Modern Chemosurgery—Microscopically Controlled Excision

Chemosurgery is no longer the slow, painful, last-resort technique for skin cancer. With recent modifications the chemosurgery method, now called microscopically controlled excision (MCE), retains the careful microscopic tracing of even the smallest tumor strands but avoids the morbidity of zinc chloride paste. So far, the cure rate for microscopically controlled excision of difficult, recurrent or large basal cell carcinomas is comparable with that obtained by the classic procedure. This modification is more adaptable to current concerns for cosmesis, cross-specialty usage and early treatment for lesions known to have poor cure rates by standard modalities.     

Radiation Therapy for Skin Cancer

Local control, cosmesis and functional results were evaluated in 315 cases of skin cancer in 247 patients treated with radiation therapy. The initial recurrence rate for basal cell carcinoma was 7.8 percent and for squamous cell carcinoma was 14.9 percent. Ultimate local control was achieved in 98.7 percent of the cases of basal cell carcinoma and in 94.0 percent of the cases of squamous cell carcinoma with use of further irradiation or other therapeutic modalities. Ultimate local control rates were comparable to other therapeutic modalities. Cosmetic and functional results were excellent. Cartilage necrosis was not a significant problem. Radiation therapy may offer advantages in certain clinical situations and should be considered as a mode of therapy in the treatment of skin cancer.     

Clinical management of patients with invasive cervical cancer following a negative Pap smear

Among 535 patients with invasive cervical carcinoma seen between January 1975 and June 1986, 26 were found to have developed the disease within six months (65 percent), 35 within 12 months (88 percent), 37 within 13 months (93 percent), and three developed the disease within 17 months after a negative Pap smear. Eighty-eight percent of these 40 patients were under age 40 at diagnosis. Rapidly progressive cancers are highly resistant to radiation therapy. Seven stage IB patients treated only with radiation died within nine to 29 months after initial therapy. By contrast, 15 patients treated by radical hysterectomy and four by radical hysterectomy and post-surgical radiation were alive with no evidence of disease from six to 109 months after surgery (median, 30 months). Six of nine patients with stage II to IV disease treated with radiation have died; the remaining three are alive. One patient is well 14 months after therapy, but two others have developed metastases seven and 12 months after treatment. Surprisingly, 37 of 40 patients had symptoms of pain, bleeding, and discharge at the initial diagnosis, but their physicians had a false sense of security because of a recent negative Pap smear. Early biopsy diagnosis and radical hysterectomy with bilateral pelvic lymphadenectomy is the most effective management for this cancer.     

The effect of radiation on pedicled TRAM flap breast reconstruction: outcomes and implications

The purpose of this study was to examine the effect of postreconstruction radiation therapy on patients undergoing pedicled TRAM flap breast reconstruction. Post-TRAM radiation patients were compared with patients who received pre-TRAM radiation and a control TRAM-only group who received no radiation. Overall aesthetic appearance, evidence of symmetry, flap contracture, and hyperpigmentation were assessed by blinded reviewers. A total of 171 pedicled TRAM reconstructions were performed in 150 patients. Total flap complications were seen in 49.5 percent of the control patients, 57.1 percent of pre-TRAM radiation patients, and 50 percent of post-TRAM radiation patients but were not statistically different. The complete flap necrosis rate was 0.6 percent and the partial flap necrosis rate was 7.6 percent, again with no statistical differences among the groups. Donor-site complications occurred in approximately one third of patients in each of the groups. Deep venous thrombosis and pulmonary embolus each occurred once and only in the post-TRAM radiation group. In terms of overall aesthetic outcome, symmetry, and contracture, the control group consistently rated better than the pre-TRAM (p = 0.021, p = 0.03, p = 0.03, respectively) and the post-TRAM (p = 0.0001, p = 0.0001, and p =0.0001, respectively) radiation groups. The control group also had clinically and statistically significant less hyperpigmentation than the post-TRAM radiation group (p = 0.0002). In contrast, irradiated postreconstruction patients had scores, including aesthetic outcome, symmetry, and contracture, worse than those of irradiated prereconstruction patients. When these two groups were compared with each other, except for contracture, no statistical significance, because of a small patient sample, was found. Neither preoperative nor postoperative radiation increased the risk for flap or donor-site complications. In contrast, radiation of any type did affect aesthetic appearance, symmetry, contracture, and hyperpigmentation. The authors recommend that TRAM flap breast reconstruction be postponed in those patients known or expected to receive postmastectomy radiation.     

Analysis of pharyngocutaneous fistula following free jejunal transfer for total laryngopharyngectomy

The development of a pharyngocutaneous fistula is the most common and troublesome complication in the early postoperative period following free jejunal transfer for total laryngopharyngectomy. However, many aspects of this complication remain unclear. In this study, the authors analyzed their experience with the pharyngocutaneous fistula formation following free jejunal transfers to evaluate its clinical behavior, determine the significance of the anastomotic technique used, and evaluate the role of preoperative radiation therapy on its formation and management. Of 168 patients who underwent free jejunal transfers following total laryngopharyngectomy at the authors' institution between July of 1988 and March of 2000, 23 patients (13.7 percent) with postoperative fistulas were identified. The mean onset of fistula formation was 16 days. Of the 23 fistulas, 13 (56.5 percent) occurred at the proximal and 10 (43.5 percent) at the distal anastomoses. Whereas the majority of the proximal fistulas (69.2 percent) developed near the mesenteric side of the jejunal flap, most of the distal fistulas (90 percent) were located anteriorly. The incidence of proximal fistula formation was higher in patients with a single-layer repair than in patients with a two-layer repair of a proximal anastomosis (80 percent versus 38.5 percent, p = 0.09). The incidence of fistula formation was greater in patients who received preoperative radiation therapy than in those who did not (16.3 percent versus 11.4 percent, p = 0.36). In addition, whereas a majority of fistulas (80 percent) occurred at the proximal anastomosis in patients who did not receive preoperative radiation therapy, most fistulas (61.5 percent) occurred at the distal anastomosis in patients who did receive radiation therapy (p = 0.09). The fistulas closed spontaneously in 15 patients (65 percent). On average, spontaneous closure occurred in 7.4 weeks. Proximal fistulas had a significantly higher rate of spontaneous closure compared with distal fistulas (85 percent versus 40 percent, p = 0.04). The rate of spontaneous fistula closure was higher in patients who had not received preoperative radiation therapy than in those who had (90 percent versus 46 percent, p = 0.07). Surgical closure of the fistula was required in five patients. The fistulas were not repaired in three patients because of recurrent tumor. Twenty patients (87 percent) resumed oral feeding after the closure of the fistula, with 17 (85 percent) of 20 patients tolerating a regular diet and three (15 percent) of 20 a liquid diet only.In conclusion, most fistulas occur at the proximal anastomosis and near the mesenteric side of the jejunal flap, and the use of a two-layer anastomotic technique seems to be associated with a lower incidence of fistula formation at the proximal suture line. Most fistulas close spontaneously, especially ones that occur proximally. Preoperative radiotherapy does seem to increase the risk of fistula formation, especially at the distal anastomotic site and make subsequent resolution of the fistulas more difficult. Most patients are able to resume oral feeding once the fistula is closed.     

Treatment of Malignant Pheochromocytoma

Pheochromocytoma is a tumor derived from chromaffin tissue, which secretes catecholamines. Today, about 90 percent of patients with this tumor are cured by surgical procedures. In 8 to 15 percent of patients with this tumor there is unresectable, recurrent or metastatic disease, which causes significant morbidity and mortality. The natural history of metastatic disease includes long-term survivors; many, however, die early of disseminated disease. The most common site of metastatic lesions is the skeleton. Palliation for these lesions can often be achieved with the use of radiation therapy. Other sites are, in general, less responsive to radiation therapy. Chemotherapy has been used in combination with radiation therapy, but the results generally have been disappointing. Chemotherapy with doxorubicin hydrochloride and cyclophosphamide in combination with radiation therapy has provided good palliation for skeletal disease for about five months, when disease progression was again noted. Further information is needed concerning the optimal chemotherapeutic treatment of this unusual tumor.     

Staged breast reconstruction with saline-filled implants in the irradiated breast: recent trends and therapeutic implications

A retrospective review was performed of one surgeon's experience with 40 consecutive patients who had undergone two-stage saline-filled implant breast reconstruction and radiation during the period from 1990 through 1997. A randomly selected group of 40 other two-stage saline-filled implant breast reconstructions from the same surgeon and time period served as controls. This review was undertaken because of the absence of specific information on the outcome of staged saline implant reconstructions in the radiated breast. Previously published reports on silicone gel implants and radiation have been contradictory. At the same time, the criteria for the use of radiation in the treatment of breast cancer have been expanded and the numbers of reconstruction patients who have been radiated are increasing dramatically. For example, in a 1985 report on immediate breast reconstruction, only 1 of 185 patients over a 6-year period underwent adjuvant radiation therapy, whereas in this review, there were 40 radiated breasts with saline-filled implants, 19 of which received adjuvant radiation therapy during their expansion. The study parameters included patient age, breast cup size, implant size, length of follow-up, number of procedures, coincident flap operations, Baker classification, complications, opposite breast procedures, pathologic stage, indications for and details about the radiation, and outcomes. The use of radiation in this review of reconstructed breasts can logically be divided into four groups: previous lumpectomy and radiation (n = 7), mastectomy and radiation before reconstruction (n = 9), mastectomy and adjuvant radiation during reconstruction/expansion (n = 19), and radiation after reconstruction (n = 5). The largest and most rapidly growing group of patients is of those receiving postmastectomy adjuvant radiation therapy. A total of 47.5 percent (19 of 40) of radiated breasts with saline implants ultimately needed the addition of, or replacement by, a flap. Ten percent of a control group with nonradiated saline implant reconstructions also had flaps, none as replacements. Fifty percent or more of both the radiated and control groups had contralateral surgery. Complications were far more common in the radiated group; for example, there were 32.5 percent capsular contractures compared with none in the control group. The control nonradiated implant-only group and the flap plus implant radiated group did well cosmetically. The radiated implant-only group was judged the worst. The increasing use of radiation after mastectomy has important implications for breast reconstruction. The possibility for radiation should be thoroughly investigated and anticipated preoperatively before immediate breast reconstruction. Patients with invasive disease, particularly with large tumors or palpable axillary lymph nodes, are especially likely to be encouraged to undergo postmastectomy radiation therapy. The indications for adjuvant radiation therapy have included four or more positive axillary lymph nodes, tumors 4 cm (or more) in diameter, and tumors at or near the margin of resection. More recently, some centers are recommending adjuvant radiation therapy for patients with as few as one positive lymph node or even in situ carcinoma close to the resection margin. The use of latissimus dorsi flaps after radiation has proven to be an excellent solution to postradiation tissue contracture, which can occur during breast expander reconstruction. The use of the latissimus flap electively with skin-sparing mastectomy preradiation is probably unwise, unless postmastectomy radiation is unlikely. Skin-sparing mastectomy with a latissimus flap thus should be preserved for patients unlikely to undergo adjuvant radiation therapy. Purely autologous reconstruction such as a TRAM flap is another option for these patients, either before or after radiation therapy.     

Immediate free TRAM reconstruction in lumpectomy and radiation failure patients

Local recurrence after lumpectomy and radiation therapy indicates failed breast conservation surgery. These patients often proceed to mastectomy and are candidates for autogenous breast reconstruction. Free transverse rectus abdominus muscle (TRAM) reconstruction in these patients is complicated by repeated axillary dissection and the use of irradiated tissue. Complication rates for pedicled TRAMs have been reported at 33 percent when used in irradiated tissue beds. We report our results using the free TRAM for breast reconstruction after lumpectomy and radiation failure. All patients within this study developed a local recurrence after lumpectomy and radiation therapy. All patients had undergone axillary dissection for staging at the time of their lumpectomy. Patient records were reviewed for patient age, total radiation dose, associated risk factors for TRAM failure, operative time, donor vessels used for anastomosis, status of the native thoracodorsal vessels at the time of surgery, and postoperative complications. Over a 7-year period, 16 TRAM patients had undergone previous breast conservation surgery. Of these 16 patients, 14 underwent reconstruction with a planned free TRAM after simple mastectomy. Average operating room time was 7 hours. There were no partial or total flap losses. Complications were seen in 14 percent of the overall group. Overall, we found that the free TRAM provided an excellent aesthetic result with a lower complication rate than previously reported for pedicled TRAM flaps in irradiated beds. The thoracodorsal vessels provided an adequate donor vessel in 93 percent of the cases. The free TRAM provides a superior alternative in immediate reconstruction in patients who have failed breast conservative surgery.     

Microsurgical scalp reconstruction in the patient with cancer

The literature regarding reconstruction of large scalp wounds with free tissue transfer consists mostly of case reports and small series, and none of the published reports focus on the particular problems of the oncology patient. Here the authors describe their experience with 37 flaps in 32 patients, all of whom required scalp reconstruction with free tissue transfer after tumor extirpation. Twenty-seven free flaps were performed at the time of the initial surgery and 10 were performed after a prior reconstruction failed. The authors describe the characteristics of the patients and procedures, including tumor type, wound size and complexity, flaps and recipient vessels used, preoperative and postoperative radiation therapy, and complications. Most (72 percent) of the tumors were recurrent or persistent. The free tissue transfer was successful in all patients. There was a 59 percent overall complication rate with 32 percent of patients requiring a secondary surgical procedure. Most of the complications were wound-healing complications. Although there were two cases of vein thrombosis, these were salvaged by revision, and no flaps were lost. Nine patients underwent postoperative radiation therapy that was well tolerated. Only four patients underwent cranioplasty at the time of the initial operation, and no secondary cranial reconstructions were performed. The authors conclude that preoperative and postoperative radiation therapies as well as the need for expedient tumor resection and immediate flap coverage are issues that make free tissue transfer attractive for the oncology patient who needs scalp reconstruction. Although the complication rate is relatively high and a significant percentage of patients require a secondary procedure, free flap coverage was efficacious for all patients in this group. Cranioplasty is not usually required but, if needed, alloplastic or autologous cranial reconstruction does not appreciably increase morbidity in the selected patient.     

Germ Cell Tumors of the Testes

Most malignant testicular neoplasms are of germ cell origin. They are divided into five basic types: seminomas, embryonal carcinomas, teratocarcinomas, adult teratomas and choriocarcinomas. Clinically they may present as an enlarging testicular mass, or with symptoms resulting from metastases or hormonal secretions. The treatment of choice for patients with seminomas is orchiectomy, followed by radiation therapy. This combination results in an 80 to 100 percent five-year survival rate in patients with nonmetastatic or locally metastatic disease. The treatment of nonseminomatous germ cell tumors is more controversial. An aggressive approach, however, with retroperitoneal lymph node dissection and adjuvant chemotherapy has resulted in an overall 78 percent survival rate. Several placental and fetal proteins are secreted by these tumors. Two of these, human chorionic gonadotropin and alpha-fetoprotein, have been shown to be useful for the diagnosis of these neoplasms, for following the disease activity during therapy and for detection of recurrences.     

Comparison of immediate and delayed free TRAM flap breast reconstruction in patients receiving postmastectomy radiation therapy.

Tumor pathologic features and the extent of nodal involvement dictate whether radiation therapy is given after mastectomy for breast cancer. It is generally well accepted that radiation negatively influences the outcome of implant-based breast reconstruction. However, the long-term effect of radiation therapy on the outcome of breast reconstruction with the free transverse rectus abdominis myocutaneous (TRAM) flap is still unclear. For patients who need postmastectomy radiation therapy, the optimal timing of TRAM flap reconstruction is controversial. This study compares the outcome of immediate and delayed free TRAM flap breast reconstruction in patients who received postmastectomy radiation therapy.All patients at The University of Texas M. D. Anderson Cancer Center who received postmastectomy radiation therapy and who also underwent free TRAM flap breast reconstruction between January of 1988 and December of 1998 were included in the study. Patients who received radiation therapy before delayed TRAM flap reconstruction were compared with patients who underwent immediate TRAM flap reconstruction before radiation therapy. Early and late complications were compared between the two groups. Early complications included vessel thrombosis, partial or total flap loss, mastectomy skin flap necrosis, and local wound-healing problems, whereas late complications included fat necrosis, volume loss, and flap contracture of free TRAM breast mounds. Late complications were evaluated at least 1 year after the completion of radiation therapy for patients who had delayed reconstruction and at least 1 year after reconstruction for patients who had immediate reconstruction.During the study period, 32 patients had immediate TRAM flap reconstruction before radiation therapy and 70 patients had radiation therapy before TRAM flap reconstruction. Mean follow-up times for the immediate reconstruction and delayed reconstruction groups were 3 and 5 years, respectively. The mean radiation dose was 50 Gy in the immediate reconstruction group and 51 Gy in the delayed reconstruction group.One complete flap loss occurred in the delayed reconstruction group, and no flap loss occurred in the immediate reconstruction group. The incidence of early complications did not differ significantly between the two groups. However, the incidence of late complications was significantly higher in the immediate reconstruction group than in the delayed reconstruction group (87.5 percent versus 8.6 percent; p = 0.000). Nine patients (28 percent) in the immediate reconstruction group required an additional flap to correct the distorted contour from flap shrinkage and severe flap contraction.These findings indicate that, in patients who are candidates for free TRAM flap breast reconstruction and need postmastectomy radiation therapy, reconstruction should be delayed until radiation therapy is complete.     

Cancer of the Nasopharynx

Of 75 consecutive patients with nasopharyngeal cancer treated at UCLA Center for Health Sciences, 42 were eligible for long-term study. Fourteen (33 percent) survived five years, and one survived ten years. Since the management of nasopharyngeal cancer is primarily irradiation, a well-planned aggressive treatment program using supravoltage therapy is recommended. In spite of cranial nerve involvement or skull erosion, radiation therapy occasionally may offer long term control of the disease.     

Aesthetic results following partial mastectomy and radiation therapy

This study was undertaken to determine the aesthetic changes inherent in partial mastectomy followed by radiation therapy in the treatment of stage I and stage II breast cancer. A retrospective analysis of breast cancer patients treated according to the National Surgical Adjuvant Breast Project Protocol B-06 was undertaken in 57 patients from 1984 to the present. The size of mastectomy varied between 2 x 1 cm and 15 x 8 cm. Objective aesthetic outcome, as determined by physical and photographic examination, was influenced primarily by surgical technique as opposed to the effects of radiation. These technical factors included orientation of resections, breast size relative to size of resection, location of tumor, and extent and orientation of axillary dissection. Regarding cosmesis, 80 percent of patients treated in this study judged their result to be excellent or good, in comparison to 50 percent excellent or good as judged by the plastic surgeon. Only 10 percent would consider mastectomy with reconstruction for contralateral disease. Asymmetry and contour abnormalities are far more common than noted in the radiation therapy literature. Patients satisfaction with lumpectomy and radiation, however, is very high. This satisfaction is not necessarily based on objective criteria defining aesthetic parameters, but is strongly influenced by retainment of the breast as an original body part.     

Management of parotid hemangioma in 100 children

Most problematic infantile hemangiomas are successfully treated with pharmacological therapy. However, there are reports that hemangioma of the parotid gland responds poorly to corticosteroid and interferon. To better clarify the management of parotid hemangioma, the authors retrospectively studied the records of 100 consecutive patients, seen between 1975 and 2002. The characteristics of the tumor, including sex ratio, presence at birth, size, side, complications, and involvement of adjacent structures, were recorded. The indications for and response to treatment and the need for surgical procedures were documented and statistically analyzed. The female-to-male ratio was 4.5:1. Forty percent of parotid hemangiomas were on the right side, 36 percent were on the left, and 24 percent were bilateral. Forty-five percent of patients had a premonitory cutaneous lesion at birth. Fifty-nine percent of parotid hemangiomas ulcerated during the early proliferative phase. Eighty-eight percent involved nearby structures (ear, 70 percent; lip, 34 percent; subglottic region, 21 percent; eye, 18 percent; and nose, 3 percent). Seven percent of patients required tracheostomy, and 3 percent had signs of congestive heart failure. Seventy infants received pharmacological treatment. Sixty-seven patients were initially managed with corticosteroids; regression or stabilization was noted in 83 percent of tumors (56 of 67 tumors). Twenty-one patients received interferon: 11 in whom corticosteroid therapy had failed, seven in whom the tumor stabilized with corticosteroid therapy but further regression was needed, and three who had interferon as primary therapy. Ninety-five percent of the lesions that were resistant to corticosteroid subsequently responded to interferon alfa-2a or -2b. The overall response rate to pharmacological therapy was 98 percent. A reconstructive procedure was necessary during the involuting or involuted phase in 66 percent of patients: 92 percent had preauricular excision of redundant skin and/or fibrofatty tissue and 37 percent of patients had auricular revision. In summary, drug therapy was effective in the majority of infants with parotid hemangioma, whether given because the tumor was large, deforming, ulcerated, or involved nearby structures with functional consequences. Infantile hemangioma in the parotid gland responded to pharmacological treatment in a similar manner as hemangioma in other locations.     

Nipple-areola reconstruction: satisfaction and clinical determinants

After performing a chart review, the authors identified 120 patients who underwent breast cancer-related reconstruction. All charts were evaluated with regard to breast mound reconstruction type, nipple-areola reconstruction type, the interval between breast mound and nipple-areola reconstruction, the number of procedures needed to achieve nipple-areola reconstruction, patient history of radiation therapy, and complications. A questionnaire was then developed and mailed to all of the patients who underwent both breast mound and nipple/areola reconstruction (n = 105) to evaluate their level of satisfaction. Of the 43 patients who returned the questionnaire, 41 completed all portions correctly. The questionnaire evaluated patient satisfaction with breast mound reconstruction; patient satisfaction with nipple-areola reconstruction; what the patient disliked most about the nipple-areola reconstruction; and whether or not the patient would choose to have breast reconstruction again. Several parameters were then tested statistically against the reported patient satisfaction.A review of all patients who underwent breast reconstruction revealed that their breast mound reconstructions were done using either a TRAM flap (59 percent), a latissimus dorsi flap and an implant (19 percent), an expander followed by an implant (9 percent), an implant only (4 percent), or other means (9 percent). The nipple-areola was reconstructed in these patients with either a star flap (36 percent), nipple sharing (10 percent), a keyhole flap (9 percent), a skate flap (9 percent), an S-flap (8 percent), a full-thickness skin graft (6 percent), or by another means (22 percent). The number of procedures needed to achieve nipple-areola reconstruction was either one (in 66 percent of the patients), two (in 32 percent of the patients), or three or more (2 percent of the patients). Eleven percent of the patients experienced the complication of nipple necrosis.Satisfaction with breast mound reconstruction was reported by 81 percent of patients to be excellent/good, by 14 percent of patients to be fair, and by 5 percent of patients to be poor. Reported satisfaction with nipple-areola reconstruction was excellent/good for 64 percent of patients, fair for 22 percent of patients, and poor for 14 percent of patients. The factors patients disliked most about their nipple-areola reconstruction were, in descending order, lack of projection, color match, shape, size, texture, and position. Statistical analysis of the data revealed inferior patient satisfaction when there was a longer interval between breast mound and nipple areola reconstruction (p = 0.003). No significant difference was observed in nipple/areola reconstruction satisfaction ratings when compared with breast mound reconstruction type (p = 0.46), nipple-areola reconstruction type (p = 0.98), and history of radiation therapy (p = 0.23). There was also no significant difference when breast mound reconstruction was compared with technique (p = 0.51) and history of radiation therapy (p = 0.079). Overall, there was a greater satisfaction with breast mound reconstruction than with nipple-areola reconstruction (p = 0.0001).     

Free-flap mandibular reconstruction: a 10-year follow-up study

Free-flap reconstruction of oncologic mandibular defects has become the modern standard of care. However, no previous studies have established the long-term results of such reconstructions. The objective of this study was to review functional and aesthetic outcomes in patients a decade after free-flap mandibular reconstruction.A single surgeon's experience with free-flap reconstruction of the mandible was retrospectively reviewed. Eighty-two consecutive patients who underwent reconstruction from January of 1987 to December of 1990 were identified. Of the 34 patients still alive, 20 agreed to participate (response rate, 59 percent). To assess complications and functional outcome, patients were interviewed using validated questions and questions developed specifically for the study. Aesthetic outcome was judged by two independent observers. Panorex radiographs were obtained to assess bone resorption. Bone height was measured at standardized locations on the body, ramus, and symphysis and compared with the immediate postoperative Panorex radiographs. Differences in Panorex magnification were adjusted for by comparison of miniplate measurements. Mean length of follow-up was 11 years. Mean patient age at the time of the study was 48 years. Nineteen of 20 patients had malignant disease, one of whom had a local recurrence during the follow-up period. Two patients received radiation therapy preoperatively and 13 postoperatively. Mean length of mandible resection was 13 cm. Defect types were as follows (Jewer's classification): 12 L, 4 H, 3 LC, and 1 LCL. All flaps survived.At 10-year follow-up, aesthetic outcome was judged to be excellent in 55 percent of patients, good in 20 percent, fair in 15 percent, and poor in 10 percent. The aesthetic results were remarkably stable over time. Slight accentuation of subtle postoperative asymmetry became evident as facial aging progressed. Dental rehabilitation in the study group included five patients with osteointegrated implants and seven with conventional dentures. Seventy percent of patients reported a regular diet. The remainder required a soft diet. Food tolerance was good, as rated by the List Scale (mean score, 77 percent). Seventeen patients had easily intelligible speech, whereas three were intelligible with effort. At the midbody of the mandible, 92 percent of the postoperative bone height was preserved; at the midramus, 93 percent was maintained; and at the symphysis, 92 percent remained. In several patients, there was greater age-related bone loss from the residual native mandible compared with the reconstructed site. One patient developed an orocutaneous fistula following postoperative radiation therapy. Nine patients had miniplates removed, either because of plate problems or to allow implant placement. There were no cases of osteoradionecrosis, bone fracture, or miniplate fracture. There was no significant long-term disability related to the donor site.Free-flap reconstruction of the mandible provides excellent functional and aesthetic results that remain stable over time. Bone resorption is surprisingly minimal, even in the face of postoperative radiation therapy. The majority of patients are able to tolerate a regular diet and to either wear dentures or acquire osteointegrated implants. Acceptable speech and appearance are restored and continue to be a source of patient satisfaction at least a decade after surgery.     

Treatment of midfacial defects using prostheses supported by ITI dental implants

The purpose of this study was to evaluate retrospectively the use of ITI dental implants used for anchoring facial prostheses in the restorative treatment of midface defects. The authors analyzed the clinical data of 26 patients with orbital defects (n = 11), orbitonasal defects (n = 4), orbitonasomaxillary defects (n = 3), and nasal defects (n = 8). Data included age, sex, primary disease, implant position, implant length, implant failure, prosthetic attachment, radiation therapy, and peri-implant skin reactions. Follow-up was at 1, 3, 6, and 12 months and then on a yearly basis. The authors noted the status of healing and complications, if any. In total, 62 implants were placed as follows: 27 (43.5 percent) for orbital prostheses, 12 (19.4 percent) for orbitonasal prostheses, 14 (22.6 percent) for orbitonasomaxillary prostheses, and nine (14.5 percent) for nasal prostheses. Thirty-eight implants (61.3 percent) were placed in previously irradiated areas in 18 patients (69.2 percent). Mild skin reactions together with mild accumulation of sebaceous crusting around implants were recorded in 14.2 percent of the skin observations. No patient experienced severe inflammation requiring administration of systemic antibiotics or surgical revision. Implant success was 100 percent in both irradiated and nonirradiated patients. In conclusion, ITI dental implants result in a high rate of success in retaining midface prostheses and offer good stability and aesthetic satisfaction.     

Primary treatment of the infected sternotomy wound with muscle flaps: a review of 211 consecutive cases

Between 1978 and 1987, 15,595 median sternotomies were performed at Emory University Hospitals. Sternal wound infections developed in 246 patients (1.6 percent). Mediastinitis was present in 211 patients, while superficial infections were detected in the remaining 35 patients. Debridement and muscle or omental flap closure were performed in all instances of mediastinitis, with an overall mortality rate of 5.3 percent. The results of this treatment are reviewed, and the evolution of current therapeutic guidelines is described. When compared with closed-catheter irrigation and open granulation techniques, flap closure is shown to result in a fourfold decrease in mortality, an increased success of primary therapy, and a diminished length of hospitalization following treatment. This evidence supports the conclusion that debridement and flap closure should be considered the primary therapy for patients with poststernotomy mediastinitis.     

Breast reconstruction in women treated with radiation therapy for breast cancer: cosmesis, complications, and tumor control.

The records of 55 patients who had breast cancer treated by mastectomy, irradiation, and breast reconstruction were reviewed for cosmetic outcome, complications, and tumor control. Median follow-up was 35 months. Local control rates were 95 percent in patients treated for high risk factors or breast conservation and 85 percent in patients treated for recurrent breast cancer. Acceptable cosmetic results were obtained in only 42 percent of patients. The incidence of complications was 55 percent. Transverse rectus abdominis muscle (TRAM) reconstructions gave superior cosmetic results compared with all other types of reconstructions. The timing of reconstruction in relation to mastectomy or radiation therapy did not significantly influence cosmetic outcome, although other factors suggest that delayed reconstruction may give better results. A majority of patients were satisfied with cosmetic outcome.