Congenital posterior choanal atresia.

Although described more than two centuries ago, congenital choanal atresia remains an entity for which optimum treatment is not yet established. In a study of 29 cases of cogenital choanal atresia during a 14-year period, 14 male and 15 female patients were diagnosed, in contrast with the 2:1 female-male ratio usually reported. Thirty-two operative procedures were performed on 16 surgically treated patients in the series. The two classes of surgical treatment, transpalatal and transnasal techniques, were marked by 66% and 73% recurrence rates, respectively, from 2 months to 6.5 years of follow-up. In previous studies, facial growth disturbances have been shown to result from transpalatal resection in the growing child, whereas transnasal techniques have been indicted as a cause of serious neurologic complications. Because no major morbidity resulted from 20 endonasal procedures in this series, early serial endonasal perforation is advocated as a means of establishing and maintaining a patent nasal airway until definitive transnasal repair can be performed when facial growth is more complete.

Reconstructive surgery of the cervical esophagus.

Free heterotopic transplantation of segments of the distal alimentary tract revascularized in the neck provide a very satisfactory, straightforward method of reconstruction of the cervical esophagus. At present pharyngoesophageal reconstructions are of four major types: (1) free skin grafts; (2) local or regional skin flaps; (3) subcutaneous or intrathoracic interposition or migration on a vascular pedicle of more distal positions of the alimentary tract--stomach or colon; and (4) a free graft of jejunum or colon. This report is an account of each of these methods with an emphasis on free revascularized grafts of the jejunum. Fifty-five such reconstructions have been performed at Emory Affiliated Hospitals. There were six graft failures for a transfer reliability of 90%. There were three perioperative deaths for a perioperative mortality of 5%. Comparison with similar reported series using either direct esophagogastric anastomosis, colon interposition, or staged deltopectoral skin flap reconstruction would suggest that the free jejunal graft procedure has lower morbidity and mortality. I believe it to be the method of choice in reconstruction of the cervical esophagus.

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.

Reconstruction of male external genitalia with elephantiasis.

The surgical rehabilitation of a patient with severely deformed and functionally disabled genitalia due to long-standing lymphedema and infection is described and illustrated. The term "elephantiasis" has been applied to such gross lesions. Appropriate surgery to the penis, scrotum, and perineum has yielded a gratifying result. The principles and techniques of the surgical approach in such an undertaking are presented and discussed.

Reconstruction of cervical esophagus, hypopharynx and oral cavity using free jejunal transfer.

Experience with 22 cases of reconstruction of the cervical esophagus, hypopharynx and oral cavity using free jejunal transfer is presented. The method requires an experienced team with high technical competence, but the benefits related to rapid single-stage completion and low morbidity certainly justify its use.

Tumor angiogenesis as a prognostic factor in oral cavity tumors.

BACKGROUND: Lymph-node metastasis is the single greatest predictor of survival in patients with oral cavity cancers. Tumor angiogenesis has been correlated with metastasis in breast cancer and may have prognostic value in other tumors. PATIENTS AND METHODS: Sixty-six patients with clinically node-negative oral cavity squamous cell cancers were reviewed. Samples were cut and stained for factor VIII. The percentage of area of tissue stained for factor VIII was quantitated by a computerized image analyzer. Tumor depth was measured with an ocular micrometer to the nearest 0.1 mm. Variables were statistically examined against regional recurrence. RESULTS: The probability of metastasis (%) was 2 for tumor staining of < or = 10% and 93 for tumor staining > 10% (P < 0.0001). The tumor depth was < or = 4 mm in 10 and > 4 mm in 83 (P < 0.0001). Patients with < or = 4 mm and < or = 10% staining had a 2% rate of recurrence, and patients with > 4 mm and > 10% staining had a 100% rate of recurrence (P < 0.0001). CONCLUSION: Although tumor thickness was suggestive of predictability, only angiogenesis was a statistically significant predictor of recurrence in a multivariate analysis (P < 0.0001). Angiogenesis showed a strong correlation with regional recurrence and may be used as an independent prognostic indicator.

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.

Recent advances in breast reconstruction: transposition of the latissimus dorsi muscle singly or with the overlying skin.

This article presents the details of an operation for the transposition of the latissimus dorsi muscle as an integral part of the reconstruction of the breast. Muscle alone may be transposed to restore lost pectoralis major muscle contour following the standard Halsted radical mastectomy, or a compound island flap of skin and muscle may be used to replace both the resected muscle and skin.

Hidradenitis suppurativa.

Hidradenitis suppurativa is a chronic, relapsing, inflammatory disease process that primarily involves the axilla and/or inguinal region and does not manifest itself until after puberty. Typically, the process begins as a local occlusive disease of a sweat gland; secondary bacterial infection then occurs. The early stages of hidradenitis suppurativa are usually managed by the dermatologist. Once the disease becomes extensive and chronic, surgical excision of all the involved tissue is indicated.

The use of free revascularized grafts in the amelioration of hemifacial atrophy.

Nine female and three male patients, 5 to 47 years old, were treated by free revascularized grafts for Romberg's disease. Greater omentum was transferred in nine, de-epithelialized skin flaps in three. Follow-up ranges from several months to 7 years. Microvascular failures or donor site complications did not occur. To further trim transferred tissue, overcome gravitational sag, or both, all but one patient required a secondary procedure. The only facial complication included partial loss of the transferred omentum and spotty necrosis of the overlying skin. The choice of omentum or de-epithelialized skin and subcutaneous fat is dictated by the extent of the facial defect. Generalized defects are corrected with omentum and localized segmental defects with de-epithelialized flaps. Because of observed late complications, including chronic inflammation, induration, and sinus tracts, we no longer recommend medical-grade liquid silicone as a therapeutic option in the palliation of Romberg's disease.

The subcutaneous mastectomy cripple: surgical rehabilitation with the latissimus dorsi flap.

Despite the advances in reconstruction after subcutaneous mastectomy, we have seen a group of patients who have developed disabling complications of their surgery. These patients have become "subcutaneous mastectomy cripples." In general, these patients have two primary reconstructive problems: (1) inadequate coverage of their silicone implant, and (2) loss of breast skin from infection and ischemic necrosis of skin flaps. The latissimus dorsi flap easily corrects these two defects. We have presented our experience with the "subcutaneous mastectomy cripple" and described the use of latissimus dorsi muscle and musculocutaneous flaps in their management.

Basal cell carcinoma of the medial canthal area.

We advise an aggressive approach in ablating basal cell carcinomas which have originated in the region of the medial canthus. Extirpation of the entire tumor under accurate histological control, whether it includes skin only or the entire orbital contents and ethmoid air cells--and reconstruction with one of the described procedures--gives the surgeon an effective armamentarium to successfully treat these potentially lethal lesions.

Breast reconstruction after a radical mastectomy.

Breast reconstruction after a radical mastectomy remains a complex problem. We describe the use of a latissimus dorsi myocutaneous flap, a transverse abdominal flap, or a pedicled flap of the greater omentum to obtain satisfactory cover for the implant and enable us to correct the deformity in one operation.

Extensions and further applications of muscle flap transposition.

Muscle flap transposition requires a precise knowledge of the vascular and functional anatomy of the muscles used. Safe, effective, one-stage transpositions can be performed in many body regions, as demonstrated in the brief review of our recent experience with this procedure. Our suggestions for further uses of these include distally-based muscle flaps, island muscle flaps, and myocutaneous flaps.

The "reverse" latissimus dorsi muscle and musculocutaneous flap: anatomical and clinical considerations.

A "reverse," posteriorly based transposition of a latissimus dorsi musculocutaneous flap on its segmental blood supply is presented. This adds new possibilities to this versatile and reliable musculocutaneous unit. The variable modes of blood supply to the musculocutaneous units are discussed, and the question of the strategic vascular and neurosympathetic delays are raised.

Transverse abdominal flaps and the deep epigastric arcade.

Further experience with the transverse abdominal flap, based on the deep epigastric arcade, is described. This flap is a logical extension of the concept of the deltopectoral flap (based on the internal mammary). The transverse abdominal flap derives its blood supply from the perforating branches of the deep epigastric arcade, and it can be used without a delay procedure when so constructed.

The transverse lumbosacral back flap.

The transverse lumbosacral back flap is presented as a good one to use for coverage of sacral defects. Its reliability appears to be due to an axial pattern of its proximal portion, and to an uninterrupted subdermal vascular plexus across the midline of the back (supplying the terminal portion). A retrospective analysis of its use in 20 patients, over the last 3 years, suggests that when it is designed properly it can be most useful in the management of sacral pressure sores.

The platysma musculocutaneous flap: experience with 24 cases.

The platysma musculocutaneous flap has been used in 24 patients for reconstruction in the head and neck area. In 22 patients, the superior vascular pedicle, the submental branch of the facial artery, was used, and in two other patients, the inferior pedicle, the superficial branch of the transverse cervical artery, was used. Twelve patients had reconstruction of the intraoral lining with a skin paddle on the platysma. The buccal mucosa and mandibular alveolar ridge are particularly well suited to this flap. Six patients had restoration of external skin, four had provision of both skin and lining with the same flap, and two had coverage of vulnerable structures with muscle alone. Forty-two percent of patients experienced a minor complication. Only four patients, however, required further surgery, and all 24 patients ultimately had satisfactory results. Of seven patients experiencing loss of a portion of the skin paddle, six had intraoral reconstruction. Meticulous dissection and attention to anatomic detail is necessary in raising the flap. Because of its thinness and pliability, we feel that the platysma musculocutaneous flap is an important addition to the techniques of head and neck reconstruction.

Stimulation of healing of chronic wounds by epidermal growth factor.

We evaluated the effect of topical epidermal growth factor treatment on healing of chronic wounds in a prospective, open-label, crossover trial. Five males and four females who ranged in age from 40 to 72 years (average 57 +/- 9 years) were enrolled. Four patients had adult-onset diabetes mellitus, two had rheumatoid arthritis, two had old burn scars, and one had a failed abdominal incision. The average duration of the ulcers prior to treatment with epidermal growth factor was 12 +/- 5 months (range 1 to 48 months). Following failure of the wounds to heal with conventional therapies, including debridement, skin graphs, and vascular reconstruction, wounds were treated twice daily with Silvadene alone for periods ranging from 3 weeks to 6 months. No evidence of healing was observed in any of the patients' wounds during Silvadene treatment, and patients were crossed over to twice a day treatment with Silvadene containing 10 micrograms epidermal growth factor per gram. Wounds of eight patients healed completely with epidermal growth factor-Silvadene treatment in an average of 34 +/- 26 days (mean +/- SD, range 12 to 92 days) and did not reoccur for periods ranging from 1 to 4 years. One patient failed therapy. These results suggest that topical treatment of chronic wounds with epidermal growth factor may stimulate healing.

Total reconstruction of the "end-stage" cleft lip and palate deformity.

The purpose of this paper is to present a 5-year experience using a comprehensive surgical approach to reconstruct what we have chosen to call the "end-stage cleft lip and palate deformity." The deformity consists of varying degrees of midface retrusion, malocclusion, nasal deformity, and lip deformity. Most of the patients afflicted had unacceptable upper lip anatomy characterized by tightness and lack of cupid's bow and bulk. All had severe palatal scarring with resulting arch collapse and severe malocclusion. Most had had multiple surgical attempts to improve nasal aesthetics using standard rhinoplasty techniques with little or no improvement. The procedure involves splitting the upper lip with incisions extending into the upper buccal sulcus and rim of the nose allowing wide skeletalization of the maxilla and osteocartilagenous nasal skeleton. LeFort I or II maxillary advancement, nasal reconstruction, and upper lip modification (with Abbé flap if indicated) are done. The jaws are placed in intermaxillary fixation for 6 to 8 weeks. This comprehensive approach has been used in 16 patients, aged 15 to 29 years, with follow-up of up to 5 years. Excellent functional and aesthetic improvement has occurred in all patients, and complications have been minimal.