Immediate reconstruction of the pharynx and cervical esophagus with the pectoralis major myocutaneous flap following laryngopharyngectomy.

The "island" pectoralis major myocutaneous flap has been used in nine patients for immediate hypopharyngeal and cervicoesophageal reconstruction following laryngopharyngectomy. Two patients underwent total hypopharyngeal and cervicoesophageal reconstruction. Postoperative evaluation revealed adequate lumens with no evidence of stricture. There was retained innervation of the flaps through the lateral pectoral nerve, but no additional innervation from the cricopharyngeal musculature could be demonstrated. Normal esophageal motility was maintained, but cervicoesophageal pressures were diminished. Donor site morbidity was minimal, and the complication rate was low. We present the pectoralis major myocutaneous flap as an alternate method for hypopharyngeal and cervicoesophageal reconstruction.

Anterior mediastinal tracheostomy with a pectoralis major musculocutaneous flap.

We suggest the pectoralis major musculocutaneous flap is a simple and reliable technique in constructing a mediastinal tracheostomy. It has the advantage of excellent vascularity and reliability even in those patients who have undergone preoperative radiation therapy. In addition, a well-vascularized lobe of thyroid tissue placed over the pharyngogastric anastomosis may decrease anastomotic leaks.

Reconstruction of the upper and lower lip using a modified Bernard-Burow technique.

Our experience with a modified Bernard-Burow technique for upper and lower lip reconstruction is described with preservation of the muscular lip sphincter. The use of local skin and buccal mucosal flaps sliding over the preserved muscular sphincter enables reconstruction with an acceptable cosmetic result even when almost total lip resection is required.

Further experience with the tensor fascia lata musculocutaneous flap.

We have found the tensor fascia lata myocutaneous flap to be exceedingly reliable with a consistent vascular pedicle; it can be elevated easily and rapidly in its subfascial plane. It is a useful flap in the paraplegic patient for colsure of ischial, trochanteric, and sacral pressure sores, and may also be used as a free flap with little donor morbidity. At present, we recommend this as the flap of choice for closure of trochanteric pressure sores. Additionally, it appears to have further applications in defects of the groin, perineum, abdominal wall, and lower chest wall. Eleven tensor fascia lata musculocutaneous flaps, utilized for soft tissue coverage for varying defects in 9 patients, are discussed.

Pectoralis major musculocutaneous flap: a new flap in head and neck reconstruction.

The pectoralis major musculocutaneous flap described by Ariyan has great potential in single stage reconstructions of the head and neck. The advantages of the flap are greater length, improved vascularity, bulk, and one-stage reconstruction of oropharyngeal defects. The flap was used successfully in eight patients to reconstruct large defects in the head and neck area. Experience to date indicates that this flap has greater versatility than the deltopectoral flap in one-stage head and neck reconstructions.

Long-term experience with childhood thyroid carcinoma.

Twenty patients with well-differentiated thyroid carcinoma, 20 yr of age or younger have been treated at Vanderbilt University Hospital. The young patient with thyroid carcinoma frequently presents with far-advanced disease but enjoys an improved survival. Preoperative scintiscanning is useful in the evaluation of patients with childhood thyroid carcinoma. A new noninvasive scan is described and appears to be promising in the preoperative differentiation between benign and malignant thyroid lesions in children and young adults. There is a high instance of nodal metastases, but long-term follow-up would indicate that lobectomy and modified neck dissection are sufficient for most patients. However, total thyroidectomy can be performed safely in those patients with disease in both lobes. Additionalally, frozen section diagnoses were found to be helpful in diagnosing and staging thyroid carcinoma.

Resection of a massive arteriovenous malformation of the head and neck.

We report a patient with a massive arteriovenous malformation of the head and neck treated by surgical extirpation of the lesion. Arteriography, hypotensive hypothermic anesthesia, and the intraoperative use of the Doppler flowmeter were most helpful in this case.

Use of the free dorsalis pedis flap in head and neck repairs.

Many defects of the head and neck can be readily repaired with a free dorsalis pedis flap, and we report success with these flaps in 9 of 12 cases. A precise knowledge of the anatomy of the arterial supply of the flap is necessary. Preoperative arteriography is recommended if the dorsalis pedis artery is not easily palpable, or if an anomalous distribution of the artery along the dorsum of the foot is sus pected. However, the transfer of the flap should be delayed for two weeks after preoperative arteriography is performed. The one-stage soft tissue reconstruction with a free dorsalis pedis flap has been associated with minimal morbidity and good acceptance by patients. A delay procedure for the flap seems to enhance the chances of complete survival which is so necessary in the repair of intraoral and pharyngeal defects. Careful attention to details and close monitoring of the flap will minimize morbidity. In case of an early failure of a flap, a secondary reconstruction by a different flap can be done in the first 48 to 72 hours. Early postoperative radiotherapy has been well tolerated over these free flaps.

Vascular access for chronic hemodialysis: use of bovine xenografts to create arteriovenous fistulas.

Adequate vascular access is the hallmark of successful chronic hemodialysis for end-stage renal disease. Between May 1975 and August 1975, it was necessary to use a bovine xenograft in 91 instances to create an arteriovenous fistula for vascular access in patients receiving chronic hemodialysis at the Vanderbilt University Affiliated Hospitals. Forty-two patients had one xenograft, 14 patients had two, and seven had three xenografts. Of all fistulas created with the xenografts, 53% were patent six months after the operation, 36% were patent at 12 months, and 15% have remained patent for 24 months. Thirty-seven percent of the xenografts failed during the first three months after operation. The most common reason for failure was thrombosis of the xenograft. Other complications encountered were false aneurysms, infection of the graft, ischemia of the extremity, and bleeding. Amputation of the lower extremity due to ischemia from septic emboli was necessary in one case. There was no deaths directly related to the use of these xenografts. It is out current opinion that the bovine xenograft should be reserved for use in patients who have had failure of the more conventional type of internal fistula (Cimino type). In selected patients in whom it is not possible to create a Cimino shunt, the xenograft offers adequate primary vascular access.

Esthesioneuroblastoma. Case report.

We present a case of esthesioneuroblastoma, and we emphasize the importance of considering this tumor in the differential diagnosis of primary intranasal carcinomas. Although the tumor is uncommon, we feel that many cases have been misdiagnosed histologically. The typical history in these patients is one of intermittent recurring epistaxis or nasal destruction and frequently, at the time of the initial examination, the tumor has reached a considerable size with evidence of local invasion.

Carcinoma of the thyroid with description of a new scanning technic.

A statistical analysis of 193 patients with thyroid carcinoma encountered at Vanderbilt University Hospital from 1925 to 1974 is reported, from which the following conclusions are drawn: (1) Papillary thyroid carcinoma is an extremely favorable lesion that when grossly limited to one thyroid lobe can usually be managed successfully by ipsolateral total lobectomy. (2) Cervical lymph node enlargement in patients with papillary carcinoma requires lymph node dissection. When feasible, the spinal accessory nerve should be preserved. (3) Failure to cure papillary and follicular thyroid carcinoma is influenced by advanced age, inadequate local extirpation, and unresectability of the carcinoma. (4) Prophylactic lymph node dissection is rarely indicated in the treatment of follicular carcinoma. A new isotope scanning procedure, developed at Vanderbilt University Hospital, promises to be helpful in preoperatively differentiating benign from malignant solitary thyroid nodules.