Osteoradionecrosis and microvascular free flap failure managed with negative pressure wound therapy: A case report.

A 56-year-old female with a history of meningioma status post subtotal resection (Simpson grade IV) and extensive radiation therapy presented with osteoradionecrosis (O.R.N.) managed previously with a microvascular free flap (MVFF). The evaluation revealed worsening O.R.N. and a scalp defect of 15 × 10 cm. The patient underwent MVFF reconstruction utilizing a free latissimus muscle flap covered by meshed split-thickness skin graft (STSG). Her surgery was complicated by delayed free flap failure and Serratia marcescens growth, which occurred sometime after discharge from the hospital. This was managed with removal of the free muscle flap and skin graft, serial debridement's, antibiotics, and replacements of a synthetic dural matrix and negative pressure wound therapy (NPWT). Once a clean wound bed was again obtained, the patient underwent fasciocutaneous anterolateral thigh (A.L.T.) MVFF reconstruction, which was complicated by left hypoglossal nerve injury, dehiscence of the flap inset, and dehiscence of the neck access incision requiring revision surgery. On the last follow-up 2 weeks after her surgery, the patient had 100% flap viability and a 2 × 1.5 cm on the left parietal aspect of the flap healing be secondary intent. We demonstrate that NPWT is successful in managing open calvarial wounds due to O.R.N.

A Toolbox of Surgical Techniques for Palatal Fistula Repair.

OBJECTIVE: To provide an inventory of oronasal fistula repair techniques alongside expert commentary on which techniques are appropriate for each fistula type. DESIGN: A 4-stage approach was used to develop a consensus on surgical techniques available for fistula repair: (1) in-person discussion of oronasal fistula cases among cleft surgeons, (2) development of a schema for fistula management using transcripts of the in-person case discussion, (3) evaluation of the preliminary schema via a web-based survey of additional cleft surgeons, and (4) revision of the management schema using survey responses. PARTICIPANTS: Six cleft surgeons participated in the in-person case discussion. Eleven additional surgeons participated in the web-based survey. Participants had diverse training experiences, having completed residency and fellowship at 20 different hospitals. RESULTS: A schema for fistula management was developed, organized by fistula location. The schema catalogues all viable approaches for each location. For fistulae involving the soft palate, the schema stresses the importance of evaluating for velopharyngeal insufficiency (VPI) and incorporating VPI management into fistula repair. For fistulae involving the hard palate, the schema separately enumerates the techniques available for nasal lining repair and for oral lining repair in each region. The schema also catalogues the diversity of approaches to lingual- and labioalveolar fistula, including variation in timing, orthodontic preparation, and simultaneous alveolar bone grafting. CONCLUSIONS: This study employed consensus methods to create a comprehensive inventory of available fistula repair techniques and to identify preferential techniques among a diverse group of surgeons.

Patient-Centered Satisfaction After Secondary Correction of the Cleft Lip and Nasal Defect.

OBJECTIVE: To evaluate patient-reported aesthetic and psychosocial outcomes of secondary cleft lip and nose revision procedures. DESIGN: Single-center cohort study. SETTING: Tertiary care pediatric hospital. PATIENTS/PARTICIPANTS: Patients who underwent secondary revision procedures for cleft lip and nasal defect (N = 42). INTERVENTIONS: Patients were administered a survey during a routine postoperative clinic visit. MAIN OUTCOME MEASURE(S): Outcome measures were planned prior to data collection and included improvement in appearance seen in lip and nose, satisfaction with revision procedure, changes in self-confidence, likelihood to participate in social activities, and effect on teasing by peers. RESULTS: Patients agreed that an improvement was seen in the appearance of their lip (1.93) and nose (1.98) following surgery. Overall, patients felt satisfied with the results of their revision procedure (1.76). An improvement in confidence and decrease in feelings of self-consciousness was reported. Patients were teased less by their peers and more likely to participate in social activities. CONCLUSIONS: Secondary revision procedures of the cleft lip and nasal defect provide a patient-reported improvement in appearance and a positive psychosocial impact on patient's lives.

Intracranial Venous Hypertension in Craniosynostosis: Mechanistic Underpinnings and Therapeutic Implications.

Patients with complex, multisutural, and syndromic craniosynostosis (CSO) frequently exhibit intracranial hypertension. The intracranial hypertension cannot be entirely attributed to the craniocephalic disproportion with calvarial restriction because cranial vault expansion has not consistently alleviated elevated intracranial pressure. Evidence has most strongly supported a multifactorial interaction, including venous hypertension along with other pathogenic processes. Patients with CSO exhibit marked venous anomalies, including stenosis of the jugular-sigmoid complex, transverse sinuses, and extensive transosseous venous collaterals. These abnormal intracranial-extracranial occipital venous collaterals might represent anomalous development, with persistence and subsequent enlargement of channels normally present in the fetus, either as a primary defect or as nonregression in response to failure of the development of the jugular-sigmoid complexes. It has been suggested by some investigators that venous hypertension in patients with CSO could be treated directly via jugular foraminoplasty, venous stenting, or jugular venous bypass, although these options are not in common clinical practice. Obstructive sleep apnea, occurring as a consequence of midface hypoplasia, can also contribute to intracranial hypertension in patients with syndromic CSO. Thus, correction of facial deformities, as well as posterior fossa decompression, could also play important roles in the treatment of intracranial hypertension. Determining the precise mechanistic underpinnings underlying intracranial hypertension in any given patient with CSO requires individualized evaluation and management.

Evidence-Based Medicine: Wound Management.

LEARNING OBJECTIVES: After reading this article, the participant should be able to: 1. Describe the basic science of chronic wounds. 2. Discuss the general and local factors that should be considered in any patient with a chronic wound. 3. Discuss the rationale of converting a chronic wound into an acute wound. 4. Describe techniques used to prepare chronic wounds. 5. Discuss the appropriate use of different dressings presented in this article. 6. Discuss the pros and cons of the adjuncts to wound healing discussed in this article. SUMMARY: This is the second Maintenance of Certification article on wound healing. In the first, Buchanan, Kung, and Cederna dealt with the mechanism and reconstructive techniques for closing wounds. In this article, the authors have concentrated on the chronic wound. The authors present a summary of the basic science of chronic wounds and the general and local clinical factors important in assessing any chronic wound. The evidence for interventions of these conditions is presented. The surgical and nonsurgical methods of wound preparation and the evidence supporting the use of the popular wound dressings are presented. The authors then present the evidence for some of the popular adjuncts for wound healing, including hyperbaric oxygen, electrotherapy, and ultrasound. A number of excellent articles on negative-pressure wound therapy have been written, and are not covered in this article.