previous methods not only because of the superior cosmetic results achieved, but also because of its safety and reproducibility. Reoperation rate was less than 10 percent overall and was necessary only in patients with complex cranial vault abnormalities. Mean follow-up was 22.8 months, with no deaths, infections, or damage to visual or cerebral function. Postoperative head circumference demonstrated an immediate increase followed by a normal growth curve.

Rhabdomyosarcoma of pterygoid fossa. Resection for cure utilizing an innervated facial flap and craniofacial reconstruction.

Tumors of the pterygoid fossa are often regarded as unresectable because of their anatomic inaccessibility. The rapidly developing techniques of craniofacial surgery have advanced sufficiently to now allow safe ablative surgery in this area and yet preserve the functional status and cosmetic appearance of the patient. A technique utilizing a bicoronal incision that is extended to the angle of the mandible on the involved side is described. This allows wide exposure of the bony structures at the lateral base of the skull while maintaining the integrity of the facial nerve within the cutaneous flap. Temporary removal of the zygomatic arch achieves direct access to and visualization of the contents of the temporal and pterygoid fossae. Skull, mandibular, and maxillary bone adjacent to tumor can easily and safely be resected to obtain complete tumor-free margins. Craniectomy bone is harvested and split into inner and outer tables to reconstruct the bony defects. This approach was successfully utilized in a 5-year-old boy with a Group III rhabdomyosarcoma with residual tumor following combined chemo- and radiotherapy. He remains tumor-free at 15 months, postoperation. The technique can be adapted for a variety of mass lesions located at the anterior base of the skull, both intra- and extracranially. Morbidity and mortality should be minimal with an experienced craniofacial team.