Autologous tracheal cartilage composite graft for a subglottic defect after laryngotracheal resection for invasive papillary thyroid carcinoma

@#<p style="text-align: justify;"><strong>OBJECTIVE: </strong>To present a function-preserving surgical technique of post-laryngotracheal resection reconstruction of the subglottic airway using autologous tracheal cartilage composite graft.</p><p style="text-align: justify;"><strong>METHODS:</strong></p><p style="text-align: justify;"><strong>     Design:</strong>            Case Report</p><p style="text-align: justify;"><strong>     Setting:</strong>           Tertiary Government Training Hospital</p><p style="text-align: justify;"><strong>     Participants:</strong>   One</p><p style="text-align: justify;"><strong>RESULT: </strong>A 77-year-old woman diagnosed with papillary thyroid carcinoma with laryngotracheal invasion underwent total thyroidectomy with laryngotracheal resection. The tracheal defect was reconstructed using end-to-end anastomosis of the trachea to the remaining cricoid. The cricoid (subglottic) defect was repaired using the harvested tracheal cartilage with mucosa. Post-operatively, the patient was maintained on nasogastric tube feeding and tracheostomy tube for 2 weeks. Subsequently, the nasogastric tube and tracheostomy tube were removed and the patient tolerated oral feeding without any airway problem. The last follow-up of the patient was 6 months post-operatively without complications.</p><p style="text-align: justify;"><strong>CONCLUSION: </strong>Autologous tracheal cartilage may be a potentially promising composite graft for reconstruction of the cricoid (subglottic) defect in a patient following laryngotracheal resection for invasive papillary thyroid carcinoma of the larynx and trachea.</p><p style="text-align: justify;"> </p>

Usefulness of Inferior Turbinate Bone-Periosteal-Mucosal Composite Free Graft for Cerebrospinal Fluid Leakage

BACKGROUND AND OBJECTIVES: Endoscopic repair of cerebrospinal fluid (CSF) leak can avoid morbidity of open approaches and has shown a favorable success rate. Free mucosal graft is a good method, and multi-layered repair is more favorable. The inferior turbinate has been commonly utilized for the free mucosal graft, but we newly designed it as a bone-periosteal-mucosal composite graft for multilayered reconstruction. SUBJECTS AND METHOD: Four subjects with a skull base defect were treated with this method. The inferior turbinate was partially resected including the conchal bone and was trimmed according to defect size. Both bony parts and periosteum were preserved on the basolateral side of the mucosa as a composite graft. The graft was applied to the defect site using an overlay technique. RESULTS: All cases were successfully repaired without any complications. Three of them had a defect size greater than 10–12 mm, and the graft stably repaired the CSF leakage. CONCLUSIONS: Endoscopic repair of CSF leakage using inferior turbinate composite graft is a simple and easy method and would be favorable for defect sizes greater than 10 mm.

Results of Infrainguinal Bypass with a Composite Graft Combining Polytetrafluoroethylene and Vein Graft in Absence of Appropriate Saphenous Vein Graft

PURPOSE: Use of a composite graft combining a polytetrafluoroethylene graft with an autogenous vein is an option for limb salvage in the absence of an adequate single segment vein graft. We aimed to investigate the results of infrainguinal bypass with a composite graft. MATERIALS AND METHODS: We retrospectively reviewed 11 infrainguinal arterial bypasses on 11 limbs which underwent surgery from March 2012 to November 2016. RESULTS: Critical limb ischemia was common (63.6%) indication of bypass surgery and most (90.9%) of the patients had history of failed previous treatment including endovascular treatment (36.4%) and bypass surgery (72.7%). At the 2 years after graft implantations, primary patency and amputation-free survival of below-knee bypasses using composite graft were 73% and 76%, respectively. CONCLUSION: Infrainguinal arterial bypasses with composite graft had an acceptable patency. In patients without other alternative conduits for revascularization, bypass with a composite graft can be an option.

Fluxometria intraoperatória do enxerto composto de artéria torácica interna esquerda e veia safena magna

Enxerto composto de artéria torácica interna esquerda (ATIE) e veia safena magna (VSM) na revascularização de duas ou mais artérias do sistema coronariano esquerdo (SCE)é uma técnica descrita na literatura desde a década de 1980. Apesar de recentes estudos demonstrarem que a ATIE é capaz de oferecer fluxo sanguíneo adequado, para duas ou mais artérias do SCE, tanto em situação de repouso como estresse, estudos aprofundados devem ser desenvolvidos para aprimorar esse conhecimento. O objetivo deste trabalho é analisar a dinâmica de fluxo sanguíneo neste tipo de enxerto composto, sobretudo no que concerne a adaptabilidade da ATIE eà influência da presença do segmento de VSM sobre o fluxo na ATIE.Em vinte e três pacientes foirealizadoenxerto composto em Y de ATIE e VSM, para revascularizar a artéria interventricular anterior (AIA) e outro ramo do SCE, respectivamente, sem circulação extracorpórea (CEC). O fluxo sanguíneomédio, parâmetros de perviedade do enxerto(fração diastólica e índice de pulsatilidade)e reserva de fluxo coronariano(RFC) foram avaliados por meio de fluxometria por tempo de trânsito (FMTT)em todos os segmentos do enxerto composto, ou seja, nos segmentos proximal e distal da ATIE e no segmento de VSM. As medidas foram realizadas em condição basal, e após estresse farmacológico com dobutamina, bem como sem e com clampeamento temporário a traumático dos segmentos distais do enxerto composto.Estresse farmacológico resultou em aumento dos valores do fluxo sanguíneo em todos os segmentos analisados(p<0,05)...

Composite graft of left internal thoracic artery (LITA) and great saphenous vein (GSV) in the revascularization of two or more arteries of the left coronary system (LCS) is a technique described in literature since the 1980s. Despite recent studies demonstrating that LITA is capable of providing adequate blood flow for two or more LCS arteries, both in basal condition and under stress, deeper studies must be developed to improve this knowledge. The objective of this study was to analyze blood flow dynamics in this kind of composite graft, specially in what concerns to LITA adaptability and to the influence of GSV segment on LITA flow. In 23 patients, a LITA and GVS composite Y-graft was realized to the anterior interventricular artery (AIA) and to another LCS branch, respectively, without extracorporeal circulation. Mean blood flow, as well as parameters of graft patency (diastolic fraction and pulsatile index) and coronary flow reserve(CFR)were evaluated throughtransit time flowmetry (TTFM) in all segments of the composite graft, which are LITA proximal and distal segments, and GSV segment. The measures were realized in basal condition and after dobutamine-induced pharmacological stress, as well as without and with non-traumatic temporary clamping of the distal segments of composite graft. Pharmacological stress resulted in increased values of blood flow in all analyzed segments (p<0,05)...

Finger Tip Composite Grafting Managed with Moist-Exposed Dressing

PURPOSE: The purpose of this study was to determine whether keeping the wound moist improves the results of composite grafting of amputated fingertip. MATERIALS AND METHODS: Between 1997 and 2010, 93 patients with traumatic amputation of 100 digits have undergone composite finger tip graft. The hand was kept elevated and a topical antibiotics was frequently applied to avoid desiccation. Their ages ranged from 10 months to 73 years. We assessed the success rate based on age, amputation level, ischemic time and etiology. RESULTS: Of these 100 composite grafts, grafting had been successful in 65. Evaluation by age revealed that grafting had been successful in 13 of 18 fingers among patients less than 6 years old, in four of five fingers among those 6 to 15 years old and in 48 of 77 fingers among those 16 years of age and older. Assessment by level of amputation showed that grafting had been successful in 37 of 56 fingers amputated in zone I, in 12 of 19 fingers amputated in zone II and in 16 of 25 fingers amputated in zone III. No statistically significant differences in graft survival were found in relation to age, amputation level, ischemic time or type of amputation. CONCLUSION: Our results demonstrate that composite finger tip graft in adult is feasible and a very high rate of survival is obtained. We believe that moist-exposed dressings should improve the success rate associated with fingertip composite grafting.

A New Technique for Composite Graft Preparation in Aortic Root Replacement / 日本心臓血管外科学会雑誌

We report the Lampshade Technique : a new technique using Carbo-Seal Valsalva (Sorin Biomedica, Saluggia, Italy) to facilitate preparation of a composite graft. A Bentall operation and an ascending aorta replacement were performed with a composite graft using a Carbo-Seal Valsalva. This new technique can be considered useful as it can reduce the time required for preparing a composite graft, and create a skirt portion for continuous suturing to prevent bleeding.

Experimental Study of Efficacy of a DBM-rifampicin Composite Graft in Healing of Segmental Radial Defect in Rabbits / 中国康复理论与实践

@#Objective To evaluate the antibiotics release characteristic and osteogenesis ability of anti-tuberculosis composite graft by observing the healing effect of segmental radial defect in rabbits.Methods Rabbit decalcified bone matrix(DBM) was made under the method of Urist and was combined with rifampicin-gelatin solution. The antibiotics release characteristics were observed by PBS release test in vitro and K-B disc diffusion test in vivo. The osteogenesis ability was measured by critical radius bone defect of rabbit.Results It was detected in release test that the antibiotic releasing time could maintain at least 28 days in vivo and in vitro and the release ratio was 87%. The rabbit critical radius bone defect could be repaired by this anti-tuberculosis composite graft perfectly.Conclusion Good antibiotics release characteristics and bone formation ability showed during this anti-tuberculosis composite graft and it definitely could be used widely in further clinics.

Correction of short collumella by using the free composite graft of ear lobe / 中华医学美学美容杂志

Objective To investigate a simple and safe method for correction of the flat nose tip with the short columella. Methods The flat nose tip with the extend strut graft was corrected by using the rib cartilage or Medpor and the secondary defect of columella was repaired with the free composite graft of ear lobe in 8 cases of rhinoplasties. Results The free composite graft of ear lobe survived well and the color was similar to the neighboring tissue. There was no obviously secondary deformation at the donor site in all the cases by following-up from 1 to 2 years. Conclusions It is a simple and effective method without secondary deformation to repair the short columella by using the free composite graft of ear lobe in rhinoplasty.

Composite Graft for Eyelid Reconstruction

PURPOSE: The purpose of this article is to describe successful reconstruction of upper eyelid defect using a composite graft from the contralateral eyelid. CASE SUMMARY: A 42-year-old-female patient presented with pigmented mass of the left upper tarsoconjunctiva. She underwent tumor resection and eyelid reconstruction with periosteal flap due to recurred malignant melanoma on her left lower conjunctiva 3 years ago. The left upper eyelid was reconstructed using a composite graft from the contralateral upper eyelid. CONCLUSIONS: A satisfactory result, both functionally and cosmetically, was obtained during the follow-up period of 10 months. Composite graft isan ideal option for the reconstruction of eyelid defect which is difficult to correct successfully with other conventional methods. A case of eyelid reconstruction using a composite graft from the contralateral eyelid is herein reported with good functional and cosmetic results.

Composite Graft for Eyelid Reconstruction

PURPOSE: The purpose of this article is to describe successful reconstruction of upper eyelid defect using a composite graft from the contralateral eyelid. CASE SUMMARY: A 42-year-old-female patient presented with pigmented mass of the left upper tarsoconjunctiva. She underwent tumor resection and eyelid reconstruction with periosteal flap due to recurred malignant melanoma on her left lower conjunctiva 3 years ago. The left upper eyelid was reconstructed using a composite graft from the contralateral upper eyelid. CONCLUSIONS: A satisfactory result, both functionally and cosmetically, was obtained during the follow-up period of 10 months. Composite graft isan ideal option for the reconstruction of eyelid defect which is difficult to correct successfully with other conventional methods. A case of eyelid reconstruction using a composite graft from the contralateral eyelid is herein reported with good functional and cosmetic results.

Preserved Superficial Fat Skin Composite Graft for Correction of Burn Scar Contracture of Hand

PURPOSE: Split or full thickness skin graft is generally used to reconstruct the palmar skin and soft tissue defect after release of burn scar flexion contracture of hand. As a way to overcome and improve aesthetic and functional problems, the authors used the preserved superficial fat skin(PSFS) composite graft for correction of burn scar contracture of hand. METHODS: From December of 2001 to July of 2007, thirty patients with burn scar contracture of hand were corrected. The palmar skin and soft tissue defect after release of burn scar contracture was reconstructed with the PSFS composite graft harvested from medial foot or below lateral and medial malleolus, with a preserved superficial fat layer. To promote take of the PSFS composite graft, a foam and polyurethane film dressing was used to maintain the moisture environment and Kirschner wire was inserted for immobilization. Before and after the surgery, a range of motion was measured by graduator. Using a chromameter, skin color difference between the PSFS composite graft and surrounding normal skin was measured and compared with full thickness skin graft from groin. RESULTS: In all cases, the PSFS composite graft was well taken without necrosis, although the graft was as big as 330mm2(mean 150mm2). Contracture of hand was completely corrected without recurrence. The PSFS composite graft showed more correlations and harmonies with surrounding normal skin and less pigmentation than full thickness skin graft. Donor site scar was also obscure. CONCLUSION: The PSFS composite graft should be considered as a useful option for correction of burn scar flexion contracture of hand.

The Effect of Lateral Approximations on the Survival of the Free Composite Flap

Non-vascularized free composite graft is one of the simple and effective reconstructive options, but its clinical use has been limited due to questionable survival rate. Early vascularization is essential for graft survival and is mainly carried out via recipient bed or repaired sites. This study was designed to investigate the effect of the lateral marginal approximations on the survival of the free composite flap using a model of skin-subcutaneous composite graft in rats. Thirty 1.5 x 1.5 cm2 sized square shape composite flaps were elevated freely and reposed in place immediately on the dorsum of five Sprague-Dawley rats, and divided into five groups of six flaps. In all groups, graft bed was isolated with silastic sheet. In the group I, all sides of flap were repaired with blockage of silastic sheet insertion. Three, two, and one sides of flap were treated with same method in the group II, III, and IV respectively. Other sides of flaps were repaired without blockage, so all sides of flap were repaired in the group V. At 14 days later, the survived rate of each flap was evaluated according to the numbers of the repair sites. Histological examination was done for the evaluation of new vessel development quantitatively. Overall survived rates were increased with the number of repaired sites, but the group V only showed increased survival rate up to more than fifty percentile of the flap size with a significant difference statistically. New vessels were also increased in proportion with the number of repaired sites, and the repair site more than two had significant effect on the increased number of new vessels. In conclusion, at least more than threefourth of flap circumference should be repaired in order to increase flap survival effectively under the condition of bed isolation.

Correction of Hook Nail Deformity with Composite Graft

PURPOSE: Hook nail deformity is caused by inadequately supported nail bed due to loss of distal phalanx or lack of soft tissue, resulting in a claw-like nail form. A composite graft from the foot bencath the nail bed gives adequate restoration of tip pulp. METHODS: From September of 1999 to March of 2004, six patients were treated for hook nail deformity and monitored for long term follow up. Donor sites were the lateral side of the big toe or instep area of the foot. We examined cosmetic appearance and nail hooking and sensory test. The curved nail was measured by the picture of before and after surgery. RESULTS: In all cases, composite grafts were well taken, and hook nail deformities were corrected. The curved nail of the 4 patients after surgery were improved to average 28.7 degrees from average 55.2 degrees before surgery. The static two point discrimination average was 6.5mm and the moving two point discrimination average was 5.8mm in the sensory test. CONCLUSION: Composite graft taken from foot supports the nail bed with the tissue closely resembling the fingertip tissue, making it possible for anatomical and histological rebuilding of fingertip.

A case report of the external nose reconstruction using forehead flap and auricular composite grafts

There are various surgical methods for reconstruction of the nasal defect. Among them, there is some difference in the choosing the proper reconstruction method according to defect size and position. When the defect involved the tip, the columella, and the alar, the local flaps may be preferred, because they can provide sufficient amount of tissue. However, the composite grafts from the ear have been effectively used in reconstructions of smaller sized defects of the columella and ala. We excised total external nose because of squamous cell carcinoma on the nasal tip, columella, and nasal septum. We reconstructed the nasal tip, both alae, and columella with forehead flap. After division of the regional flap, we found partial necrosis of the columella and narrowness of the nostril. So, we used chondrocutaneous auricular composite grafts for reconstruction of the columella and both nostrils. We used the file-folder designed auricular composite graft for reconstruction of columella and the wedge shaped ear helical composite grafts for widening of nostrils. 6 months later, there were no significant problems, except some mismatched dark color in the grafted alar tissues. Here, we report a successful reconstruction of large nasal defect using combined two different reconstructive methods.

Reconstruction of the Lower Eyelid with Septal Mucochondral Composite Graft and Upper Eyelid Musculocutaneous Flap

Although various procedures for reconstructing the lower eyelid have been reported, their basic principle is always to build a new eyelid that is composed of three elements: an outer cutaneous layer, an inner mucosal layer, and a semirigid supporting tissue between the two layers. Mustarde cheek rotation flap over a chondromucosal graft has been used often to reconstruct the full thickness defect of the lower eyelid. However, Mustarde cheek flap leaves a large unacceptable scar on the face. Therefore we have repaired three cases of lower eyelid defect after resection of the basal cell carcinoma using monopedicled or bipedicled upper eyelid musculocutaneous flap over a septal chondromucosal composite graft. In addition, in case of wide defect including overall tarsal plate, the authors increased indication of mucochondral composite graft by halving method of mucochondral composite tissue. As a result, we made a minimal donor site scar and get the effect of upper blepharoplasty as well by using upper eyelid musculocutaneous flap. Based on follow-ups of 10 to 19 months, the functional and aesthetic results were found to be good in all cases. This procedure may be applicable for total or subtotal reconstruction of the lower eyelid.

Correction of Posttraumatic Deviated Finger Deformity Using Preserved Superficial Fat Skin Composite Graft

The electrical burn or amputation of fingers gives damages not only to the soft tissue, but also to the bone, tendon and joint structure and causes severe deformity. To correct severe deformity, surgeons perform osteoplasty, tenolysis, capsulotomy, arthro- plasty, and flap surgery. However, such surgery can not be performed under some circumstances because patients wish to undergo surgery step-by-step, in stead of taking all at once. The deformity would have been more severe if the corrective surgery had been delayed without any treatment. The authors have reconstructed only soft tissue using the preserved superficial fat skin graft taken from the medial side of the foot or great toe. Nine patients who had deviated fingers were corrected from June 2001 to June 2002. Seven patients had deformity due to electrical burn, one due to amputation and the other due to congenital syndactyly. The period of follow-up was from 19 to 31 months. At surgery, a skin incision on the scar vertical to the finger and release of contraction of the deviated finger was performed. The soft tissue defect was reconstructed with a composite graft taken from medial side of the foot or great toe, with a preserved superficial fat layer. To accelerate healing of the grafted tissue, antibiotic ointment was applied to preserve the moisture environment. The composite graft was well taken without complication, and especially, there was no necrosis although the composite tissue was as big as 18x15mm to 33x11mm. The preoperative deformity was corrected better than we expected after surgery. The color and tissue texture were excellent and well harmonized with the surrounding skin, and the donor site healed without complication. We also observed a new bone formation in some cases.

Accelerated Healing of Composite Graft in a Wet Environment: a Pig Model

Composite grafts have served as a versatile tool in plastic surgery, but their usefulness has been limited by unpredictable survival in the case of larger defects. We compared composite grafts take rates in a wet environment, known to be ideal for wound healing, a moist environment with mild compression, and a dry environment in an established porcine model. The subjects of this study were 7 female Yorkshire pigs with 54 composite grafts. These 3x3cm sized composite grafts, composed of skin and subcutaneous fat, were harvested as samples on the back of the subjects to be reimplanted based on random patterns. Group I was introduced to a wet environment with sufficient antibiotic ointment and semi-occlusive polyurethane film(Opsite(R)) coverage, while group II was introduced to a moist environment and mild compression with hydrocellular foam dressing(Allevyn(R) and Opsite(R)coverage. Meanwhile, group III was applied simply with dry. Two weeks after the grafting, the survival rates of groups I(89%) and II(83%) were significantly higher than those of group III(31%)(p<0.05). The degrees of inflammation and fibrosis in groups I and II were less than in group III. Epithelial connections between the grafts and the recipients were the fastest in group II. According to the results of this study, maintaining a wet environment and mild compression may not only increase the composite graft take rate but also increase the size of grafts that could be transferred successfully.

Topical Hyperbaric Oxygen Therapy on Composite Graft & Local Flap on Facial Area

Composite graft and local flaps are good modality for the correction of deformatic scars in facial area but there are several limitations in size, shape and graft bed condition. Hyperbaric oxygen therapy is a good adjunctive therapy for the successful take of the composite graft and local flaps by providing high arterial oxygen pressure and hyperoxic state promoting angiogenesis and collagen synthesis. However, it has some substantial risks of systemic oxygen toxicity to central nervous system, lung and eyes, and needs hyperbaric chamber system and high cost. We designed a modified technique for administrating hyperbaric oxygen topically with the use of simple materials and wall oxygen for the composite graft and local flap wound. 8 patients who had undergone composite graft and local flap on facial scar area were treated with topical hyperbaric therapy for average 6 days. Grafts were relatively large in size and all of the graft bed was scar tissue due to previous operation, trauma and burn injury. All cases showed successful result and there was no complication reported. The potential advantage of this method includes fairly low expense, no need for specialized equipment, simplicity of the application and lack of systemic complication. We conclude that topical hyperbaric oxygen therapy was a simple, cost-effective and safe method for the adjunctive treatment to the composite graft and local flaps.

Clinical Cases of Composite Graft for Reconstruction of Fingertip Amputations using Combination Procedure of Tie-over Dressing and Drain

The treatment of fingertip amputation is difficult and controversial. Although the microsurgery has been accepted as a procedure of choice, in distal location, however, both reattachment of amputated portion as a composite graft and microvascular anastomosis are prone to failure. The fact that microscopic reconstruction of vessels is safer means of replacing amputated digits, makes considerably smaller the need to use the technique of composite graft nowadays. Nevertheless, there still remains a group of distal digital amputations which cannot be replaced by microsurgical procedure and the composite grafting is the only way of achieving a full length digit with a normal nail complex. Nowadays, it is generally accepted that replacement should be made as early as possible for the prevention of bacterial and proteolytic activity. However, if the replacement is made so quickly that bleeding doesn't stop, there is a layer of clot blocking adhesion between the two surfaces, and the union will not be achieved. We report a new strategy: the tie-over dressing ensures not only fixation, but also hemostasis, and the drainage application is used to drain retained blood, so composite graft doesn't need to be delayed until the bleeding stops. We achieved good results by using this new technique.

Experimental study on efficacy of perichondrium and an acellular cartilage matrix for generating cartilage / 中国微创外科杂志

Objective To study the possibility of generating cartilage with a free composite graft of perichondrium and matrix. Methods A composite graft of a free perichondrium flap wrapped around acellular auricular cartilage matrix was implanted in the back subcutaneously of young New Zealand rabbits (GroupⅠ). As controls,double folded perichondrium free flap (GroupⅡa) and acellular auricular cartilage matrix without perichondrium cover (GroupⅡb) were implanted. Results 3 weeks and 6 weeks after implantation , obvious differences of chondroblasts derived from the perichondrium were observed between the GroupⅠand GroupⅡa (P