Anatomic basis of anorectal reconstruction by dynamic graciloplasty with pudendal nerve anastomosis.

BACKGROUND: Dynamic graciloplasty has been proposed for anal reconstruction, but this method has 2 major drawbacks. First, an electrical device is required for control of the gracilis. The anastomosis with the pudendal nerve will provide more physiological control. Second, the limitation in the mobility of the muscle flap results in wrapping the anal canal with the muscle's distal portion, which is tendonlike and inelastic. Enhancing the mobility of the muscle flap will enable wrapping with the proximal, muscle-like, and extensible portion, possibly providing better sphincteric function. However, the basis for such an operative method is lacking. OBJECTIVE: The aim of this study is to provide the basis for the refined method of anal sphincter reconstruction by dynamic graciloplasty with pudendal nerve anastomosis and to verify the feasibility of lengthening the nerve to the gracilis muscle flap by dissecting into the muscle belly, detaching the gracilis muscle from its origin, and enhancing the mobility of the muscle flap. STUDY DESIGN: This is a retrospective, descriptive study. METHODS: The results from the anatomical study on 9 cadavers are reported. RESULTS: Tension-free anastomosis of the pudendal nerve and nerve to the gracilis was successfully performed in all the 9 cases: in 2 cases, by lengthening the nerve. The detachment of the muscle origin improved the mobility of the muscle flap, and the more proximal portion could be used for wrapping the anal canal, as confirmed in 4 cases. LIMITATIONS: The limited number of cases was a shortcoming of this study. CONCLUSIONS: By lengthening the nerve to the muscle, the gracilis can be used for anal sphincter reconstruction with pudendal nerve anastomosis, negating the need for an electrical device. By detaching the origin of the gracilis muscle, its proximal portion can be used to wrap the anal canal, possibly enabling a longer functional canal with stronger constricting force and better vascularity. These modifications to past methods may improve fecal continence after the operation.

Recruited minced skin grafting for improving the skin appearance of the donor site of a split-thickness skin graft.

OBJECTIVE: To improve skin appearance at the donor site of a split-thickness skin graft, part of the harvested skin was minced and grafted back onto the site in a process we named "recruited minced skin grafting." MATERIALS AND METHODS: Thirteen Japanese patients who needed split-thickness skin grafts were treated with recruited minced skin grafting. Five patients were used as controls, in whom donor sites were treated with the traditional method. Part of the split-thickness skin was minced using two surgical blades (number 24) to an approximate particle size of less than 0.5 mm. Minced skin was spread and transplanted onto the donor site and covered with polyurethane foam. Twelve months after the operation, donor sites were scored for hypopigmentation, hyperpigmentation, redness, and disruption of skin texture. Gross appearance was evaluated according to total score. RESULTS: Donor sites treated with recruited minced skin grafts had significantly better appearance than those of controls. Donor sites that had more than 5% of the total area treated tended to have better results. CONCLUSION: Recruited minced skin grafting is a good method of improving the appearance of the donor site.

Palatoplasty for bilateral oblique cleft of the soft palate accompanied by Tessier number 5·7 cleft.

Craniofacial cleft is a rare congenital deformity in which there are fissures of a facial structure classified by Tessier. A palatoplasty to reconstruct the muscle sling and to close the cleft of the velum was performed. Acceptable postoperative appearance of the velum was seen after 6 months. Although further follow-up is still needed for velopharyngeal function, this case report provides details of the anatomical deformities and our surgical approach to this atypical bilateral cleft palate.

A biomechanical study on the effect of premature fusion of the frontosphenoidal suture on orbit asymmetry in unilateral coronal synostosis.

OBJECTIVE: The coronal ring of patients with unilateral coronal synostosis (UCS) presents premature fusion. This study aims to elucidate whether or not the dynamic behavior of the orbit in response to intracranial pressure (ICP) differs between patients in whom the premature fusion exists only in the frontoparietal suture (FPS) and those in whom the premature fusion extends to the frontosphenoidal suture (FSS). METHODS: A total of 15 UCS patients were included in the present study. Patients in whom premature fusion was seen inside the FPS and those in whom premature fusion extended to the FSS were categorized as FP Only (4.2 +/- 1.4 m/o) and FP + FS groups (4.6 +/- 2.2 m/o), respectively. On the basis of computed tomography (CT) data, computer-aided design models were produced. Pressure of 15 mm Hg was applied to the neurocranium of each skull model to simulate ICP. Using the finite element method, the displacements presented by each model's orbits were calculated. Displacements of the two groups were compared. RESULTS: The orbit demonstrated greater displacement in the FP Only group than in the FP + FS group, suggesting that premature closure of the FSS disturbs growth of the orbit in response to ICP. CONCLUSION: In performing surgical treatment for UCS, the degree of fusion that the FSS presents should be evaluated carefully. In cases in which the FSS presents premature fusion, it is recommended to release the fusion at an early stage of cranial growth to improve the appearance of the orbital region.

A vascularised gracilis flap with tibial bone for the reconstruction of the Achilles tendon.

Rupture of the Achilles tendon is a very common trauma. Reconstruction of a chronic Achilles tendon defect is challenging for reconstructive surgeons, and several methods have been described. The ideal reconstruction would result in the patients resuming the activity level they were accustomed to before the injury. In our patient, the Achilles tendon was reconstructed using the gracilis muscle flap, and the flap was fixed using a fragment of the tibial bone, yielding satisfactory results. In this report, we describe this procedure employed and provide a description of the case.

Wing flap reconstruction for large defects of the lower lip.

Full-thickness lower lip defects most often occur due to tumour resection or injury. Because the lower lip is important for both eating and speaking, reconstruction of the region must restore the structure and function of the tissue. Here, we describe a new procedure to reconstruct the lower lip, using a 'wing flap': a mental V-Y rotational advancement flap that contains the mental nerve. This flap can preserve the sensory innervation of the lower lip, and it allows effective reconstruction of the muscle sling. We have employed this method twice and have obtained good aesthetic and functional outcomes. No special technique is required to reconstruct the lip using this flap, and it yields a satisfactory outcome. Thus, we recommend it as an effective method for reconstruction in wide lower lip defects.