Resource utilization and patient morbidity in head and neck reconstruction.

Many papers have addressed the technical aspects of free tissue transfer in head and neck cancer patients. However, there has not been a critical assessment of the impact of free tissue transfer on resource utilization and patient morbidity compared with pedicle flap reconstructions. Two cohorts of patients derived from 245 consecutive reconstructions were tightly matched by age, site, stage, and histology, yielding 44 patient pairs differing in method of reconstruction. Patients undergoing free flap reconstruction spent more time in the operating room than those reconstructed with pedicled flaps (993 min vs. 777 min, P < 0.0001). The group with free flap reconstruction spent fewer days in the surgical intensive care unit and hospital (2 days vs. 2.5 days; 18.5 days vs. 22.6 days). This difference is attributed to the paucity of postoperative complications in the group with free flap reconstruction (fistula formation 4.5% vs. 21%, P < 0.04). These data indicate that the continued use of sophisticated reconstructive techniques in head and neck cancer patients is economically sound as assessed by patient morbidity and resource utilization.

Comparison of cost and function in reconstruction of the posterior oral cavity and oropharynx. Free vs pedicled soft tissue transfer.

OBJECTIVE: To compare the cost and functional results of free and pedicled soft tissue reconstruction after posterior oral cavity and oropharyngeal extirpation. DESIGN: Retrospective study of 53 consecutive patients undergoing extirpation with primary soft tissue reconstruction from January 1, 1991, to December 31, 1995. Median follow-up was 298 days. SETTING: Academic tertiary care medical center. INTERVENTION: Twenty-four patients underwent reconstruction with a pedicled pectoralis major myocutaneous flap (PMMF); 29 patients, with a fasciocutaneous free flap (FF) (27 radial forearm, 1 lateral arm, and 1 scapular). MAIN OUTCOME MEASURES: Direct (inpatient hospital resources used and monetary costs) and intangible (post-operative complications and function) costs. RESULTS: Operative time was longer for FF reconstructions (P = .003), but both patient groups had similar intensive care unit and hospital stays. Treatment cost for FF reconstructions was $41,122, compared with $37,160 for PMMF reconstructions (P = .003). This difference was due to increased professional fees for FF reconstruction (P < .001) which was offset by intangible cost differences. The PMMF group tended toward an increased rate of flap-related complications, compared with the FF group. At last follow-up, 4 patients in the FF group (15%) and 3 in the PMMF group (15%) had their tracheotomy. In contrast, 17 (85%) patients in the PMMF group and 11 (39%) patients in the FF group required enteral tube feedings (P = .002). Also, 18 (64%) patients in the FF group were eating at least a soft diet compared with 6 (30%) patients in the PMMF group (P = .02). CONCLUSIONS: Comparison of direct costs reveals only a modest difference in reconstruction costs that is outweighed by the intangible costs of PMMF reconstruction. The functional benefits of FF reconstruction appear to justify its slight increased expense and its use rather than PMMF reconstruction after extirpation in the posterior oral cavity and oropharynx.

Epidemiology and management of open fractures of the lower limb.

Epidemiological analysis indicates that 40% of open fractures occur in the lower limb and that the tibial and femoral diaphyses are most commonly affected. Recent advances in fracture stabilization and soft tissue reconstruction technique have improved the outcome of these fractures.

A comparison of resource costs for head and neck reconstruction with free and pectoralis major flaps.

A series of 178 immediate reconstructions with regional or distant tissue for repair of oropharyngeal defects caused by treatment of head and neck cancer was reviewed to determine whether reconstruction with free flaps was more or less expensive than reconstruction with regional myocutaneous flaps. In this series, three types of flaps were used: the radial forearm free flap (n = 89), the rectus abdominis free flap (n = 56), and the pectoralis major myocutaneous flap (n = 33). Resource costs were determined by adding all costs to the institution of providing each service studied using salaried employees (including physicians). The two free-flap groups were combined to compare free flaps with the pectoralis major myocutaneous flap, a regional myocutaneous flap. Failure rates in the two groups were similar (3.0 percent for pectoralis major myocutaneous flap, 3.4 percent for free flaps). The mean costs of surgery were slightly higher for the free flaps, but the subsequent hospital stay costs were lower. Therefore, the total mean resource cost for the free-flap group ($28,460) was lower than the cost for the myocutaneous flap group ($40,992). The pectoralis major myocutaneous flap may have been selected for more patients with advanced disease and systemic medical problems, contributing to longer hospitalization and added cost. Nevertheless, this study suggests that free flaps are not more expensive than other methods and may provide cost savings for selected patients.

Follow-up of University of Virginia experience with the modified Lothrop procedure.

Current surgical treatment of the frontal sinus disease include external approaches to obliterate or ablate the sinus and both external and transnasal methods to restore drainage into the nasal cavity. The original Lothrop procedure resects the medial frontal sinus floor, superior nasal septum, and intersinus septum, creating a large frontonasal communication. However, as described, the external approach used in this procedure often allowed medial collapse of soft tissue and the stenosis of the nasofrontal communication. This report further relates our experience with the modified transnasal endoscopic Lothrop procedure using suction drills for cases in which frontal recess exploration had failed to relieve obstruction of the frontal sinus. We present an update of the University of Virginia experience in performing the modified Lothrop procedure in 20 patients from 10/93 to 4/95. Our findings over the follow-up period (average 12 months) have verified that this procedure is effective, with a 95% patency rate for the surgically enlarged frontal sinus ostium. When compared to osteoplastic flap with fat obliteration, the modified transnasal Lothrop procedure offers the advantages of a less invasive procedure with a shorter and usually no hospitalization, less morbidity, and the increased ability to evaluate post-operatively for recurrent disease. A patient charge analysis was also performed comparing patients undergoing frontal sinus obliteration during the same time period, revealing an additional benefit of decreased patient costs for the modified transnasal Lothrop procedure. None of our patients experienced complications, and all showed significant improvement, if not complete resolution of their symptoms. Although this procedure has produced favorable results, it should be noted that this procedure is technically demanding and will require further long term follow-up to verify its efficacy and proper role in the spectrum of surgical approaches for the treatment of chronic sinusitis.

The radial Chinese flap at the expense of the palmar radiocarpal arch. A case report.

The retrograde flow Chinese flap has been shown to be a useful cover for extensive losses of palm tissue. We report a case in which vascularization was based on the palmar radiocarpal arch, with angiographic verification, in view of the post-injury absence of palmar arches. Considering the results obtained, the technical modifications introduced with respect to earlier studies are described (flap pivoting 2 cm from the Lister tubercle), and the palmar anastomotic network of the carpal bones is proposed as a new end effective vascular axis in the preparation of retrograde flow antebrachial axial flaps with an intact volar radiocarpal region.

[Postoperative swallowing function in tongue and oral floor cancer patients reconstructed with a recto-abdominal myocutaneous free flap after glossectomy--quantitative assessment of reconstructed tissue movement].

We examined the postoperative swallowing function of 12 tongue and oral floor cancer patients reconstructed with a recto-abdominal myocutaneous free flap after glossectomy. On the basis of the resection site, the present cases were classified into either anterior type or lateral type. Subjective evaluation of postoperative swallowing function was obtained from self-reports from patients. The movement of the reconstructed tissue was evaluated videofluorographically during swallowing, by tracking the movement of two small pellets temporarily attached to the anterior and central portions of the reconstructed tongue. The trajectory of the two pellets and the selected point of the hyoid bone were recorded together with the distance between the plate and the tongue dorsum, and between the posterior pharyngeal wall and the tongue base. Using a personal computer, a quantitative study of the video images was performed. The results were summarized as follows. 1) The movement pattern of the reconstructed tissue was generally saccadic rather than smooth. It was suggested that the swallowing pattern of the patients was different to that of normal controls. 2) Postoperative swallowing function was poorer in cases of the anterior type when compared to the lateral type. 3) In general, cases which showed relatively wide movement range appeared to achieve subjectively satisfactory swallowing function.

The hypothenar fat pad flap for management of recalcitrant carpal tunnel syndrome.

The hypothenar fat pad flap interposes adipose tissue from the hypothenar eminence between the median nerve and overlying transverse carpal ligament and surgical scar. This retrospective study reviews 62 hands in 58 patients (46 non-workers' compensation and 16 workers' compensation) with recurrent symptoms after failed open carpal tunnel release who underwent revision carpal tunnel decompression and in whom a hypothenar fat pad flap was used. The follow-up period averaged 33 months. Patient satisfaction was 6 in the non-workers' compensation group and 4 in the workers' compensation group. Average time to return to work for the non-workers' compensation group was 12 weeks, compared to 37 weeks for the workers' compensation group. Study results indicate that the hypothenar fat pad flap produces excellent results in procedures designed to alleviate recalcitrant idiopathic carpal tunnel syndrome.

Cost and outcome of osteocutaneous free-tissue transfer versus pedicled soft-tissue reconstruction for composite mandibular defects.

Thirty-nine patients underwent reconstruction of composite mandibular defects following resection for squamous cell carcinoma. Thirty-four underwent immediate reconstruction, while 5 were reconstructed secondarily. Twenty-one received soft-tissue reconstruction only with a pectoralis major myocutaneous flap, 14 underwent osteocutaneous free-tissue transfer, and 4 received a reconstruction plate with free-tissue transfer for soft-tissue coverage. The mandibular defects in the pectoralis major myocutaneous flap group tended to be posterolateral, while free-tissue transfer defects were more severe, usually involving the anterior mandible. Length of surgery and duration of intensive care unit care were significantly longer for free-tissue transfer patients, while flap complications were more common in the pectoralis major myocutaneous flap patients. Facial appearance scores were higher for the free-tissue transfer group by both patient and physician assessment. Social function, speech, and oral function did not differ significantly. Patients reconstructed secondarily with free-tissue transfer reported significant improvement in appearance, oral continence, and social function, with little change in speech intelligibility, deglutition, or diet tolerance. The cost of the main hospitalization was significantly higher in the free-tissue transfer group than in the pectoralis major myocutaneous flap group, although when the costs of subsequent hospitalizations are included, the difference in total cost narrows. Despite more adverse defects, free-tissue transfer provided more predictable aesthetic results and expeditious return to normal social function than did pectoralis major myocutaneous flap reconstruction. The fiscal impact of these complex reconstructions is, however, significant. Cost-containment issues are presented and recommendations are made.

Temporal fascial periosteal and musculoperiosteal flaps in the pig: design and blood flow assessment.

The availability of a vascularized periosteal flap with bone-forming potential could greatly enhance the reconstructive capabilities of the craniofacial surgeon. Previous observations seem to indicate that the bone-forming potential of periosteal flaps depends on the vascularity of the flap. The purpose of the present experiment was to design temporal fascial periosteal and musculoperiosteal flaps in the pig and to compare the periosteal blood flow with unoperated periosteum in the same location. The radioactive microsphere (15-micron diameter) technique was used to measure periosteal capillary blood flow in periosteal flaps and unoperated control, randomized to each side of the head in nine pigs (Yorkshire; weight, 12-14 kg). The periosteum was (1) raised based on the temporalis muscle with vascular supply from the deep temporal vessels (n = 6), (2) raised based on temporoparietal fascia-deep temporal fascia with blood supply from the superficial temporal vessels (n = 6), or (3) left intact (n = 6). The mean periosteal capillary blood flow rates in the intact periosteum (0.107 +/- 0.001 ml/min/g), the temporal musculoperiosteal flaps (0.081 +/- 0.01 ml/min/g), and temporal fascial periosteal flaps (0.087 +/- 0.012 ml/min/g) were not significantly different. These observations indicate that the blood flows for both musculoperiosteal and fascial periosteal flaps were comparable to control intact temporal periosteum.

Reconstruction of the base of the tongue with the microvascular ulnar forearm flap: a functional assessment.

Ten patients with infiltrating carcinomas of the base of the tongue/tonsillar region underwent 30 to 100 percent resection of the base of the tongue and lateral pharyngeal wall. The surgical defect was reconstructed (9 primary, 1 secondary) with a large microvascular ulnar forearm flap that was selectively contoured to provide bulk for the base of the tongue and a thin lining for the pharyngeal wall. Seven patients were evaluated for swallowing and speech 6 weeks to 2 years following the reconstruction. Cineradiographic studies showed excellent base of the tongue and flap mobility allowing glossopharyngeal closure in all patients and complete pharyngeal evacuation in four patients. Four patients who were in good health preoperatively were able to eat a regular diet postoperatively, and the remaining three patients were able to handle soft food. Functional recovery after major tongue base surgery is contingent upon a three-dimensional microvascular reconstruction using a thin forearm flap.

Cleft cluster: a strategy for concurrent correction of multiple secondary clefting deformities.

We have developed a strategy for concurrent correction of multiple secondary clefting deformities based on the model proposed by Henderson and Jackson [1] which combines several cleft-related procedures. We have expanded this concept significantly to include as many as eleven procedures. The selected procedures are dictated individually by patients' needs. The constellation of corrective cleft-related surgeries has been given the name "cleft cluster" in the interest of simplicity. We are reporting on our experience with 85 consecutive patients using this approach. All patients in this series received bone grafting of the alveolar cleft as the primary procedure, plus multiple additional procedures as necessary. None of the patients reported received primary lip or palate surgery by the authors. The average number of procedures performed was 7.2. The average hospitalization was 4.1 days. The patients have been followed from 1 to 7 yrs. The fistula recurrence rate was 8%. Average patient age was 16.8 yrs with a range of 8 to 54 yrs. This approach eliminates multiple hospitalizations and outpatient procedures, allows flexibility to individualize patient care, provides consistent results, and is cost-effective.

Alternative technique of constructing bilateral cleft palate in late childhood: a case report and literature review.

Although great advances in treatment of oro-facial clefts have been made over the past 50 years; in developing countries, due to social stigmas and unavailability of specialised medical facilities and personnel to the majority of the population, there is an increasing incidence of patients coming late for repair of oro-facial clefts. This presents a challenge to both plastic, oral surgeons and associated specialists. The aim of the present article is to demonstrate, in the form of a case report, an alternative surgical technique that has be successful in 8 cases for the late repair of severe bilateral cleft palate utilizing locally available and affordable materials. The objective of managing patients with cleft palate in developing countries is to provide the best repair and rehabilitation with as few operations and in-patient care as possible due to limited financial resources experienced by the majority of in-patients. A multidisciplinary approach to the management of oro-facial clefts is emphasised.

Salvage surgery for locally advanced and locally recurrent breast cancer.

OBJECTIVE: To determine if local control of breast cancer can be regained in patients with locally advanced and recurrent tumors using aggressive surgical treatment and reconstruction. DESIGN: A retrospective review of 15 consecutive patients. Patients were followed up from 8 to 32 months. SETTING: A university tertiary care facility in a metropolitan area. PATIENTS: All patients with locally advanced or recurrent breast cancer without known metastatic disease who underwent radical surgical resection of locally advanced breast cancer with reconstruction. MAIN OUTCOME MEASURES: Primary outcome measures were pathological findings, type of surgery, length of hospital stay, complications, local recurrence, and survival. RESULTS: Pathological findings showed 12 adenocarcinomas (80%) and three sarcomas (20%). Thirteen patients (86.7%) had undergone previous surgery, 11 (73.3%) had undergone previous radiation therapy, and all adenocarcinomas were progressing while patients were receiving chemotherapy. Full-thickness chest wall resection that included bone was required in 46.7%. The average hospital stay was 11.5 days. While 10 patients (66.7%) eventually manifested metastatic disease, local recurrence developed in only one. Minor complications occurred in six patients (40%) and major complications occurred in three (20%). There were no perioperative deaths. CONCLUSIONS: Patients presenting to our service had locally aggressive tumors that were recalcitrant to maximal medical management. With radical surgical treatment and reconstruction, there were no deaths, significant morbidity was low, and all but one patient regained local control. We found that aggressive surgical treatment and reconstruction is not only feasible in patients with locally advanced breast cancer but may be the only hope for local control in these patients who are difficult to treat.

Assessment of the abdominal wall after pedicled TRAM flap surgery: 5- to 7-year follow-up of 150 consecutive patients.

To define the long-term abdominal consequences of the TRAM flap procedure, 150 consecutive patients were evaluated 5 to 7.5 years postoperatively. Of 137 surviving patients, 135 (98.5 percent) returned a questionnaire (68 single pedicle, 63 double rectus harvest, and 4 single pedicle with contralateral microvascular augmentation) and 132 (96.4 percent) were examined and tested. By questionnaire, 64 percent noted overall improvement of the abdomen, 72 percent noted improved abdominal appearance, and 20 percent noted improved posture. Decreased abdominal strength was noted by 46 percent, and decreased exercise ability was noted by 25 percent. These figures were higher after double rectus harvest (60 and 35 percent) than after single rectus harvest (35 and 16 percent) (p = 0.005 and p = 0.014, respectively). Activities of daily living were rarely (4.0 to 5.8 percent) affected. Three of the patients had uncomplicated pregnancies and deliveries (two vaginal, one cesarean section). Situp performance was worse comparing postoperative patients with unoperated controls (p < 0.0005) and comparing double rectus harvest with single rectus harvest patients (p < 0.0005). Comparing double rectus harvest patients with direct abdominal closure and those closed with mesh, there was a trend toward poorer situp performance in the mesh subgroup; however, this was not statistically significant. On examination, a classic post-TRAM hernia was not encountered in any patient, but three single-pedicle patients had asymptomatic diffuse bulges through the fascial harvest site, visible only on straining to do a situp. Eight patients (seven bilateral and one single pedicle) had varying degrees of abdominal laxity, but only one had operative correction of diffusely attenuated abdominal fascia following pregnancy and delivery. Examiners' ratings of aesthetic abdominal appearance were higher for postoperative patients than for unoperated controls (p = 0.05). The vast majority of patients considered the TRAM procedure worthwhile (93 percent) and continued to recommend it to others (96 percent).