Ablation of advanced tongue or base of tongue cancer and reconstruction with free flap: functional outcomes.

AIM: To evaluate the functional outcomes of patients who underwent total or nearly total glossectomy for advanced tongue or base of tongue cancer. MATERIAL AND METHODS: We used the radial forearm free flap (RFFF), anterior lateral thigh flap (ALTF) or fibular osteocutaneous flap (FOCF) to reconstruct the oral defect after radical resection in 39 patients undergoing total or nearly total glossectomy with laryngeal preservation. RESULTS: Good functional outcomes, measured by independent feeding, speech and swallowing were achieved in 35, 36 and 35 patients, respectively. The cumulative 4-year survival rates were 63.8% for tongue cancer and 42.9% for base of tongue cancer. CONCLUSION: Reconstruction with free flaps is a feasible method to restore the functional outcomes in speech and deglutition among patients who undergo total or nearly total glossectomy with laryngeal preservation.

Distally based sural island flap for the reconstruction of a large soft tissue defect in an open tibial fracture with occluded anterior and posterior tibial arteries-a case report.

To repair a 10 x 16 cm soft tissue defect of right lower leg that accompanied with occluded anterior and posterior tibial arteries in a 30-year-old man who sustained comminuted type III(B) Gustilo open tibial and fibular fracture, we present a successful reconstruction by using a large distally based sural island flap perfused by the lowermost perforator of the peroneal artery. This flap is a useful alternative for distal extremity reconstruction when anterior and posterior tibial arteries are occluded, as large flaps can be elevated safely based on only one peroneal perforator.

Percutaneous puncture and pre-operative cyanoacrylate obliteration of a traumatic false aneurysm of an angular artery branch.

We report a case of traumatic false aneurysm developed in the right glabella in a 5-year-old boy 3 weeks after an innocuous fall. Ultrasound, CT and facial arteriography did not reveal the feeding artery. After direct puncture of the glabellar bulge and rapid aspiration of blood, percutaneous contrast agent infusion revealed that the false aneurysm was supplied by the contralateral angular artery. Intralesional obliteration with cyanoacrylate was subsequently performed smoothly. Succeeding excision was easy and the cosmetic outcome was excellent.

Free anterolateral thigh flap for extremity reconstruction: clinical experience and functional assessment of donor site.

From August of 1995 through July of 1998, 38 free anterolateral thigh flaps were transferred to reconstruct soft-tissue defects. The overall success rate was 97 percent. Among 38 anterolateral thigh flaps, four were elevated as cutaneous flaps based on the septocutaneous perforators. The other 34 were harvested as myocutaneous flaps including a cuff of vastus lateralis muscle (15 to 40 cm3), either because of bulk requirements (33 cases) or because of the absence of a septocutaneous perforator (one case). However, vastus lateralis muscle is the largest compartment of the quadriceps, which is the prime extensor of the knee. Losing a portion of the vastus lateralis muscle may affect knee stability. Objective functional assessments of the donor sites were performed at least 6 months postoperatively in 20 patients who had a cuff of vastus lateralis muscle incorporated as part of the myocutaneous flap; assessments were made using a kinetic communicator machine. The isometric power test of the ratios of quadriceps muscle at 30 and 60 degrees of flexion between donor and normal thighs revealed no significant difference (p > 0.05). The isokinetic peak torque ratio of the quadriceps and hamstring muscles, including concentric and eccentric contraction tests, showed no significant difference (p > 0.05), except the concentric contraction test of the quadriceps muscle, which revealed mild weakness of the donor thigh (p < 0.05). In summary, the functional impairment of the donor thighs was minimal after free anterolateral thigh myocutaneous flap transfer.

Concomitant ipsilateral pedicled fibular transfer and free muscle flap for compound tibial defect reconstruction.

Three patients with compound injuries of the lower extremities were treated with pedicle fibular grafts and a free muscle flap concomitantly. There were 1 female and 2 male patients, all of whom sustained high-energy trauma in a motor vehicle accident. The bone defect of the tibia ranged from 8 to 12 cm. The size of the soft-tissue defect ranged from 24 x 15 cm to 28 x 15 cm. All patients underwent preoperative angiography to ensure the patency of the peroneal artery and to avoid its use by risking viability of the leg. All patients were treated with an antegrade-flow pedicle fibular graft. The fibular graft was inserted as a single strut in 2 patients and as a double-barrel strut in 1 patient. The pedicle of the free muscle flap was anastomosed to the distal runoff of the fibular bone flap. All free muscle flap transfers succeeded without complication. Bone scans performed on postoperative day 7 showed viability of transferred bone. The average time to radiological union was 9 months, and the average time to full weight bearing was 12 months. Screw loosening occurred in 2 patients and osteomyelitis was noted in another patient who was treated successfully with sequestrectomy and antibiotics. Indications for this technique are a large segmental bone defect with a huge soft-tissue defect, and patency of the peroneal artery and at least one other major artery. This method provides the advantages of one-stage reconstruction, avoidance of contralateral donor site morbidity, easy control of infection, and chance for early weight bearing. When selected carefully, this technique can be considered when one wants to avoid a two-stage, two free flap transfer.

Prognostic factors for walking attainment in very low-birthweight preterm infants.

The purpose of this study was to compare the age of walking attainment between very low-birthweight (VLBW) preterm infants and normal term infants, and to determine the variables that affect the walking attainment in VLBW infants. Ninety-six VLBW preterm infants and 82 normal term infants were prospectively followed to determine their age of walking attainment and to monitor gross motor development with sequential clinic visits at 6, 9, 12 and 18 months corrected age. Perinatal and sociodemographic data were collected through review of medical records. The VLBW infants were significantly older at attainment of walking (median 14 months) than the term infants (median 12 months) after correction for prematurity. By the age of 18 months, all term infants had attained walking ability; while 11% of VLBW infants were still unable to walk. Multivariate proportional hazards regression analysis revealed that low gestational age was significantly associated with late attainment of walking in VLBW infants. With the adjustment for gestational age, prolonged ventilation (or oxygen therapy) and severe retinopathy of prematurity were significant predictors of late walking attainment. Our findings indicate that VLBW preterm infants have an increased risk of delayed attainment of walking. Furthermore, the contribution of low gestational age to the delayed walking attainment in VLBW infants may occur via the plausible pathways of neonatal respiratory distress and severe retinopathy of prematurity.

Healing of untidy traumatic skin defect of the face by secondary intention.

BACKGROUND: Untidy facial skin defects manifest extensive soft tissue injury and contamination. Since modern surgical principles emphasize immediate wound closure, most surgeons should learn to convert an untidy wound to a tidy one and to reconstruct defects immediately if possible with the use of grafts and flaps. However, in some situations, healing by secondary intention remains advantageous. The purpose of this study is to reevaluate this traditional approach. METHODS: Twenty patients with untidy facial skin defects were treated conservatively over a 4-year period. The defects ranged from 2 x 2 cm2 to 6 x 4 cm2 in size. The depths of wounds were classified into partial-thickness in 9 patients, full-thickness in 7 patients, and deep defects in 4 patients. Each patient was instructed on wound care, which included daily cleaning with normal saline, followed by application of hydrocolloid occlusive dressing. Prophylactic antibiotics were not used. RESULTS: The mean follow-up period was 17 months. All wounds healed within 3 to 5 weeks. There was no wound infection. One patient developed a hypertrophic scar over the cheek, and received excision of the scar and resurfacing with full-thickness skin graft. Two patients had residual traumatic tattooing which was resolved by laser therapy. Two patients had hypopigmentation/hyperpigmentation problems. Most patients (18/20) were satisfied with both functional and cosmetic results. CONCLUSION: Conservative wound care with hydrocolloid occlusive dressing allows good healing by secondary intention for traumatic facial defects in selected patients.

Alberta infant motor scale: reliability and validity when used on preterm infants in Taiwan.

BACKGROUND AND PURPOSE: The goal of this study was to examine the reliability and validity of measurements obtained with the Alberta Infant Motor Scale (AIMS) for evaluation of preterm infants in Taiwan. SUBJECTS: Two independent groups of preterm infants were used to investigate the reliability (n=45) and validity (n=41) for the AIMS. METHODS: In the reliability study, the AIMS was administered to the infants by a physical therapist, and infant performance was videotaped. The performance was then rescored by the same therapist and by 2 other therapists to examine the intrarater and interrater reliability. In the validity study, the AIMS and the Bayley Motor Scale were administered to the infants at 6 and 12 months of age to examine criterion-related validity. RESULTS: Intraclass correlation coefficients (ICCs) for intrarater and interrater reliability of measurements obtained with the AIMS were high (ICC=.97-.99). The AIMS scores correlated with the Bayley Motor Scale scores at 6 and 12 months (r=.78 and.90), although the AIMS scores at 6 months were only moderately predictive of the motor function at 12 months (r=.56). CONCLUSION AND DISCUSSION: The results suggest that measurements obtained with the AIMS have acceptable reliability and concurrent validity but limited predictive value for evaluating preterm Taiwanese infants.

Salvage of the distal foot using the distally based sural island flap.

The authors describe their additional experience with the distally based sural island flap for reconstruction of the whole foot, including the forefoot area in 8 patients. The flap is vascularized by the lowermost perforating branches of the peroneal artery. The skin flap can be elevated, based on the lesser saphenous vein and its accompanying arteries, in all parts of the sural region. This modification allows a farther reach of the flap for coverage of the distal foot and sole. All flaps, innervated by the lateral sural cutaneous nerves, were able to provide protective sensation in the distal soles. In 7 patients the flaps survived completely, and only 1 patient had partial necrosis of the flap. The advantage of this flap is its constant and reliable blood supply without sacrifice of the major artery. Elevation of the flap is simple and rapid. This flap is a versatile alternative that should be considered prior to a free flap transfer.

Reverse venous outflow of a free fibular osteocutaneous flap: a salvage procedure.

The authors report 2 patients with a massive bony defect of the tibia due to chronic osteomyelitis. They reconstructed the defect using a free vascularized fibular osteocutaneous flap. Unfortunately, venous insufficiency was diagnosed 24 hours postoperatively. The previous anastomosed veins were promptly explored. The peroneal veins of the vascularized fibular bone graft were noted to be full of thrombi. After thrombectomy, the vessels became very fragile and broke down easily. It was impossible to achieve normal antegrade venous outflow from the previous vein of the donor graft; however, they found that distal runoff of the peroneal vein achieved a reverse venous outflow from the donor graft. The great saphenous vein was dissected and reanastomosed to achieve adequate venous drainage. This procedure may offer an alternative treatment for a flap with venous insufficiency.

Toe transplantation for isolated index finger amputations distal to the proximal interphalangeal joint.

Functional deficit following single distal index finger amputations has been considered insignificant, and reconstruction is usually not recommended. Herein, 19 cases of second toe transplantation for reconstruction of isolated index finger amputation distal to the proximal interphalangeal joint are presented with long-term functional results. There are 14 men and 5 women. The average age was 26 years. The toe transplantations were performed either as a primary procedure (5 patients) while the wounds were still open or as a secondary procedure (14 patients) after the wounds healed. In 11 patients, the dominant hand was involved. All toes survived completely, although re-exploration was required in three cases (16 percent). The functional evaluation included (1) sensory recovery, where the average static and moving two-point discrimination were 8 mm (range 4 to 15 mm) and 6 mm (range 2 to 15 mm); (2) motor function, where the average of index-thumb pulp-to-pulp pinch compared with the normal hand was 67.5 percent (range 36 to 96 percent); (3) average range of motion in index finger joints (extension/flexion), where metacarpophalangeal joint was 14/90, proximal interphalangeal joint was 0/94, and distal interphalangeal joint was 19/38; and (4) functional and cosmetic results, where percentage of involvement in daily activities and functional capacity of the reconstructed index were 69 percent and 70.5 in average, respectively, over a total score of 100. Average scores of aesthetic appearance and acceptability of donor-site deformity were 74 and 87.5 over a total score of 100, respectively. Toe transplantation for distal index finger amputations improved hand function when performed in selected patients with specific job requirements or high motivation.

Head stability in walking in children with cerebral palsy and in children and adults without neurological impairment.

BACKGROUND AND PURPOSE: The location of several sensory systems in the head implies that maintenance of head stability may be a potentially important part of locomotor activity. A limited amount of research, however, has been conducted to measure stability or to compare head stability among different groups. The purpose of this study was to determine whether a method for measuring head stability during walking could differentiate among 3 groups: (1) children with cerebral palsy, (2) children without neurological impairment, and (3) adults without neurological impairment. SUBJECTS: Eight adults without known neurological impairment, 6 children without known neurological impairment, and 6 children with cerebral palsy and mild spastic hemiplegia were compared. METHODS: Subjects walked on a treadmill at their preferred speed at a number of frequencies. Head stability was characterized by fluctuations in period and amplitude of head motion in the sagittal plane across walking cycles. RESULTS: Mean period fluctuation was lower for the adults than for the children, and it was lower for the children without neurological impairments than for the children with cerebral palsy. CONCLUSION AND DISCUSSION: The method can be used to differentiate head stability among different groups during functional activities.

Neurobehavioral development at term in very low-birthweight infants and normal term infants in Taiwan.

We compared the neurobehavioral performance at term between very low-birthweight (VLBW) infants and term infants in Taiwan, and investigated the relationships between neonatal factors and neurobehavioral performance in VLBW infants. Sixty VLBW infants and 58 healthy term infants were examined using the Neonatal Neurobehavioral Examination-Chinese version (NNE-C) at 40 weeks postmenstrual age. Medical records of the VLBW infants were reviewed to assess neonatal factors. The mean total score of the preterm infants (67.4+/-5.0) was significantly lower than that of the term infants (73.8+/-3.0) (t = 8.51, P < 0.0001). Furthermore, respiratory illness had a marginal effect on the rate of low neurobehavioral score (defined as 2SD below the mean score of term infants) in the preterm infants after adjustment for gestational age (odds ratio = 7.67, chi2 = 3.36, P = 0.067). Our findings indicate that preterm infants have lower neurobehavioral scores at term than their healthy term counterparts. Furthermore, respiratory illness may be a potential risk factor for low neurobehavioral score at term in preterm infants when gestational age is adjusted for.

The distally based forearm island flap in hand reconstruction.

The distally based forearm island flap is vascularized by the perforators of the distal radial artery. The skin flap is along the axis of the radial artery, and the pivot point of its subcutaneous pedicle is about 2 to 4 cm above the radial styloid process. We have treated 12 patients with 12 flaps for soft-tissue defects of the hand. Of these recipient sites, seven were in dorsal hands, two were in thumbs, two were in forearms, and one was in the palmar area. The donor-tissue variants included eight skin flaps, two adipofascial flaps, and two sensate flaps. The sizes of the flaps ranged from 6 x 4 cm to 14 x 6 cm. The donor site wound could be closed primarily in five patients. Two sensate flaps, innervated by the lateral antebrachial cutaneous nerve, could provide sensation for thumb reconstruction. The advantage of this flap is its constant and reliable blood supply without sacrifice of the main radial artery. The elevation of the flap is simple and rapid. There is the potential that this flap can be used as an innervated flap, and there is no need of microsurgical technique.

Acute pulmonary edema after microsurgery: two case reports.

Postoperative management procedures after microsurgery are well-established. Usually, maintaining an adequate plasma volume will lower blood viscosity and will provide an adequate arterial inflow to keep the replantation or the flap viable in routine microsurgical procedures. But if the patient's underlying condition is neglected, disasterous complications may occur. The authors report two cases with severe postoperative complications after microsurgery. One patient was a 38-year-old male who suffered from diabetic foot ulcer and received a free muscle flap transfer. He developed acute pulmonary edema at day 6 postoperatively. The other patient was a 20-year-old pregnant woman at 31 weeks gestation who developed pulmonary edema on the POD 4 following microsurgical replantation of the thumb and index finger of her left hand. The complications were believed to be caused by fluid overload and neglect of the patients' underlying conditions. Knowledge of possible precipitating factors and careful monitoring of fluid should avoid acute pulmonary edema after microsurgery under certain unusual conditions.

Technical refinement in the management of circumferentially avulsed skin of the leg.

Between 1989 and 1994, 42 patients with circumferential skin avulsion of lower extremities were treated with full-thickness skin graft from defatted avulsed flap. Among them, 39 patients were run over by rubber tires during car accidents; the remaining 3 patients were victims of industrial accidents by roller machines. The full-thickness skin grafts were prepared from the avulsed skin flap in attachment to avoid junctional hypertrophic scarring. They were then secured with multiple skin staples to their anatomical position to improve skin graft take. Initial take of graft averaged 91 percent (ranged from 75 percent to 100 percent). Twelve patients underwent secondary overgrafting after tangential excision of non-viable skin graft. Follow-up averaging 2.6 years revealed stable wounds in most of the patients. Ten patients experienced occasional breakdown of skin graft in the patella and popliteal fossa, which was treated conservatively. Except for five who had deformed contours of the leg due to muscle transfers, the patients were satisfied with the cosmetic appearance of their legs. Compared with conventional methods, this approach provided better appearance and less contracture.

Resurfacing a circumferentially degloved hand by using a full-thickness skin graft harvested from an avulsed skin flap.

Twelve patients with circumferentially degloved hands were treated with full-thickness skin grafts harvested from defatted avulsed flaps. All injuries were industrial accidents caused by various roller machines, not crush injuries. Of these 12 patients, 9 patients were degloved from the wrist level and 3 patients were degloved from the forearm. There were 11 distally based skin flaps and one flap was completely detached. Four patients were avulsed distally to the mid palm, with volar neurovascular bundles damaged at the "fenestrae" of the palm, which resulted in devascularization of the involved fingers. Among them, distal fingers were successfully revascularized by microsurgical techniques in 3 patients. The full-thickness skin grafts were prepared from the attached, avulsed skin flap to avoid junctional hypertrophic scarring. The graft was then secured to its anatomic position with multiple skin staples to improve skin graft take. Initial take of the graft averaged 93% (range, 85%-100%). Compared with conventional methods, this approach provides a higher rate of skin take and better cosmetic and functional results.

Free tissue transfer for leg reconstruction in children.

Twenty-five free tissue transfers for reconstruction after lower limb trauma or release of scar contractures were performed in 23 children over an 8-year period. The ages ranged from 2 to 14 years (mean 7.1 years). Fourteen (61%) patients had major associated injuries. The reconstruction sites were all in the distal leg. The overall vascular success rate was 96%. Three patients underwent re-explorations because of vascular insufficiency. One flap failed and two were salvaged. The causes of vascular complications were considered to be inadequate debridement of an avulsed vessel, venous kinking and inadequate protection of the vascular pedicle. The three cases with vascular insufficiency were children with associated injuries on the ipsilateral leg proximally. Postoperative complications were not uncommon (28%). Six of the seven complications occurred in patients with major associated injuries. The mean follow-up was 57 months. Long-term problems such as a limping gait, frequent flap ulcers, toe contracture or a bulky flap were common. Our results suggest that free tissue transfer is reliable and safe for the reconstruction of major leg injuries in children. Associated injuries proximal to the reconstructed defects on the ipsilateral leg predispose to more vascular complications. Since postoperative complications and long-term morbidity are common in children, special precautions should be taken with the preoperative assessment, planning, execution of surgery and postoperative care to achieve better results.

Classification and reconstructive options in foot plantar skin avulsion injuries.

Between 1989 and 1994, 28 patients who had plantar avulsion injuries were treated. Patient ages averaged 30 years (range 7 to 62 years). Length of follow-up averaged 20 months. Five patients (18 percent) were classified as having suprafascial avulsions, where the shearing plane was limited to the superficial subcutaneous layer, leaving the deeper subcutaneous fat. Twenty-three patients (82 percent) were classified as having subfascial avulsions, where the stripping force extended deep into the plantar aponeurosis. For the suprafascial avulsions, defatting these flaps and replacing them with full-thickness skin grafts was the treatment of choice. For the subfascial group, the avulsions with proximally based flaps (4 patients) that were well nourished by mediolaterally orientated neurovascular bundles could be treated by sewing the avulsed flaps tension-free back to their former positions. For the subfascial group with distally based flaps (19 patients), the avulsed flaps were supplied by anteroposteriorly orientated vascular plexuses that were compromised. Primary revascularization of the soft tissue should be considered whenever possible. Among them, 10 patients attempted microvascular salvage. Only 3 patients succeeded with revascularization. In the remaining 16 patients, the avulsed flaps went on to partial or complete necrosis, and these required secondary reconstruction with free muscle flaps for heel defects.