Results of management of facial palsy with microvascular free-muscle transfer

This paper reports our experience in facial reanimation using free innervated muscle transfer in 69 patients with long-term facial palsy. The majority of patients were treated in two stages with cross-facial nerve graft as the first stage and microvascular muscle transfer at the second stage. The gracilis muscle was used in 62 patients. A system of grading results has been utilized in the long-term evaluation. The overall final result was excellent or good in 51 percent of 47 patients who were available for follow-up. Although the results are not completely satisfactory, they justify the use of this approach to a difficult clinical problem. The results are improving as technical modifications to the procedure have evolved. The gracilis muscle is a reliable free transfer with internal anatomy conductive to use for reanimation of the paralyzed face. This type of transfer, in our experience, has proved superior to nonmicrosurgical methods for treatment of complete and severe incomplete facial palsy. The seventh cranial nerve is used in the innervation of the transferred muscle, the ipsilateral being preferable if available. The authors believe that use of the same cranial nerve is superior to methods that involve other cranial nerves, where spontaneity is often not achieved.     

Long-term skeletal stability after maxillary advancement with distraction osteogenesis using a rigid external distraction device in cleft maxillary deformities

Rigid external distraction is a highly effective technique for correction of maxillary hypoplasia in patients with orofacial clefts. The clinical results after correction of sagittal maxillary deformities in both the adult and pediatric age groups have been stable. The purpose of this retrospective longitudinal cephalometric study was to review the long-term stability of the repositioned maxilla in cleft patients who underwent maxillary advancement with rigid external distraction. Between April 1, 1995, and April 1, 1999, 17 consecutive patients with cleft maxillary hypoplasia underwent maxillary advancement using rigid external distraction. There were 13 male patients and four female patients, with ages ranging from 5.2 to 23.6 years (mean, 12.6 years). After a modified complete high Le Fort I osteotomy and a latency period of 3 to 5 days, patients underwent maxillary advancement with rigid external distraction until proper facial convexity and dental overjet and overbite were obtained. After active distraction, a 3- to 4-week period of rigid retention was undertaken; this was followed by removable elastic retention for 6 to 8 weeks using, during sleep time, an orthodontic protraction face mask. Cephalometric radiographs were obtained preoperatively, after distraction, at 1 year after distraction, and 2 or more years after distraction. The mean follow-up was 3.3 years (minimum, 2.1 years; maximum, 5.3 years). The following measurements were obtained in each cephalogram: three linear horizontal and two linear vertical maxillary measurements, two angular craniomaxillary measurements, and one craniomandibular measurement. Differences between the preoperative and postoperative cephalometric values were analyzed by paired t tests (p < 0.05). The cephalometric analysis demonstrated postoperatively significant advancement of the maxilla. In addition, the mandibular plane angle opened 1.2 degrees after surgery. After the 1- to 3-year follow-up period, the maxilla was stable in the sagittal plane. Minimal anteroposterior growth was observed in the maxilla compared with that exhibited in the anterior cranial base. However, there was significant vertical maxillary growth over the 3-year observation period. The mandibular plane angle tended to decrease during the follow-up period. The cephalometric data from this study support the clinical impression of maxillary stability after maxillary advancement with rigid external distraction in cleft patients. This effective and stable technique is now considered for all pediatric patients with severe cleft maxillary hypoplasia and for adolescent and adult patients with moderate to severe deformities.     

Hemangiomas of the nasal tip.

The treatment of nasal hemangiomas is controversial. Results of nonsurgical treatment methods have been disappointing. In a series of 42 patients with nasal hemangioma, 22 patients underwent early excision. The open rhinoplasty approach proved safe and effective and yielded satisfactory long-term results. The article discusses protocols for evaluation and guidelines for treatment.     

Vagotomy and Pyloroplasty for Gastric Ulcer

In a series of 68 patients with gastric ulcer who were treated by vagotomy and pyloroplasty there were no operative deaths, though one patient who received massive transfusions died 14 weeks later from hepatic necrosis probably associated with serum hepatitis. Four patients developed recurrent peptic ulceration requiring further surgical treatment. The clinical condition of all but three of the remainder was satisfactory after an average follow-up period of three years and two months. Of the 14 patients who presented with an acutely bleeding gastric ulcer, one subsequently required gastrectomy for continued bleeding; in all the others the immediate and long-term results were satisfactory. Of 21 patients with a “high” ulcer and 29 with combined gastric and duodenal ulceration one (4·8%) and three (10%) respectively suffered recurrences. We conclude that vagotomy and pyloroplasty is a satisfactory form of treatment for a high or bleeding gastric ulcer, but that for all other gastric ulcers some form of gastric resection is preferable.     

Rotation advancement of the midface by distraction osteogenesis

A wide variety of disease processes produce alteration of midfacial skeletal growth, resulting in moderate-to-severe midface deficiency presenting as retrusion associated with Angle's class III malocclusion. Le Fort III osteotomies with advancement can provide an excellent tool for correction of this deformity. Recently, the corrective procedure of choice for advancement of midfacial segments has been distraction osteogenesis after osteotomy. Straight linear advancement is the most common choice for corrective movement of the midfacial segment, whether accomplished through acute surgical advancement or through the progressive distraction technique. Unfortunately, linear advancement can produce abnormal configurations, both at the nasal root and lateral orbits, regardless of the technique used. Enophthalmos, caused by orbital enlargement, may limit the advancement necessary to achieve class I occlusion.The authors have extended the utility of the Le Fort III procedure and have improved the final outcome by creating a controlled rotation advancement of the midfacial segment using distraction. The application of an existing internal distraction device is modified to control the movement of the midfacial segment in a rotation advancement path. Included in the series were 10 patients with severe midface retrusion secondary to multiple congenital syndromes, along with cleft lip and palate. The ages of the patients ranged from 6 to 14 years. An internal distraction system was used in all cases. Application of the distractor was substantially modified to simplify both fixation and removal and to produce controlled rotation advancement. The team orthodontist determined the final occlusal relationship. Percutaneous distractor drive rods were removed 4 to 6 weeks after active distraction to increase patient comfort. The distractors and all associated hardware were removed after 12 to 16 weeks of consolidation; follow-up periods ranged from 1 to 3 years.By using the modified distractor application to produce rotation advancement, the contour abnormalities at the nasal root and lateral orbit and the enophthalmos produced by linear advancement were eliminated. Significant improvement in facial contour and class I occlusion was obtained in all cases. Complications consisted of near exposure of the device in one patient. Stability has been excellent, with no relapse reported by the orthodontist.Rotational advancement of facial segments by distraction allows successful early intervention in patients with significant midface retrusion. The abnormal nasal root and lateral orbital configurations produced by direct linear advancement are avoided, and a stable and normalized facial configuration is produced.     

Surgical and conservative treatment of patients with congenital scoliosis: α search for long-term results

Background

In view of the limited data available on the conservative treatment of patients with congenital scoliosis (CS), early surgery is suggested in mild cases with formation failures. Patients with segmentation failures will not benefit from conservative treatment. The purpose of this review is to identify the mid- or long-term results of spinal fusion surgery in patients with congenital scoliosis.

Methods

Retrospective and prospective studies were included, reporting on the outcome of surgery in patients with congenital scoliosis. Studies concerning a small numbers of cases treated conservatively were included too. We analyzed mid-term (5 to 7 years) and long-term results (7 years or more), both as regards the maintenance of the correction of scoliosis and the safety of instrumentation, the early and late complications of surgery and their effect on quality of life.

Results

A small number of studies of surgically treated patients were found, contained follow-up periods of 4-6 years that in the most cases, skeletal maturity was not yet reached, and few with follow-up of 36-44 years. The results of bracing in children with congenital scoliosis, mainly in cases with failure of formation, were also studied.

Discussion

Spinal surgery in patients with congenital scoliosis is regarded in short as a safe procedure and should be performed. On the other hand, early and late complications are also described, concerning not only intraoperative and immediate postoperative problems, but also the safety and efficacy of the spinal instrumentation and the possibility of developing neurological disorders and the long-term effect these may have on both lung function and the quality of life of children.

Conclusions

Few cases indicate the long-term results of surgical techniques, in the natural progression of scoliosis. Similarly, few cases have been reported on the influence of conservative treatment. In conclusion, patients with segmentation failures should be treated surgically early, according to the rate of deformity formation and certainly before the pubertal growth spurt to try to avoid cor- pulmonale, even though there is lack of evidence for that in the long-term. Furthermore, in patients with formation failures, further investigation is needed to document where a conservative approach would be necessary.     

Hidradenitis suppurativa: patient satisfaction with wound healing by secondary intention

Ariyan and Krizek, in 1976, reported on three patients with perineal hidradenitis suppurativa who, following excision, achieved satisfactory closure allowing spontaneous wound healing by secondary intention. We have used this approach and have considered it very satisfactory from the surgeon's point of view. We now report from the point of view of patients and review the records of 20 consecutive patients with perineal hidradenitis treated by excision and secondary healing. Surgical results and patient satisfaction were assessed 1 year following complete wound closure. All patients reported minimal inconvenience and interruption of daily activities from this method of management. Analgesic requirements were minimal, and little reinforcement was necessary to maintain vigorous wound care. Uncomplicated wound closure was uniformly achieved with unrestrictive, stable scars providing long-term relief of this disabling disease. Two patients expressed dissatisfaction as a result of a new onset of disease in previously uninvolved and therefore unresected apocrine tissue. With this exception, patient satisfaction has been great and hospitalization time and costs reduced.     

Functional reconstruction after a total maxillectomy using a fibula osteocutaneous flap with osseointegrated implants

The fibula osteocutaneous flap with osseointegrated implants was used for reconstruction of a total maxillectomy defect. We have achieved satisfactory reconstruction of three-dimensional facial structure, orbit support, and a functional prosthesis. Our procedure restored the patient's masticatory function of the maxilla and enabled good speech and a natural facial appearance. A very high quality of function was obtained without any complications, but long-term follow-up is necessary for maintenance of the implants.     

Clinical review of nucleus caudalis dorsal root entry zone lesions for facial pain

Twenty-seven patients with intractable facial pain underwent dorsal root entry zone thermocoagulation lesion of the nucleus caudalis of the spinal trigeminal nucleus. Retrospective review revealed a success rate of 85% in the immediate postoperative period declining to 52% on subsequent follow-up. The best results were in the subgroup of patients with postherpetic neuralgia, of which 67% achieved definite relief. There tended to be some correlation of satisfactory results and pain quality as well as extent of pain along trigeminal territory. The operative morbidity was low although most patients were observed to have a mild transient ipsilateral dysmetria.     

VHL-Related Neuroendocrine Neoplasms And Beyond: An Israeli Specialized Center Real-Life Report

Objective: Von Hippel-Lindau (VHL) syndrome is a rare and complex disease. In 1996, we described a 3 generation VHL 2A kindred with 11 mutation carriers. We aim to share our experience regarding the long-term follow-up of this family and the management of all our other VHL patients focusing on frequently encountered neuroendocrine neoplasms: pheochromocytoma/paraganglioma and pancreatic neuroendocrine neoplasms (PNEN).Methods: All VHL patients in follow-up at our tertiary center from 1980 to 2019 were identified. Clinical, laboratory, imaging, and therapeutic characteristics were retrospectively analyzed.Results: We identified 32 VHL patients in 16 different families, 7/16 were classified as VHL 2 subtype. In the previously described family, the 4 initially asymptomatic carriers developed a neuroendocrine tumor; 7 new children were born, 3 of them being mutation carriers; 2 patients died, 1 due to metastatic PNEN-related liver failure. Pheochromocytoma was frequent (22/32), bilateral (13/22;59%), often diagnosed in early childhood when active screening was timely performed, associated with paraganglioma in 5/22, rarely malignant (1/22), and recurred after surgery in some cases after more than 20 years. PNEN occurred in 8/32 patients (25%), and was metastatic in 3 patients. Surgery and palliative therapy allowed relatively satisfactory outcomes. Severe disabling morbidities due to central-nervous system and ophthalmologic hemangiomas, and other rare tumors as chondrosarcoma in 2 patients and polycythemia in 1 patient were observed.Conclusion: A multidisciplinary approach and long-term follow-up is mandatory in VHL patients to manage the multiple debilitating morbidities and delay mortality in these complex patients.     

Transorbital lobotomy; its use in relapsing psychotic states

Twenty-five private patients were treated by transorbital lobotomy. The period of observation after operation was from six months to three years. In 14 cases of affective disorders in which there was not adequate response to shock therapy, nine patients made social recovery and maintained good health and four were improved. Some follow-up shock therapy was necessary for about one-fifth of the patients. Of eight schizophrenic patients four made excellent social recoveries, two improved and two were not improved. In three cases of obsessive compulsive states, results were not satisfactory. In light of the factors of less disturbance to the total personality, absence of postoperative complications, shortened hospitalization, pecuniary savings and better clinical results, the authors prefer transorbital lobotomy to prefrontal lobotomy in private psychiatric practice and believe that in cases of frequent relapse early use of the procedure should be considered to prevent development of a chronic state.     

TRANSORBITAL LOBOTOMY—Its Use in Relapsing Psychotic States

Twenty-five private patients were treated by transorbital lobotomy. The period of observation after operation was from six months to three years. In 14 cases of affective disorders in which there was not adequate response to shock therapy, nine patients made social recovery and maintained good health and four were improved. Some follow-up shock therapy was necessary for about one-fifth of the patients. Of eight schizophrenic patients four made excellent social recoveries, two improved and two were not improved. In three cases of obsessive compulsive states, results were not satisfactory.In light of the factors of less disturbance to the total personality, absence of postoperative complications, shortened hospitalization, pecuniary savings and better clinical results, the authors prefer transorbital lobotomy to prefrontal lobotomy in private psychiatric practice and believe that in cases of frequent relapse early use of the procedure should be considered to prevent development of a chronic state.     

A Long-Term Follow-Up and Comprehensive Observation of Risk and Prognosis Factors of Recurrence and Survival After Resection of Hepatocellular Carcinoma

Although HBV, liver function and tumor characteristics were proven as hepatocellular carcinoma (HCC) prognosis-related, no large-scale and long-term follow-up studies have ever given robust evidence about prognosis predictive effect and contribution to different stage of postoperation. In this study, we evaluated the influence of above index on overall survival (OS) and disease-free survival (DFS) and other clinical data in a rather large population and long-term follow-up. Our study consisted of 1,326 HCC patients who underwent radical resection from 1996 to 2010. Epidemiology, clinical and prognosis data were analyzed. Risk factors of OS and DFS were explored. Cumulative survival comparison between groups was performed with log-rank. Multivariate analysis for independent prognostic factors was determined by Cox proportional hazards model. HBsAg status was a universal factor of HCC recurrence, while preoperational albumin (ALB) and portal vein tumor thrombus (PVTT) affected survival during the whole lifetime. Early stage recurrence was associated with capsule intact [OR (95 %) = 1.54,1.12–2.12, p = 0.009], preoperational alpha-fetoprotein (AFP), TNM and BCLC stages were the most important prognosis factors of recurrence in the early 5 years and PVTT affected the rest time. Survival was mainly associated with tumor characteristic and ALB. Short-time survival was affected with age and AFP, while BCLC was related with the long-time survival. We confirmed that during different periods after resection, factors affecting prognosis did not remain unchanged. Liver function and tumor characteristic affected DFS and OS the whole time, especially the early recurrence. However, HBV infection situation was associated with later recurrence. PVTT showed an opposite effect between early and later recurrence.     

Advancement of the orbits and the midface in one piece, combined with frontal repositioning, for the correction of Crouzon's deformities

We describe the use of radical craniofacial osteotomies, to improve the correction of exorbitism and to obtain better esthetic results in children with Crouzon's syndrome. We suggest some minor modifications to improve the fixation and the mechanical stability of the mobilized segments of the skull. Our procedure consists, essentially, of advancement of both orbits and the midface in one piece, plus advancement and reshaping of the frontal area. The results obtained by this technique, in children with a Crouzon's deformity without open bite, have been most satisfactory. We believe the satisfactory resultant appearance will be maintained during and after growth of the face, although these children have not been followed long enough yet to ascertain this with certainty.     

Reconstruction of infant thoracic wounds

From 1985 through 1987, five of eight infants with thoracic wounds at Yale-New Haven Hospital underwent chest-wall reconstruction. In total, the eight infants underwent 17 procedures (including multiple open resuscitations) exclusive of the reconstructive operations. Patients undergoing reconstruction ranged from 1 to 10 months of age and 3 to 7 kg in weight. All reconstructed patients underwent bilateral pectoralis major advancement flaps, with three of the five patients each requiring the simultaneous use of a rectus abdominis flap. With 2 to 18 months of follow-up, healing was complete in all five of the reconstructed patients, with two prosthetic pulmonary-systemic shunts and two outflow tract patches thus salvaged. These patients were found to be distinct from their adult counterparts, with special critical care requirements and expectedly delicate muscular anatomy. The gratifying results now expected in adults with sternal wound complications can be achieved in their infant counterparts. Furthermore, the group of patients whose chests cannot initially be closed owing to resultant cardiac compression may look to sternocostal debridement and flap reconstruction as a means of not only achieving wound closure, but of effectively increasing their mediastinal volume and compliance. Questions about skeletal development remain unanswered and demand further follow-up.     

Long-term complications of polyurethane-covered breast implants

The authors's personal experience using an earlier manufactured polyurethane-covered gel prosthesis is presented. Very long-term follow-up did not validate the author's initial enthusiasm. It is to be hoped that the newer polyurethane-covered implants will give more satisfactory long-term results.     

Coronary pressure and FFR predict long-term outcome after PTCA

Although coronary stents have been the most important improvement in percutaneous coronary interventions in the last 10 years, it is well known to interventionalists that many patients after percutaneous transluminal coronary angioplasty (PTCA) have a favourable outcome without stenting. Coronary angiography, however, is not sensitive enough to identify those particular patients and it has been suggested that a combination of angiographic and functional criteria would be more suitable to distinguish patients with a low restenosis chance after plain balloon angioplasty. In the present study, the authors investigated the value of coronary pressure measurement for conditional stenting in 85 patients. It was demonstrated that in patients in whom a high fractional flow reserve (FFR) was present (> 0.90), the incidence of coronary events at two-year follow-up was almost three times lower than in those patients with an FFR below 0.90. Such high FFRs could be obtained in approximately 45% of all patients. In an additional group of patients, it was demonstrated by intravascular ultrasound (IVUS) studies that the mechanism of a high FFR after plain balloon angioplasty is most likely the result of a larger lumen compared with patients with a suboptimal FFR. This means that, in patients in whom both the angiographic and the functional result after PTCA is optimal, a restenosis rate is achieved similar to that achieved by stenting. Obviously, in such patients, additional stenting and a number of problems in the long-term possibly related to stenting can be avoided. Therefore, coronary angiography and coronary pressure measurement have a complementary value in the evaluation of PTCA results and such information can be easily obtained by using a pressure wire instead of a regular guidewire.     

Expression of cyclooxygenase-2 related to angiogenesis in uterine cervical cancers

Summary Angiogenesis is essential for development, growth and advancement of solid tumors. Cyclooxygenase (COX)-2 is recognized as an angiogenic factor in various tumors. This prompted us to study the clinical implications of COX-2 expression related to angiogenesis in uterine cervical cancers. There was a significant correlation between microvessel counts and COX-2 levels in uterine cervical cancers. COX-2 localized in the cancer cells, but not in the stromal cells of uterine cervical cancer tissues. COX-2 levels increased with advancement, and the prognosis of the 30 patients with high COX-2 expression in uterine cervical cancers was poor (60%), while the 24-month survival rate of the other 30 patients with low COX-2 expression was 90%. Furthermore, COX-2 levels significantly correlated with VEGF levels in uterine cervical cancers. VEGF associated with COX-2 might work on angiogenesis in advancement. Therefore, long-term administration of COX-2 inhibitors might be effective on the suppression of regrowth or recurrence after intensive treatment for advanced uterine cervical cancers.     

Evaluation of Early Diagnostic Services for the Elderly

Medical examination was offered to a group of “high risk” old people who were not necessarily patients or known to their family doctors, but with the agreement of these family doctors. Two clinics set up for this purpose have been running for several years, and the results of examination and follow-up of 300 consecutive patients are reported.Major conditions were found in two-thirds of patients producing functional impairment in most of these.Recommendations as to therapy and management were carried out in 161 of 194 patients but not in the remainder.Clear evidence of improvement was found in half of the patients who carried out recommendations, and this improvement was attributable to earlier diagnosis than would have been achieved without these clinics in 42% of cases.Including all patients examined, the proportion helped by early diagnosis at 18 to 30 months'' follow-up was 23%.It is concluded that the offer of a routine examination to high risk groups is of benefit to old people and a form of medical practice which should be widely adopted.     

The prognostic value of the tumor marker CA 15-3 at initial diagnosis of patients with breast cancer

CA 15-3 has been most widely used as a serum tumor marker in follow-up and detection of breast cancer recurrence. In this study we have specifically focused upon the prognostic implications and utility of preoperative CA 15-3 levels. We have identified on our database 414 patients with breast cancer in whom serial levels of the serum tumor marker CA 15-3 had been determined at diagnosis and follow-up. We have analyzed the follow-up and clinical outcomes in these patients and from this data we have assessed the potential of CA 15-3 as a predictor of five-year overall and disease-free survival. Our results show that an initially elevated CA 15-3 level is associated with a very poor prognosis in both early and late stage disease. Elevated pre-biopsy CA 15-3 levels are associated with 14% five-year disease-free survival rates and 17% overall survival rates at five years. In contrast, normal CA 15-3 levels are associated with 47% five-year disease-free survival rates and 54% overall survival rates at five years (p<0.01). Comparison of five-year survival rates between patients with elevated and normal CA 15-3 levels in early breast cancer (stage I and II) also showed significant differences, with survival being 41% and 75%, respectively (p<0.01).