Oromandibular reconstruction with vascularized free flaps: a review of 50 cases.

Fifty cases of oromandibular reconstruction using vascularized free flaps to evaluate functional parameters of results were evaluated. There were 23 iliac crest flaps, 17 fibula flaps, 30 ulnar forearm flaps, and 3 radial forearm flaps with bone. Thirteen female and 37 male patients comprised the study, with a mean age of 57.66 years. Squamous-cell carcinoma (SCC) constituted 86% of cases, of which 60% were T4 lesions and 13.9% were recurrent. Anterolateral mandibular defects constituted 48.7%, and the mean bone gap was 8.13 cm. Functional evaluation was based on the University of Washington Questionnaire (UWQ) through phone calls and personal communication. The mean hospital stay was 12.42 days. The external carotid (75%) and facial (18.3%) were the main recipient arteries. The internal jugular (47.05%) was the main recipient vein. Overall flap survival was 95.9%. Three flaps were lost due to unsalvageable venous thrombosis. Major local complications such as partial flap loss, hematoma, and orocervical fistula constituted 10% of cases. Speech was classified as "excellent" and "good" in 43.3% of cases. Swallowing was identified as "excellent" and "good" in 53.3% of cases. Cosmetic acceptance was rated "good" in 63.3% of cases. Vascularized free flap reconstruction of oromandibular defects provides excellent functional and aesthetic results. The majority of patients are able to tolerate a regular diet. Intelligible speech and acceptable appearance are restored, providing patient satisfaction.

Role of ulnar forearm free flap in oromandibular reconstruction.

The ulnar forearm flap is not frequently utilized for oromandibular reconstruction. This study evaluated the usefulness of the ulnar free flap for reconstruction. A retrospective study of 32 patients was conducted. The ulnar forearm flap was combined with an osseous flap in 24 patients. Nine females and 23 males with a mean age of 58.15 years comprised our study population. Squamous-cell carcinoma was the diagnosis in 93.75% of cases (56.25% T4), of which 20% were recurrent. Functional evaluation of swallowing was based on the University of Washington Questionnaire (UWQ). The mean hospital stay was 9.8 days. The external carotid (100%) was the recipient artery, and the internal jugular (74.07%) was the main recipient vein. Overall flap survival was 96.8%. One flap was lost due to unsalvageable venous thrombosis. Major local complications were seen in 9.4% of cases and included partial flap loss, hematoma, and an orocutaneous fistula. At the time of this study, 21 patients were available for functional evaluation. Speech was rated excellent and good in 33.3% of patients. Swallowing was found good in 28.6% of patients. Chewing was rated excellent and good in 47.6% of patients. Cosmetic acceptance was rated good in 71.4% of cases. The ulnar forearm is a useful free flap in oromandibular reconstruction. It is available when the radial artery is the dominant artery of the hand. Being more hidden, it may be more cosmetically accepted. It affords pliable soft tissue for lining and/or covering of oromandibular defects, and can be used as a second choice after other free-flap failures.

A computer analysis of reflex eyelid motion in normal subjects and in facial neuropathy.

OBJECTIVE: To demonstrate how computerized eyelid motion analysis can quantify the human reflex blink. DESIGN: Seventeen normal subjects and 10 patients with unilateral facial nerve paralysis were analyzed. BACKGROUND: Eyelid closure is currently evaluated by systems primarily designed to assess lower/midfacial movements. The methods are subjective, difficult to reproduce, and measure only volitional closure. Reflex closure is responsible for eye hydration, and its evaluation demands dynamic analysis. METHODS: A 60Hz video camera incorporated into a helmet was used to analyze blinking. Reflective markers on the forehead and eyelids allowed for the dynamic measurement of the reflex blink. Eyelid displacement, velocity and acceleration were calculated. The degree of synchrony between bilateral blinks was also determined. RESULTS: This study demonstrates that video motion analysis can describe normal and altered eyelid motions in a quantifiable manner. CONCLUSIONS: To our knowledge, this is the first study to measure dynamic reflex blinks. Eyelid closure may now be evaluated in kinematic terms. This technique could increase understanding of eyelid motion and permit more accurate evaluation of eyelid function. Dynamic eyelid evaluation has immediate applications in the treatment of facial palsy affecting the reflex blink. Relevance No method has been developed that objectively quantifies dynamic eyelid closure. Methods currently in use evaluate only volitional eyelid closure, and are based on direct and indirect observer assessments. These methods are subjective and are incapable of analyzing dynamic eyelid movements, which are critical to maintenance of corneal hydration and comfort. A system that quantifies eyelid kinematics can provide a functional analysis of blink disorders and an objective evaluation of their treatment(s).

Inferior angle of the scapula as a vascularized bone graft: an anatomic study.

In reconstructing patients with massive midface losses, the authors required a vascularized bone graft that could be used to reconstruct the palate and orbital floor, provide vertical maxillary support, and provide soft tissue. The inferior angle of the scapula appears to be a promising source of vascularized bone stock, and until now, there has been no clear description of its vascular anatomy. The purpose of this study was to define the vascular anatomy of the inferior angle of the scapula. Thirteen fresh cadavers were studied. The subscapular artery was injected with Microfil (Flow Tec, Carver, MA) at its origin. Two branches of the subscapular artery were found to converge on the angle of the scapula: the descending osseous branch of the circumflex scapular, and the transverse branch of the thoracodorsal. The descending osseous branch of the circumflex scapular artery supplied the inferior angle of the scapula in 100 percent of cases. The transverse branch of the thoracodorsal artery supplied it in 76 percent of cases. The descending osseous branch of the circumflex scapular artery is the principal artery supplying the inferior angle of the scapula.

Inframammary fold: a histologic reappraisal.

The inframammary fold is a defining element in the shape and structure of the female breast. It should be preserved whenever possible in ablative procedures and recreated accurately when the breast is reconstructed after mastectomy. To date, no accurate anatomic description of this essential structure exists. Previous studies have suggested that the fold is produced by a supporting ligament running from the dermis in the fold region to a variety of locations on the rib cage. This clinic's experience with mastectomy, augmentation mammaplasty, and breast reconstruction does not support the existence of a ligamentous structure. To define the structure of the inframammary fold, 10 female and 2 male cadavers were studied. The anterior chest wall was removed en bloc and frozen in orthostatic position. Parasagittal sections were made of the inframammary fold with the chest wall intact. After decalcification of the ribs and routine histologic preparation, thin sections were stained with Gomori's trichrome. On light microscopic examination, no demonstrable ligamentous structure of dense regular connective tissue could be identified in the fold region in any of the 12 specimens. Superficial and deep fascial layers were uniformly observed anterior to the pectoralis major and serratus anterior muscles. The superficial fascia was connected to the dermis in the fold region in a variety of configurations. In some cases, the deep fascia fused with the superficial fascia and dermis at the fold level. In other cases, bundles of collagen fibers arising from the superficial fascial layer were found to insert into the dermis at the inframammary fold, slightly inferior to it, or both. These bundles were observed consistently in sections from the sternum to the middle axillary line. They were distinct from Cooper's suspensory ligaments, which are seen more superiorly in the glandular tissue.

Cutaneous burns caused by sulfuric acid drain cleaner.

BACKGROUND: Highly concentrated solutions of sulfuric acid are available to unclog drains. We have noted a substantial number of both accidental and intentional cutaneous burns caused by these agents. METHODS: A retrospective review was conducted of children and adults who sustained sulfuric acid burns over a 13-year period ending in May 1996. Reports of injuries related to drain cleaners filed with the United States Consumer Product Safety Commission between 1991 and 1995 were also reviewed. RESULTS: Twenty-one patients (13 children, 8 adults) sustained cutaneous burns caused by concentrated sulfuric acid solutions. In 8 instances, the burn was accidental, whereas in 13 cases, sulfuric acid was used as a weapon. Median total body surface area burned was 5% (range, 1-25%). Approximately 50% of burns involved the face and neck. Skin grafting was required in 14 patients (66%). It is estimated that nationwide approximately 3,000 injuries per year are related to drain cleaners and that one-third of these involve cutaneous burns. CONCLUSION: Highly concentrated sulfuric acid drain cleaner can produce full-thickness cutaneous burns that require skin grafting in the majority of cases. Proper use of these agents and sequestering them from children may reduce accidental contact; however, their abuse as agents of assault remains a source of significant morbidity.

A comparison of immediate and staged reconstruction of the dorsum of the hand.

The treatment of complex dorsal hand lesions involving skin and subcutaneous tissues, extensor tendons, and bone remains a difficult problem for reconstructive surgeons. Traditional treatment of these defects uses staged reconstruction, first obtaining soft tissue cover and then performing bone and tendon grafts. The purpose of this study was to compare a series of seven patients who underwent staged reconstruction with seven patients who had immediate reconstruction involving primary bone and tendon grafting. All procedures were performed to correct similar severe dorsal hand defects. Patients with immediate reconstruction had a significantly faster return to maximum range of movement (ROM) (214 days compared to 630 days, P = 0.002), significantly fewer operations (2.1 compared to 5.9, P = 0.002) and a greater chance of returning to work (86% compared to 48.2%, P = 0.3) than patients with staged reconstruction.

Clearance and maintenance of blood nucleotide levels with adenosine triphosphate-magnesium chloride injection.

ATP-MgCl2 has been found to be helpful in experimental animals after shock and ischemia with improvement in organ function and survival. The reasons for this pharmacologic action are unclear. To evaluate the clearance and circulation of ATP and its metabolites after intravenous injection, 20 rabbits received ATP-MgCl2 as a bolus injection or a continuous intravenous infusion. Arterial blood was withdrawn, and ATP and its metabolites were measured using a high-performance liquid chromatography (HPLC) technique with ultraviolet (UV) absorption. Forty seconds following a bolus injection, only 1% of the injected dose was present in arterial blood as ATP, and at 280 sec only inosine remained. With a 60 min continuous ATP-MgCl2 infusion, the inosine level peaked at 62.9% at 30 min and was 37.6% at 60 min, whereas ATP was 4.9% and AMP was 17.4% at 60 min. Thus a single dose of ATP-MgCl2 has a half-life of less than 40 sec as ATP. With a continuous infusion, although some ATP circulates, inosine and AMP are the major remaining nucleotides. Thus, the beneficial effects of ATP-MgCl2 may be through ATP itself with magnesium or with adenine nucleotide metabolites for recycling of the nucleotides, phosphorylation of cell membrane inositides, and/or its vasoactive effects.

Is early prediction of outcome in severe head injury possible?

To determine whether the outcome of patients with severe head injury could be predicted early after presentation to the hospital, the records of 306 trauma patients with head injury and Glasgow Coma Scale scores of 10 or less were reviewed. There was poor correlation between initial scores at patient arrival and eventual outcome, while scores 6 hours after presentation correlated better with eventual outcome. Many patients with scores as low as 3 had good neurologic recovery. Patient age, associated injuries, blood pressure, mechanism of injury, presence of spontaneous ventilation, and computed tomographic findings all affected survival. However, considering even these parameters, statistical analysis could not provide sensitive prediction of outcome, which we defined as identifying those patients who eventually had good recovery. We conclude that initial therapy should be aggressive for patients with severe head injury, regardless of initial neurologic status, because accurate prediction of outcome within 6 hours of presentation is impossible.