Dynamic cleft maxillary orthopedics and periosteoplasty: benefit or detriment?

In 1990, Drs Millard and Latham published their initial experience with dynamic maxillary appliances (DMAs) and periosteoplasty for children with cleft lip and palate. The technique provided for alveolar alignment and consolidation, with elimination of oronasal fistulas. Opponents to this approach speculated about impairments to facial growth. To date no longitudinal studies have been published. Over the last 10 years, 35 unilateral and 10 bilateral complete clefts have been treated with this technique. All patients have been followed and documented clinically, orthodontically, and radiographically. Cephalometric analyses were performed on children after the age of 6 years. The children have excellent facial aesthetics with well-balanced lips and noses. Radiographs demonstrate bone within the repaired alveolar clefts. Articulated impressions show anterior and lateral crossbites in the unilateral patients that improve over time and appear to be correctable orthodontically. The bilateral patients have satisfactory occlusions and arch forms. Cephalometric analyses confirmed no evidence of skeletal crossbites or midfacial growth retardation. This is a work in progress that will continue as the children grow. Although definite and final conclusions would be premature, it can be stated that to date all patients are following consistent and favorable growth patterns. Our team is confident in proceeding with this technique.

A socioeconomic analysis of digital replantations resulting from home use of power tools.

Forty-seven digits in 21 patients who sustained partial or complete amputations from the home use of power tools were replanted or revascularized during a 1-year period. This represented 69% of the microvascular surgery performed for hand injuries during that year. The cost of repairing an average of 2.4 digits was $7000 (surgeon's fee) plus $697 per hour (operating room fee), as per fiscal year 1987. Postoperative hospitalization averaged 15 days at a cost of $15,679. Hand rehabilitation averaged 8 months at a cost of $3348. Fifty-four percent of the patients had no insurance. Fourteen of 21 patients (67%) required at least one additional procedure. Two patients had to make a career change after the injury. The majority of patients with digital replantations were dissatisfied with the emotional costs and the number of subsequent operations. Lack of patient and family awareness of the length of the rehabilitative period was particularly evident.

Long-term fate of the vascularized iliac crest bone graft for mandibular reconstruction.

Vascularized bone grafts, such as the iliac crest, have become a major tool for mandibular reconstruction. Due to the growing trend toward immediate bone replacement followed by implant osseointegration and dental rehabilitation, further understanding of the long-term characteristics of these grafts is essential. Early postoperative bone scans demonstrate increased activity within the vascularized graft relative to surrounding bone. This study addressed the use of bone SPECT (single photon emission computed tomography) scintigraphy as a long-term method of evaluating the integrity of vascularized bone grafts.

Functional mandibular reconstruction: prevention of the oral invalid.

Composite mandibulectomy for carcinoma can create an "oral invalid," with difficulty in mastication. Functional reconstruction has fallen short of ideal. Three patients were seen with significant anatomic deficits and functional debilitations resulting from large composite mandibulectomies for oral carcinoma. Each patient underwent reestablishment of the mandibular arch with a vascularized iliac crest bone graft. Following complete healing, the dental arch was replaced with a fixed prosthesis by the technique of osseointegration. The creation of a fixed osseodental unit has allowed each of these individuals to return to a state of anatomic, functional, psychological, and social good health. Follow-up has been from 6 months to 2 years.

Osseointegrated denture in a vascularized bone transfer: functional jaw reconstruction.

Total functional reconstruction of the lower jaw often falls short of ideal goals. While reconstructive techniques are available to close large defects with both hard and soft tissue, the insertion of a prosthetic dental appliance and the return to normal masticatory function are often technically impossible or not even attempted. Presented here is a case report of a patient successfully rehabilitated with a fixed dental appliance supported by jaw fixtures osseointegrated into a vascularized iliac crest mandibular reconstruction. At present, 6 additional patients have had mandibular reconstructions and are in various phases of functional dental rehabilitation. When these data are complete, a series report will be presented for publication.

Eyelid reconstruction using temporary tissue expanders and cartilage grafts.

Temporary tissue expanders have been used in general plastic surgery to expand skin for breast reconstruction and for scar revision. A specifically designed eyelid tissue expander was used to reconstruct both upper and lower eyelids in a patient suffering a severe lye burn. The implant consists of an expander and a reservoir, connected by silicone tubing. The implants are inserted into the remnant of both eyelids and expanded slowly with multiple injections of saline into the reservoir. After full expansion is achieved the expanders are removed and ear cartilage grafts inserted into the eyelids. The newly created eyelids resemble normal eyelids. The technique of tissue expansion has had very limited use in oculoplastic surgery but new applications are waiting to be discovered.

Microvascular free muscle reconstruction of a large plantar defect.

Large plantar defects present a difficult problem in reconstructive surgery. Skin grafts are not durable and most distant flaps are too bulky to allow for ambulation in conventional footwear. Free muscle transfer with skin graft may represent a modality to provide a contoured and durable reconstruction for large plantar defects when local tissue is not available. This study presents a case of sole of foot and distal heel reconstruction with a free microvascular latissimus muscle transfer. The transfer was contoured to fit the defect and then covered with a split-thickness skin graft. Three months following surgery, the patient was walking without assistive devices and using conventional footwear. Now, two and one-half years after surgery, he is employed full-time in a job that entails walking, and has never experienced a tissue breakdown.

The survival of free nonvascularized bone grafts in irradiated areas by wrapping in muscle flaps.

In this paper, the concept of vascularizing the bed as opposed to the bone was tested with regard to bone grafting in irradiated areas. Thirteen rabbits underwent cross-transfer of a healthy rib into a bed that received 4500 rads of orthovoltage radiation. Eight of these grafts were wrapped in rotated, nonirradiated latissimus dorsi muscle. At 3 months, these grafts were evaluated radiologically, grossly, and histologically. Seven of eight grafts wrapped in muscle demonstrated evidence of union and survival (88 percent), whereas only one of five of those grafts placed directly into the irradiated bed demonstrated union and survival (20 percent). Statistical analysis showed this to be significant to 97.5 percent, with a lambda 2 value of 5.9.

Removable thermocouple probe microvascular patency monitor: an experimental and clinical study.

Based upon experimental animal evaluation and a preliminary clinical experience in 18 patients with 3 recognized failing flaps, the implantable thermocouple probe microvascular method of vessel patency assessment would appear to be a promising new technique worthy of further clinical investigation.

Microvascular transfer of free tissue for closure of bone wounds of the distal lower extremity.

Extensive compound fractures of the distal lower extremity may result in chronic infection of the deep tissues and bone if primary healing does not occur. Treatment may require several operations and prolonged hospitalization. In an attempt to improve the management of such problems, 18 patients who had chronic bone-exposure wounds and four patients who had extensive compound fracture wounds of the distal lower extremity were treated with radical debridement, intravenous antibiotics, and microvascular transfer of vascularized tissues for immediate wound closure. All wounds healed, and there was no evidence of recurrent infection during a mean follow-up period of 19.3 months in the patients with chronic wounds and 16.3 months in those with acute wounds. In selected patients this free-tissue-transfer method of wound closure appears to have considerable advantages over conventional methods of management.

Latissimus dorsi free muscle flap in lower-extremity reconstruction.

The free latissimus dorsi skin-muscle flap has gained wide popularity to solve a variety of difficult reconstructive surgical problems. However, the donor site of this skin-muscle flap leaves a conspicuous scar and indentation, and frequently in the recipient site the skin-muscle flap leaves a conspicuous scar and indentation, and frequently in the recipient site the skin-muscle flap requires staged defatting procedures. This case demonstrates the use of the latissimus dorsi muscle flap for lower-extremity reconstruction, where a new blood supply and soft-tissue coverage are required to solve a chronically infected, open ankle joint. By taking the latissimus muscle only through a short, axillary incision, much of the donor-site deformity is minimized, and after transfer, the muscle can be molded and shaped to fit the recipient site with split-thickness skin graft coverage. This combination of free muscle flap transfer and skin graft would appear to provide a flexible, contoured, well-vascularized muscle with a relatively inconspicuous incision and skin-graft donor site.