Free temporoparietal fascia flap in reconstruction of the lower extremity.

Twenty-one patients with open wounds of the non-weight-bearing foot or the ankle underwent coverage with a free temporoparietal fascia flap and split-thickness skin graft. Our indications for this thin, well-vascularized flap included osteomyelitis and exposed tendon, bone, or fixation hardware. The pliability of the flap allowed superior restoration of natural anatomical contours. Only one flap was completely lost (95.2% overall success). There were four cases (20%) of partial flap loss, none of which required flap revision or a new flap. Four patients (19%) experienced transient donor-site alopecia, and one patient suffered transient palsy of the temporal branch of the facial nerve. One patient (4.7%) had an area of persistent scar alopecia in the temporal scalp after a donor-site hematoma that required revision under local anesthesia. Follow-up was available on 95% of the patients and averaged 20 months (range, 1-54 months). All patients resumed weight-bearing ambulation within 1 month from operation using unmodified footwear. The free TPF flap is a reliable coverage option, with long-term durability and minimal donor-site morbidity, for relatively superficial wounds of the distal lower extremity.

Practical management of congenital choanal atresia.

Prevailing theories on the causation of choanal atresia are presented, with emphasis on some of the embryologic and anatomic abnormalities that are consistently found. The teleologic significance of nose breathing has been emphasized. This neonatal characteristic leads to a tongue-palate seal that can be rapidly fatal. Treatment of these patients has been divided into two phases. Phase I deals with immediate establishment of an airway, and phase II deals with the definitive surgical management in these patients. Our preference is for the transpalatine approach. Representative cases highlight our technique. A wire-reinforced double-barreled Elastomer stent has been developed and is described. Successful use in five patients is reported.

Treatment of congenital pseudarthrosis of the tibia with free vascularized bone graft.

Considering the often poor results obtained with conventional methods of bone grafting in the treatment of congenital pseudarthrosis of the tibia, the free vascularized bone graft may offer the best chance of cure to these unfortunate patients. A segment of rib or fibula may be harvested with its vascular supply and used as a graft to the involved segment of the tibia, using microvascular techniques to anastomose its vasculature to that of the affected leg. The advantages of this approach include a one stage procedure with minimal hospitalization, and a minimal donor defect especially when the rib is used. Although the procedure is time consuming the overall operative effort is far less than that of multiple procedures often needed with conventional methods of grafting. Although published reports are few, preliminary reports from microsurgeons using this technique indicate a high success rate, even after previous failures of conventional grafts. The increasing use of microvascular free bone transfers may eliminate the need for amputation in many of these children.

Free latissimus dorsi muscle flap coverage of an electrical burn of the lower extremity.

High-voltage electrical injury results in progressive deep tissue necrosis after debridement, often resulting in amputation when the extremity is involved. Early debridement and coverage with a vascularized free muscle flap, when local flaps are unsuitable, may protect partially devitalized structures, preserve function, and reduce the incidence of amputation. A successful case of free latissimus dorsi muscle flap coverage of an electrical burn to the lower extremity is presented.

The adverse effects of sperm during vasovasostomy.

The 119 non-splinted vasovasostomies that were performed on 95 rats demonstrated that sperm granulomas were present in 99 per cent of the 49 anastomoses that failed. Anastomoses performed on vasa that contained no sperm resulted in 95 per cent patency without granulomas. This procedure was accomplished in immature animals followed to adulthood or by testosterone suppression of spermatogenesis in adult rats. Alternatively, normal adults with sperm in the vasa were irrigated with normal saline at the time of vasovasostomy and this resulted in decreased numbers of granuloma and dramatically improved success rates. Sperm granuloma formation appears to be an important cause of failure of vasovasostomy in the rat.