Velar closure and ear tubings as a primary procedure in the repair of cleft palates.

This ten-year study reviews 36 patients with complete clefts of the hard and soft palates treated with primary velar closure, bilateral myringotomies, and tubings performed when the infant was 12 to 15 months of age. The hard palate and prepalate were not closed until the child was at least 5 1/2 years of age. By early velar closure, a population with an almost 100% incidence of otitis media with effusion has been converted to a population with a 17% incidence of recurrent otitis media requiring repeat myringotomies and tubings.

Reconstruction after mediastinal tracheostomy.

Mediastinal tracheostomy has been associated with high morbidity and mortality, often due to skin necrosis, with resultant exposure of the great vessels and subsequent hemorrhage. During a 4 year period, 11 patients underwent mediastinal tracheostomy. Reconstruction included the use of a pectoralis major musculocutaneous flap to provide well-vascularized skin for anastomosis to the superior portion of the tracheostoma in nine patients. Whenever possible (eight patients), the trachea was transposed below the innominate artery to allow for slightly more mobility of the trachea and to remove the cartilaginous portion of the trachea from the artery. Among the eight elective operations reported herein, there were no postoperative deaths and only two minor wound-related complications. Among three patients who underwent emergency mediastinal tracheostomy, two patients died, one with an aneurysm of the innominate artery that ruptured several weeks postoperatively and the other with respiratory instability who could not be weaned from the respirator. These results suggest that use of the pectoralis major musculocutaneous flap and tracheal transposition decreases the risk of skin necrosis and resultant major vessel rupture. We advocate this approach in the reconstruction of the patient who requires mediastinal tracheostomy.

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.

The pectoralis major myocutaneous flap in head and neck reconstruction. Analysis of complications.

Sixty-seven patients underwent 73 pectoralis major myocutaneous flap procedures for the immediate reconstruction of defects after resection of head and neck cancers. Thirty-six patients experienced a total of 50 complications for an overall complication rate of 54 percent. There were 3 instances of total flap necrosis, 9 of partial flap necrosis, 12 orocutaneous fistulas, 9 suture line separations, 8 neck wound complications, 1 donor site complication, and 8 mandibular replacement complications. Most complications were minor and did not require a second procedure for correction; however, 36 percent did require a second operation. Eight of 10 patients in whom a metal appliance was placed to restore mandibular continuity required the removal of that appliance due to either flap necrosis, fistula formation, or exposure. Based on our experience, we conclude that attention to flap design, operative technique, and post-operative management were useful in reducing the incidence of complications. We also conclude that a metal appliance was an unsatisfactory means of restoring mandibular continuity when utilized beneath a pectoralis major myocutaneous flap. Although the overall incidence of complications was high, the actual incidence of flaps failing to accomplish their intended purpose and requiring secondary repair was acceptable. The pectoralis major myocutaneous flap was reliable in the reconstruction of defects in the head and neck region.

Tubed pectoralis major musculocutaneous flaps for cervical esophageal replacement.

Five patients undergoing laryngopharyngectomy and cervical esophagectomy for cancer were reconstructed using a tubed pectoralis major musculocutaneous flap for esophageal replacement. One patient had no complications, 2 had pinpoint fistulas with rapid healing, a fourth died of a myocardial infarction, and the fifth had a partial breakdown requiring secondary flap closure. This flap is safe, reliable, and easy to rotate and tube on itself; use of the tubed pectoralis major musculocutaneous flap obviates the necessity for laparotomy for colon interposition, gastric pull-through, or jejunal free grafts. In addition, microvascular anastomoses are not required. Therefore, it is recommended as an excellent means of replacing the cervical esophagus and should be considered a method of choice in debilitated patients.

The pectoralis major musculocutaneous island flap in single-stage reconstruction of the pharyngoesophageal region.

The pectoralis major island musculocutaneous flap is reliable. The size of the skin island may vary from 5 X 8 cm to 8 X 20 cm. The pharyngoesophageal region can be reconstructed in a single stage with this versatile flap (both primary and secondary cases). We have reconstructed seven patients by this method without major complications.

Hemangioendotheliomas of the hand: case reports.

Hemangioendotheliomas are rare benign vascular tumors which may be grossly and histologically difficult to distinguish from highly malignant angiosarcomas. They coexist with other vascular tumors in the hand, e.g., hemangioma. Three case histories are presented of hemangioendothelioma occurring in the hand. This report offers a plea for permanent section pathological analysis for diagnosis and wide excision to avoid recurrence of this benign lesion.

The dorsal ganglion with anomalous muscles.

Either an anomalous extensor indicis proprius muscle or an extensor digitorum brevis manus may coexist with a dorsal wrist ganglion. To assure relief of symptoms, treatment must include division of the fourth dorsal extensor compartment in the case of the former muscle, and excision in the case of the latter.

Xeromammography--a reason for using saline-filled breast prostheses.

In 5 patients, silicone gel implants obscurred the image, while in 5 patients with saline-filled implants a good 3-dimensional examination of the breast was possible with xeromammography. If saline-filled implants routinely allow better cancer diagnostic surveillance than do silicone gel implants, this should be considered by the surgeon at the time he does an augmentation mammaplasty.

Nasolabial flap reconstruction of the floor of the mouth after extirpation of oral cancer.

The transbuccal nasolabial flap is an extremely valuable method for primary or secondary reconstruction of the floor of the mouth. We urge its frequent use.

Secondary reconstruction of the cervical esophagus.

Ten patients have had secondary reconstructions of the cervical esophagus after ablation of the laryngopharyngeal complex for cancer. Our use of deltopectoral flaps for this is described.