Application of the extended superficial musculoaponeurotic system flap to facial clefts.

We believe that the extended SMAS technique may be useful in selected facial cleft patients. In three Treacher Collins patients, this technique produced a modest improvement in the quantity and quality of the malar soft tissue that had not been achieved after orbitozygomatic or maxillomandibular surgery.

Endonasal premaxillary osteotomy.

In our hands, the endonasal premaxillary osteotomy is an improvement over the buccal sulcus tunnel and transpalatal techniques not only because of preservation of the blood supply but also because of improved visualization to the premaxilla. We have found the technique to be particularly useful in the bilateral cleft patient in whom the palate has been closed before Le Fort I osteotomy.

Central tongue reduction for macroglossia.

Unhappy with our postoperative results from standard tongue reduction methods, we have developed a central tongue reduction technique. This technique allows for alteration of the tongue base as well as tongue height and width while minimizing postoperative scarring. Although the technique and its associated surgical complications are in some ways comparable with the standard tongue reduction methods, our postoperative polysomnographic and tongue functioning results are improved. It is noteworthy that none of our patients had worse speech postoperatively and that our one Down syndrome patient had improved speech. Our indication for central tongue reduction is macroglossia of any sort in appropriate patients.

Intraoral reconstruction with a microvascular peritoneal flap.

The microvascular peritoneal flap offers a new reconstructive option for closure of intraoral defects. The flap is easy to raise, and donor-site morbidity is low. Unlike fascial flaps, in which the raw surface may take weeks to "mucosalize," the peritoneal surface heals primarily. Finally, the rectus muscle effectively covers all forms of mandibular reconstruction, and the reliable skin paddle makes possible the closure of substantial cutaneous defects.

Salvage of proximal humeral amputations with a remnant forearm flap.

Spare-part surgery of upper extremity avulsions may facilitate primary soft-tissue healing and prosthetic rehabilitation. This procedure also may be applicable to the management of analogous proximal lower extremity avulsions where a short femoral stump and a shortage of soft tissue exist.

Midline craniectomy for sagittal suture synostosis: comparative efficacy of two barriers to calvarial reclosure.

This report quantitatively compares long-term head remolding achieved by two methods for retarding bone reunion after midline craniectomy for sagittal suture synostosis. In one group of six children the adjacent bone edges were overlayed with 1.0-cm-wide U-channel silicone strips, and in the other group, composed of seven patients, a considerably larger extent of the adjacent cranium was covered with silicone sheets. Mean percent change in the cephalic indices of the former group 18 months postoperatively was 9.1% +/- S.D. = 6.7, and of the latter group 23.7% +/- S.D. = 6.0 (p congruent to 0.01). These results indicate that the use of large silicone sheets lead to a significantly greater normalization of cranial proportions.

Abdominal wall reconstruction (the "mutton chop" flap).

Reconstruction of full-thickness abdominal wall defects can be a difficult surgical challenge. Reconstructing the epigastrium may be especially vexing. The use of prosthetic mesh has significant drawbacks, and the use of pedicled myofascial and myocutaneous flaps should be advantageous. We present 15 consecutive cases demonstrating highly successful reconstructions of massive abdominal wall defects using myofascial and myocutaneous flaps without prosthetic mesh. The extended rectus femoris flap, or "mutton chop" flap, which is capable of resurfacing the epigastrium, is described. Complications were minimal, and use of myofascial units, particularly the rectus femoris, should be considered as the technique of choice for reconstruction of major abdominal wall deficits.

Simultaneous reconstruction of cervical soft tissue and esophagus with a gastro-omental free flap.

A microvascular transfer of gastric tube and omentum was used to simultaneously reconstruct cervical soft-tissue and esophageal defects in five patients. All patients had previous high-dose radiation and multiple flap reconstructions. The largest esophageal and soft-tissue defects were 10 cm and 160 cm2, respectively. All wounds healed primarily except for one orocutaneous fistula. There was one death from an intraoperative stroke. The gastro-omental flap is useful in cases where the reconstructive surgeon is faced with both esophageal and soft-tissue defects--particularly in heavily irradiated patients who have few reconstructive options.

Obstructive sleep apnea in Apert's and Pfeiffer's syndromes: more than a craniofacial abnormality.

Nine acrocephalosyndactyly type I patients (Apert's syndrome) and three acrocephalosyndactyly type V patients (Pfeiffer's syndrome) were evaluated for the relative importance of upper and lower airway abnormalities in the generation of obstructive sleep apnea. All patients were found to have a combination of upper and lower abnormalities. The influence of lower pathology was greater in the infants, and the influence of upper airway, specifically pharyngeal, was greater in the adults. A comparison between preoperative and postoperative polysomnography revealed little improvement with standard craniofacial advancements. Furthermore, three patients are described who succumbed to pulmonary death despite tracheostomy. Conservative treatment with prone or lateral positioning and medical pulmonary regimens is advocated. Finally, the pathogenesis of this diffuse airway pathology is discussed.

Retroperitoneal transposition of rectus abdominis myocutaneous flaps to the perineum and back.

Rectus abdominis myocutaneous flaps may be transposed through the retroperitoneum to reconstruct defects of the back and perineum. Cadaver dissections and clinical cases are presented to demonstrate the surgical technique and reconstructive possibilities of this flap.

Free flap fricasse: iatrogenic thermal injury to a lateral arm flap.

An iatrogenic thermal injury to a lateral-arm free tissue transfer is described. The thermal characteristics of the injurious agent are documented. Free tissue thermal conductivity and reparative potential are discussed.

Internal hemipelvectomy as a treatment for end-stage pressure sores.

Internal hemipelvectomy was used to treat recalcitrant pressure sores in the absence of flap options following leg fillet. The bony hemipelvis was resected in the subperiosteal plane, resulting in the removal of the iliac wing, ischium, and pubic rami. This procedure creates enough mobile soft tissue to allow even large ulcer defects to be closed primarily. We have used the technique successfully in 5 patients; follow-up ranged from 4 to 30 months. Internal hemipelvectomy is a treatment option for end-stage pressure ulcers in lieu of hemicorporectomy.

Coverage of acute vascular injuries of the axilla and groin with transposition muscle flaps: case reports.

Acute axillary or groin vascular injuries caused by farm machinery or shotgun blasts are often associated with extensive soft-tissue loss. Coverage of the repaired blood vessels with healthy tissue is necessary to avoid infection, desiccation, pseudoaneurysm, and rupture. Adjacent muscles are not always available to rotate for coverage, due to unacceptable functional loss, or injury to the principal vascular pedicle. We used proximally based trunk musculature with vascular pedicles out of the areas of injury to achieve coverage of four extensive axillary wounds and one extensive groin wound. Arterial repair only was performed in three axillary wounds. Combined arterial and venous repair were performed in one groin wound and one axillary wound. Followup ranging from 9 months to 5 years revealed no vascular failure or soft-tissue complications. We conclude that coverage of vascular repairs and soft-tissue defects with viable muscle is necessary in cases of extensive injury. Adjacent muscle is preferred for coverage, but when this is unavailable, coverage can still be achieved using more proximally pedicled muscles of the trunk.

Rotational muscle flaps: a new technique for covering infected vascular grafts.

Twenty-one patients with established localized infection of vascular bypass grafts were treated with aggressive debridement and rotational muscle flap coverage to control graft infection. There were six gram-positive, six gram-negative, four mixed, and three fungal graft infections. Graft material included Dacron, Gore-Tex (registered trademark of W. L. Gore Associates Inc., Elkton, Md.), Dacron and Gore-Tex in combination, and saphenous vein. Twenty of 21 patients had successful preservation of graft function, local wound healing, and control of infection. There were no amputations or deaths. The one failure was caused by incomplete debridement of an infected graft segment. Aggressive debridement and rotational muscle flap coverage is an effective means of treating locally infected vascular bypass grafts.

Stabilization of the midface with a cranium-to-alveolus bone graft.

The cranium-to-alveolus bone graft is an alternate method of reconstructing the posterior and lateral midfacial pillars where local reconstruction is not possible.

Desmoplastic melanoma of the head and neck.

The pathologic and clinical findings in cases of desmoplastic melanoma of the head and neck seen at the Mayo Clinic in Rochester, Minnesota, during the past 20 years were analyzed. The nine cases acceptable for study included six usual and three neurotropic variants as defined by light microscopic criteria. Immunopathologic studies of all cases using S-100 protein and desmin, and electron microscopy in four cases, were unsuccessful in distinguishing between the two subtypes. Clinical behavior was aggressive regardless of histologic subtype. Extensive surgical treatment when the diagnosis is made is advocated. The combination of the rarity and the subtle histologic features of desmoplastic melanoma continues to make the correct diagnosis of this entity a challenge for the clinician and pathologist.