Reconstruction of the median sternotomy wound dehiscence using the latissimus dorsi myocutaneous flap.

BACKGROUND: Currently the internal thoracic artery (ITA) is the conduit of preference for coronary artery revascularization. Although this artery offers several advantages over the saphenous vein there is a higher incidence of postoperative sternal wound infection with its use. This incidence further increases with the use of bilateral internal thoracic arteries (BITA). The use of muscle or omental flaps to treat this complication has significantly reduced the morbidity and mortality. Typically the pectoralis major (PM) or the rectus abdominis (RA) muscles are the preferred method of reconstruction of the infected sternotomy wound. METHODS: In a retrospective study over a four-year period from February 1994 to October 1998, nine patients underwent reconstruction of an infected median sternotomy wound with a latissimus dorsi myocutaneous flap (LDMF). RESULTS: All of the patients in our study were successfully treated with a single LDMF with the exception of one who required a rectus abdominis flap to cover the lateral aspect of the recalcitrant poststernotomy infected wound. There was a single patient who had a wound dehiscence at the donor site. CONCLUSIONS: The LDMF is reliable and serves as an adjunct for treating sternotomy infections. The flap provides sufficient amount of pedicle length and muscle mass for coverage. Although there is a need to turn the patient into a lateral decubitus position once the debridement is performed the flap harvest and its mobilization is technically straightforward with a short operative time, 135 minutes on average with a range of 97 to 171 minutes. Furthermore, there exists an anatomical advantage in using the LDMF; harvest of the LDMF does not disrupt collateral blood supply to the sternum and parasternal tissues.

Use of cyanoacrylate (super glue) for the fixation and prefabrication of nasal cartilage grafts.

BACKGROUND: Cartilage grafts are frequently too small to serve as dorsal grafts so that several segments must be secured together to achieve adequate dimensions. The suturing of graft segments is time-consuming and difficult. OBJECTIVE: This study examines the use of 2-octyl cyanoacrylate for the prefabrication and fixation of nasal cartilage grafts. METHODS: 2-octyl cyanoacrylate was used to prefabricate cartilage grafts and secure nasal tip grafts in 9 patients who underwent open rhinoplasty. RESULTS: Cartilage grafts appeared to maintain their volume and position. There was no evidence that 2-octyl cyanoacrylate led to inflammation, erythema, or fibrosis. CONCLUSIONS: 2-octyl cyanoacrylate is an effective method for prefabricating and securing nasal cartilage grafts. There were no negative sequelae associated with its use in this series of patients. (Aesthetic Surg J 2001;21:328-333.).

Endoscopic harvest of the rectus abdominis muscle.

The rectus abdominis muscle is a versatile muscle with many applications. The use of this muscle is often limited by its considerable donor site morbidity. This study reports a minimally invasive technique to harvest the rectus abdominis muscle. The described technique has been used successfully in 5 patients who required a superiorly based flap for reconstruction of a sternal defect. All patients have had long-term flap survival and resolution of their sternal osteomyelitis. Although initially lengthy, harvest times have been less than 1 hour for the last 3 patients. Patients report minimal discomfort at their operative site. To date there have been no hernias or other complications. The rectus abdominis muscle can be harvested successfully endoscopically. With no other modification other than port site placement, this technique could be used to harvest free flaps or harvest inferiorly based rectus flaps. This technique is learned easily, is safe, and should reduce substantially the donor site morbidity associated with more traditional harvesting techniques.

Microsurgical replantation of the lip: a multi-institutional experience.

Traumatic amputation of the lip is a rare yet devastating event affecting both form and function. Considering the available methods for reconstruction, replantation may offer a reasonable solution. We sought to characterize the variables associated with lip replantation and to assess the outcome in a retrospective review of 13 lip replantations performed in 12 institutions utilizing a form database and clinical and photographic analysis. Lip replantation was successful in all 13 patients; partial flap loss occurred in one patient owing to iatrogenic injury. Follow-up averaged 3.1 years. Average patient age at the time of injury was 21.1 years. There were six male and seven female patients. Injuries in two patients were the result of a human bite, the remaining injuries resulted from dog bites. One patient had significant associated injuries. Average length of hospital stay was 11.9 days. Ten patients suffered amputations of the upper lip, and three suffered amputations of the lower lip. Average defect size was 10.6 cm2. Operative time averaged 5.7 hours (range 2.5 to 12 hours). Warm ischemia time averaged 2.9 hours, and cold ischemia time averaged 2.7 hours. Donor and recipient veins were often scarce; all patients had at least one arterial anastomosis, whereas no vein was available in 7 of 13 patients; vein grafts were required in one patient. Leech therapy was employed in 11 of 13 patients. Anticoagulant therapy was administered in the majority of patients. Systemic heparin was utilized in 10 of 13 patients, low molecular weight dextran was used in 7 of 13 patients, and aspirin was given to 7 of 13 patients. One bleeding complication was incurred. An average of 6.2 units of packed red blood cells was administered to 12 of 13 patients (adjusted to 250 cc/unit). Antispasmodic therapy was employed in six of eight patients intraoperatively and in two of eight patients postoperatively. Intraoperative complications included difficulty identifying veins in 7 of 13 patients, arterial spasm in 1 of 13 patients, and vessel diameter < 0.5 mm in 4 patients. Postoperatively, one patient suffered vein thrombosis requiring anastomotic revision. Broad spectrum antibiotics were administered to all patients, and there were no infections. Nearly one-third (4 of 13) patients suffered prolonged edema lasting > 4 months. Color match of the replanted lip segment was rated excellent in all cases. Hypertrophic scarring occurred in 6 of 13 patients. A total of 12 revision procedures was performed in six patients. Interestingly, leech therapy resulted in permanent visible scarring as a result of the leech bite in 6 of 11 patients treated. Ten patients demonstrated active orbicularis muscle contraction in the replanted lip segment. Stomal continence was present in all lips. Sensibility return in the replanted lip segment was quite good with 12 of 13 patients demonstrating at least protective moving two-point sensibility (> or = 10 mm). Partial replant necrosis in one patient resulted in significant scar and contraction that compromised the aesthetic appearance. Overall, however, all patients were uniformly pleased with their final results. This clinical study is one of the largest of its kind on lip replantation. Although this represents a multi-institutional experience, the data are remarkably consistent. Re-establishment of venous outflow seems to be the most problematic technical challenge. By incorporating the adjuncts of anticoagulation, leech therapy, and antispasmodics, a successful outcome can be expected despite the paucity of vessels and small vessel size. The risks of blood transfusion, lengthy operative time, and hospital stay must be weighed against the functional benefits.

Split, free, jejunal transfer for pharyngoesophageal and soft-tissue reconstruction.

Pharyngoesophageal reconstruction utilizing free jejunal transfer is well established. Extensive resection or debridement for extensive tumor, infection, or radiation may necessitate additional soft-tissue coverage. The authors report a successful reconstruction using a split, free, jejunal transfer to provide simultaneous pharyngoesophageal and soft-tissue coverage.

The external rhinoplasty approach for the treatment of acromegaly.

Acromegaly produces a syndrome of physiological and physical derangements. Patients afflicted with this disease are often as concerned with the changes in their appearance as with the pituitary tumor. The external rhinoplasty approach to transphenoid hypophysectomy has recently been shown to improve visualization and to have fewer complications compared with the sublabial approach devised initially by Cushing. Three patients are presented in whom this approach was used to simultaneously treat the physiological derangement of acromegaly and to correct the nasal deformity.

The use of medicinal leeches in the salvage of flaps with venous congestion.

The use of medicinal leeches (Hirudo medicinalis) for the salvage of tissues with venous congestion has been intermittent over the last two centuries. During the last decade, interest in leech therapy has undergone a resurgence. Hirudo's tricuspid bite injects a highly potent anticoagulant. The site usually bleeds for 1 to 2 hours and under special circumstances may bleed for up to 24 hours. This collective series presents four patients in whom immediate postoperative venous congestion threatened the survival of three tissue replants and one latissimus dorsi flap. Two of the replants were completely salvaged; the other two failed due to infection. Hirudo medicinalis is an important adjunct in preventing flap or replant failure secondary to venous congestion, but its use is associated with significant risks.

Latissimus dorsi free flaps in the elderly: an alternative to below-knee amputation.

The purpose of this paper is to document that free-flap surgery may be applied in specific circumstances to elderly patients with extensive vascular insufficiency and wound coverage problems. Below-knee amputation may be a direct but not necessarily desirable answer to the elderly patient with these problems. The problems of increased energy of ambulation, prosthetic fit, and psychological depression are all accentuated in the elderly. Three free-flap patients of an average age of 80 are presented with successful wound coverage, control of ischemic pain, and early return to an independent ambulatory state. The latissimus free flap seems to be an appropriate tool for this purpose. The T-pedicle is especially suited to bridge segmental vascular deficits seen in this population. We conclude that in specific situations, this approach may be an alternative to amputation in the elderly.

Hypothyroidism following removal of a "thyroglossal duct cyst".

This case demonstrates how a midline ectopic thyroid gland can be misdiagnosed as a thyroglossal duct cyst. Awareness of this clinical entity is critical if the diagnosis is to be made preoperatively. Thyroid function tests and a 99mTc or 123I scintiscan of the neck should be performed when evaluating a patient with a midline anterior cervical mass. Although thyroid replacement will often cause regression of the enlarged ectopic thyroid gland, surgical intervention is required if a solid mass persists. When an ectopic thyroid gland has been excised and is subsequently found to be the child's only thyroid tissue, thyroid replacement is necessary. If biopsy of the mass established the diagnosis at the time of surgery, effective treatment consists of longitudinally dividing the tissue and placing each half laterally beneath the strap muscles. When this is done, long-term follow-up and periodic thyroid function tests are advised. If this tissue should become hypoactive, thyroid replacement is then required.

The use of microvascular free flaps for soft tissue augmentation of the face in children with hemifacial microsomia.

The extent of facial deformity from hemifacial microsomia varies considerably. Minor degrees of asymmetry may be barely perceptible. Severe defects involve deficiencies and asymmetry of bone and soft tissue. Hence, reconstruction of both soft and hard tissues may be necessary. The authors have utilized a free flap based on the superior gluteal vessels to replace soft tissue deficits in three children with hemifacial microsomia. The flap, composed of fascia lata, adjacent muscle and fat (two patients) and overlying skin (one patient), is harvested through an incision high on the lateral thigh in the "bathing trunk" area. The vessels, measuring 0.5--1.0 mm. were anastomosed to the facial (one patient) and superficial temporal (two patients) vessels. In one child, simultaneous mandibular restructuring was done with bone grafts. The children ranged in age from four to eight years. Follow-up is for five to seven months. Although this microvascular procedure requires a prolonged anesthetic, it permits more accurate and predictable reconstruction. Scars are placed in inconspicuous or concealed areas. Simultaneous bony reconstruction can be done. Details of the procedure and an evaluation of postoperative results are presented.

"Apple coring" the nipple in subcutaneous mastectomy.

A simple technique is described for removing the ductal tissue from the nipple in a subcutaneous mastectomy. We believe that complete removal of all the ductal tissue is desirable in this operation, and that it will also decrease the incidence of subsequent infection. The operative technique, the problems, the advantages, and the disadvantages of the procedure are described.