Transverse rectus sheath plication in abdominoplasty

The standard abdominoplasty technique uses a wide, vertically oriented plication of the rectus sheath to narrow the waistline. This reduces the contribution of the rectus sheath to the anterior abdominal wall from more than 50 percent to 25 percent or less and creates an unnaturally flat appearance. No amount of exercise can restore the native form of the rectus sheath. For the past 3 years, the authors have performed a transverse plication of the rectus sheath, to address vertical laxity, complemented by a bilateral crescent-shaped plication of the external oblique fascia, to address waistline contour. Six consecutive patients who underwent the transverse rectus plication technique were compared with a similar group of patients who underwent vertical rectus plication. Comparison was made via preoperative and postoperative photographic analysis by two impartial judges. Although the overall result was excellent in both groups, the global score was significantly higher in the transverse plication group (4.5 versus 3.9, p = 0.044). Scores for anterior abdominal contour (4.7 versus 4.2, p = 0.029) and definition of the linea semilunaris (4.6 versus 3.7, p = 0.008) were also significantly higher for the transverse plication group. The difference for waistline contour (4.5 versus 3.8, p = 0.067), definition of the linea alba (4.4 versus 3.9, p = 0.067), and hip-waist transition (4.4 versus 3.7, p = 0.067) did not reach statistical significance. The outline of the rectus sheath is a significant portion of what is perceived as an aesthetic abdomen. Transverse plication of the rectus sheath with bilateral crescent-shaped plications of the external oblique fascia retains this native form. The result is improved anterior abdominal contour and definition of the rectus sheath with a comparable or better improvement in waistline contour and transition from the hips to the waist when compared with wide, vertical rectus plication.     

Intraabdominal pressure after full abdominoplasty in obese multiparous patients

This study measured intraabdominal pressure in morbidly obese and multiparous patients who underwent abdominoplasty with musculoaponeurotic plication. The purpose of this study was to evaluate any potential adverse effect on pulmonary function by virtue of pulmonary function tests and measurement of peak airway pressure. The study included 43 multiparous, morbidly obese women (mean body mass index, 35.8 kg/m2) with a mean age (+/- SD) of 38.6 +/- 7 years. All had full abdominoplasty and repair of the musculoaponeurotic system during the period from June of 1999 to May of 2002. Forty-three morbidly obese multiparous patients were seen over a period of 24 months. Their intraabdominal pressure was estimated by measuring the intravesical pressure before and after repair of severe diastases (divarication) of the rectus abdominis muscles with severely flaccid myofascial component before using a hydrometer connected to a Foley catheter both before and after repair. All patients had pulmonary function checked before and 2 months after the repair. The study confirmed that there are minimal changes on the intraabdominal pressure parameters compared with measurement before and after full abdominoplasty with plication of the rectus muscles, with minimal to negligible changes in the intrathoracic pressure. These changes are clinically and statistically significant (p < 0.0001). The study also recommended the safety of full abdominoplasty and repair of the musculoaponeurotic system in multiparous and morbidly obese patients. Furthermore, no statistically significant difference was found in pulmonary function parameters before and after surgery in patients with a history of bronchial asthma.     

Reconstruction of large composite oromandibulomaxillary defects with free vertical rectus abdominis myocutaneous flaps

Large composite oromandibulomaxillary defects resulting from oncologic resection can be challenging to reconstruct with a single flap, and functional outcomes remain anecdotal. The purpose of this study was to evaluate the authors' surgical experience and scientifically analyze and describe the functional outcomes associated with the use of the vertical rectus abdominis myocutaneous flap for reconstruction of these defects. The records of seven patients (mean age, 62 years) who underwent composite resection including hemimandibulectomy, partial maxillectomy, partial pharyngectomy, and floor-of-mouth resection followed by immediate free vertical rectus abdominis myocutaneous flap reconstruction at The University of Texas M. D. Anderson Cancer Center (1998 to 2002) were retrospectively reviewed. The tumor type was squamous cell carcinoma in all seven cases; four patients had T4 primary lesions and three had local recurrences. Radiotherapy was used preoperatively in each of the three recurrent cases (mean dose, 70.6 Gy) and postoperatively in three of the four patients with primary tumors (mean dose, 63.0 Gy). The mean length of hospitalization was 8.7 days. There were no major flap complications, fistulas, or donor-site complications. Partial flap necrosis (4 percent of flap area) occurred in one patient and dehiscence of the neck incision occurred in another. Both cases were managed with surgical débridement and closure. A third patient developed a 0.75-cm superficial suture line abscess that healed with dressing changes. The mean postoperative follow-up was 15 months. Six of the seven patients remained tube dependent for their nutrition despite some swallowing improvement; one patient returned to full oral intake. The most common swallowing deficit was impaired laryngeal excursion, which occurred in all six patients evaluated with videofluoroscopic examination and resulted in risk for aspiration in patients and frank aspiration in 83 percent. Speech was intelligible on routine follow-up visits in all patients except one. Four patients died as a result of their cancer, one was alive with metastatic disease, and two were alive with no evidence of disease at last follow-up. The goal for patients undergoing extensive composite oromandibulomaxillary resection for advanced cancer is to restore structure, minimize postoperative morbidity, and optimize the quality of remaining life. Reconstruction with the free vertical rectus abdominis myocutaneous flap achieves early wound healing, allows timely delivery of adjuvant therapy, and can be accomplished with predictable success and minimal morbidity. To our knowledge, this study represents the first to scientifically analyze and quantify swallowing function following free vertical rectus abdominis myocutaneous flap reconstruction for large oromandibulomaxillary defects. Understanding of the specific physiologic swallowing deficits that typically occur after such reconstructions will provide clinicians with important surgical and reconstructive information to enable future improvements in functional success in a population for whom the prognosis is poor and treatment options are limited.     

Sensitivity of breasts reconstructed with the autologous latissimus dorsi flap

The purpose of this study was to measure, both objectively and subjectively, the sensitivity of breasts reconstructed with the autologous latissimus dorsi flap and to compare these results with those of other reconstruction techniques, especially the transverse rectus abdominis myocutaneous flap. The study population included 50 patients with autologous latissimus dorsi flap breast reconstruction; these patients had an average age of 51 years and an average follow-up of 27 months. Patients answered a seven-item questionnaire that attempted to define the sensitivity of the reconstructed and opposite breasts. This sensitivity was then measured objectively using standard techniques for heat, cold, and tactile sensations. After statistical analysis, these results were compared with those published for other reconstruction techniques. Overall results were comparable or superior to those published for other techniques for autologous breast reconstruction. A total of 56 percent of patients had fine or very fine sensitivity, but 70 percent deemed this sensitivity to be less than that of the opposite breast. A total of 94 percent of patients perceived the reconstructed breast as integral to their body image. The superior medial part of the breast had the greatest sensitivity, both objectively and subjectively. Autologous latissimus dorsi breast reconstruction, a good technique with excellent aesthetic results, affords satisfactory sensitivity. This is yet another advantage of the technique.     

Acquired strabismus following cosmetic blepharoplasty

The purpose of this study was to report on 12 patients with acquired strabismus following cosmetic blepharoplasty and to identify patterns of strabismus related to the surgical procedure. Clinical ophthalmologic examinations were performed to specifically clarify the type of strabismus. Operative reports of the blepharoplasty procedures were reviewed. Patients were followed for a minimum of 3 months after the blepharoplasty procedure before surgical intervention was considered. Operative findings at corrective strabismus surgery were noted and an attempt was made to correlate these findings with the clinical ophthalmologic examination and the blepharoplasty surgical procedure. Twelve cases of persistent vertical strabismus occurred following blepharoplasty procedures. Five patients had clinical findings consistent with the diagnosis of acquired superior oblique palsy; one of these five patients also showed signs of an acquired Brown syndrome. Seven patients developed an incomitant vertical deviation consistent with an inferior rectus paresis. Strabismus occurred after conventional lower lid, upper lid, and four-lid blepharoplasty with or without laser blepharoplasty. Acquired strabismus accompanied by persistent diplopia may occur as a complication of cosmetic blepharoplasty. Extraocular muscle damage resulting in either superior oblique muscle palsy or inferior rectus paresis was noted in these patients. In some cases, patients with inferior rectus paresis also showed mechanical restriction to upward rotation of the globe.     

Marriage abdominoplasty expands the mini-abdominoplasty concept

The marriage of aggressive superwet liposculpture of the abdomen and adjacent anatomic regions with a modification of well-established open surgical techniques to address skin excess and perform muscle plication was used to treat 29 patients presenting for aesthetic abdominal contouring over the past 3 1/2 years. The charts of 57 patients who had aesthetic contouring procedures on the abdomen performed from December of 1994 to July of 1998 were retrospectively reviewed. Fifteen patients underwent suction lipectomy alone, 13 patients were treated with conventional abdominoplasty, and 29 underwent "marriage abdominoplasty." The 29 patients who underwent marriage abdominoplasty presented with deformities marked by excess lower abdominal skin and adipose tissue, with or without muscle laxity (Psillakis types II, III, and IV). Seventeen procedures were performed under local anesthesia with deep conscious sedation on an outpatient surgical basis. In 12 patients, the operation accompanied a hysterectomy, urologic procedure, or additional aesthetic surgical procedure(s) and was done under general anesthesia. Suction aspirates ranged between 540 and 2600 cc (mean, 1160 cc) and were accompanied by lower abdominal skin excision in every case, which was performed predominantly through short and medium-length incisions (mean, 15 cm). Rectus abdominis muscle plication was performed where necessary, using vertical plication of the infraumbilical rectus muscles in 27 patients (93 percent) and full-length plication in two patients (7 percent). All patients demonstrated significantly improved contours and have seemed to manifest less pain when compared with patients treated by full traditional abdominoplasty. Postoperative complications have included upper abdominal skin waviness (2), annoying paresthesias and discomfort persisting for 6 months (1), seroma (1), and marginal skin necrosis with an open wound (1). The latter problem occurred in the only patient who was treated with a revision procedure. Thus, the complication rate was 17 percent (5 of 29 patients). The marriage of aggressive superwet liposculpture of the entire abdomen with standard open surgical techniques used to treat skin excesses and allow abdominal muscle plication where necessary offers the advantage of reduced surgery when compared with full abdominoplasty, while consistently achieving significant contour improvement. This concept is applicable to the majority of patients presenting for the treatment of abdominal deformities and has markedly expanded the application of the mini-abdominoplasty concept.     

Nylon versus polydioxanone in the correction of rectus diastasis

Nylon and polydioxanone are two sutures commonly used to correct rectus diastasis. Polydioxanone, as an absorbable suture, has the advantage of not being palpable in thin patients. Because several forces act against the plication, an absorbable suture would not be efficient in these cases. In this study, two groups of 10 patients each were studied. These patients underwent abdominoplasty and correction of rectus diastasis. In the control group, 2-0 nylon was used to plicate the anterior aponeurosis and 0-polydioxanone was used in the experimental group. The tension of the abdominal wall was measured with a dynamometer in both groups. The width of rectus diastasis was measured 3 cm above and 2 cm below the umbilicus, using a computed tomography (CT) scan before the operation and 3 weeks and 6 months after surgery. The width of rectus diastasis was measured intraoperatively at the same levels. The data were analyzed by Student's t test.Both groups had similar abdominal wall tension on both levels. The diastasis recti was completely corrected at both levels, as confirmed by the 3-week postoperative CT scan and the 6-month CT scan. At the superior level, the width of the rectus diastasis on the preoperative CT scan (2.6 +/- 0.7 cm) was similar to the values obtained intraoperatively (2.7 +/- 0.6 cm), showing no significant statistical difference. At the inferior level, the largest difference between the preoperative CT scan and the intraoperative finding was 0.3 cm.In conclusion, the correction of rectus diastasis with 2-0 nylon and 0-polydioxanone was achieved and maintained after 6 months. CT scans are an accurate method for studying rectus diastasis and other muscles of the abdominal wall.     

An aesthetic classification of the abdomen based on the myoaponeurotic layer.

An objective classification for abdominoplasty based on myoaponeurotic deformities is described. Types A, B, C, and D correspond to different myoaponeurotic deformities. Patients with type A display rectus diastasis secondary to pregnancy, and plication of the anterior rectus sheath is indicated. Patients with type B present with laxity of the lateral and inferior areas of the abdominal wall after approximation of the anterior rectus sheaths. An L-shaped plication of the external oblique aponeurosis is performed in addition to the correction of rectus diastasis. Patients with type C are those whose rectus muscles are laterally inserted on the costal margins. Release and undermining of the rectus muscles from their posterior sheath and advancement of these muscles, attached to the anterior sheath, is the procedure of choice in these cases. Patients with type D display a poor waistline definition; external oblique muscle rotation associated with plication of the anterior rectus sheath is the procedure used to correct this deformity. Eighty-eight patients who underwent abdominoplasty were reviewed, and the incidence of each deformity was determined on this population. This study presents a practical classification that permits the plastic surgeon to critically evaluate which is the best option to correct abdominal deformities considering specific areas of myoaponeurotic weakness.     

Cotrel-dubousset instrumentation for the correction of adolescent idiopathic scoliosis. Long-term results with an unexpected high revision rate

ABSTRACT: BACKGROUND: For many years, the CD instrumentation has been regarded as the standard device for the surgical correction of adolescent idiopathic scoliosis (AIS). Nevertheless, scientific long-term results on this procedure are rare. Therefore, we conducted a retrospective follow-up study of patients treated for AIS with CD instrumentation and spondylodesis. METHODS: A total of 40 patients with AIS underwent CD instrumentation in our department within 3 years and between 1990 and 1992. For the retrospective analysis, first all the patient documents were reviewed, and pre-/postoperative X-ray images as well as those at the latest follow-up were analysed. Furthermore, it was attempted to conduct a clinical survey using the SRS-24 questionnaire, which was sent to the patients after a preceding announcement on the phone. RESULTS: Radiologically, the frontal main curvature was improved from a preoperative angle of 69.2degrees to a postoperative angle of 35.4degrees, and the secondary curvature was improved from a preoperative angle of 42.6degrees to a postoperative angle of 20.5degrees. The latest radiological followup at average 57.4 months post surgery showed an average loss of correction of 9.6degrees (main curvature) and 4.6degrees (secondary curvature), respectively.Within the first 30 days post surgery, 3 out of 40 patients (7.5%) received early operative revision for the dislocation of hooks or rods.At an average of 45.7 months (range 11 to 142 months), 19 out of 40 patients (47.5%; including 2 patients with early revision) received late operative revisions: The reasons were late infection (10 out of 40 patients; 25%) with the development of fistulae (7 cases) or putrid secretion (3 cases), which was resolved with the complete removal of instrumentation after all. The average time until revision was 35.5 months (range 14 to 56 months) after CD instrumentation. Furthermore, complete implant removal was necessary in 8 out of 40 patients (20%) for late operate site pain (LOSP). The average time until removal of instrumentation was 62.7 months (range 18 to 146 months) post surgery; and one patient received partial device removal for prominent instrumentation 11 months post surgery. Altogether, only 22 out of 40 CD instrumentations (55%) were still in situ. After an average period of 14.3 years post surgery, it was possible to follow-up 14 out of 40 patients (35%) using the SRS-24 questionnaire. The average score was 93 points, without showing significant differences between patients with or without their instrumentation in situ. CONCLUSIONS: Retrospectively, we documented for the first time a very high revisions rate in patients with AIS and treated by CD instrumentation. Nearly half of the instrumentation had to be removed due to late infection and LOSP. The reasons for the high rate of late infections with or without fistulae and for LOSP were analysed and discussed in detail.     

Breast reconstruction with abdominal flaps after abdominoplasties.

After the reported safe transverse rectus abdominis myocutaneous (TRAM) flap after liposuction of the abdomen, two cases of bipedicled reconstruction with this flap after abdominoplasty were successfully performed. This operation has not previously been considered possible because of the transection of the perforator arteries during the undermining of the abdomen. To examine the possible reperfusion of the perforator arteries, the authors studied the perforator arteries of 10 patients before they underwent abdominoplasty and at 1 week, 3 months, and 6 months after the operation. The arteries were studied with color-duplex scanning and power Doppler, using 10-MHz superficial probes, and their position was marked on a map. A cadaver study of a woman who had had an abdominoplasty 10 years before her death is also presented. In every patient, reperfusion of all perforator arteries was documented, starting from the control at 1 month. In no case was the caliber of the reperfused vessels more than 40 percent of the original diameter (maximum: 0.53 mm). This was also confirmed by the cadaver study. In conclusion, after an abdominoplasty operation, constant reperfusion of the perforator arteries of the rectus muscles occurs. However, the diameter of the arteries may not be enough to provide the necessary blood supply for a TRAM flap, which is therefore strongly discouraged by the authors after abdominoplasty in favor of a vertical rectus abdominis muscle (VRAM) flap. A liposuction, which does not necessarily disrupt the perforators, is not an absolute contraindication for a TRAM flap, provided that an accurate color-duplex scanning study is done.     

Aesthetic eyelid ptosis correction: a review of technique and cases

Upper eyelid ptosis can present both functional and aesthetic problems. Because proper correction of ptosis can be difficult to achieve, numerous surgical procedures have been developed. Plication of levator aponeurosis can be combined with aesthetic blepharoplasty and facial rejuvenation procedures to successfully address ptosis. The authors assessed the effectiveness of levator aponeurosis plication for correction of acquired upper eyelid ptosis in patients presenting for concomitant cosmetic facial procedures. The medical records of 74 consecutive patients (68 women and six men) who had upper eyelid ptosis correction in conjunction with cosmetic facial procedures from January of 1994 to January of 2000 were reviewed. During this period, 400 endoscopic forehead lifts and 479 face lifts were performed. The correction was performed through an external upper blepharoplasty approach removing an ellipse of skin and orbicularis muscle. Once the orbital septum was opened, a plication of the levator aponeurosis was accomplished by one or more horizontal mattress sutures of 6-0 clear nylon (with the first bite placed at or just medial to the vertical level of the pupil). The average follow-up period was 14 months. Long-term correction of the ptosis was excellent. The complications were minor, with the most common occurrence being asymmetry. Revisions were performed on only four patients. Correction of ptosis can be performed safely and effectively in conjunction with periorbital and facial rejuvenation. The technique described is simple, reliable, and reproducible.     

The external oblique flap for reconstruction of the rectus sheath.

Despite the availability of synthetic materials and distant fascial flaps, primary closure of ventral abdominal defects with contiguous tissues remains the preferred solution. Increased experience with such defects in the lower abdomen, particularly at the time of bilateral rectus muscle transposition, led in 1985 to the investigation of an external oblique abdominis flap for closure of the anterior rectus sheath. From October of 1985 to October of 1990, 33 patients underwent repair of bilateral lower rectus abdominis defects with the help of bilateral external oblique flaps. Each of the patients had undergone synchronous chest or breast reconstruction using a transverse rectus abdominis musculocutaneous flap including bilateral rectus muscle pedicles. Although all patients in this study had undergone double-pedicle rectus muscle procedures, not all patients having had double-pedicle rectus muscle procedures required this maneuver. External oblique flaps were performed at the time of rectus sheath repair only if fascia could not be approximated without tearing. After closure of the bilateral paramedian defect, synthetic mesh overlay was added only if the direct closure still appeared excessively tight. At the time of advancement of the external oblique muscle and fascia, the internal oblique abdominis muscle and lateral cutaneous nerve of the thigh were preserved. Of the 33 patients who underwent this procedure, 7 required the addition of mesh overlay. Thirty-two patients healed uneventfully with a remarkably solid ventral abdominal wall. One patient developed an early postoperative hernia subsequent to a major and prolonged abdominal-wall infection and abscess. Patient follow-up ranged from 1 to 36 months, with a mean of 12 months.(ABSTRACT TRUNCATED AT 250 WORDS)     

Donor site sequelae after autologous breast reconstruction with an extended latissimus dorsi flap

The indications for autologous reconstruction are increasing. The standard procedure is the transverse rectus abdominis muscle flap; however, this flap has contraindications and drawbacks. The latissimus dorsi muscle flap is simple and reliable. Hokin et al. demonstrated in 1983 that this flap can be extended and used for breast reconstruction without an implant. Since then, it has been widely studied in this setting and is known to provide good aesthetic results. Dorsal sequelae, conversely, were not appraised. The aim of this study was to assess objective and subjective dorsal sequelae after the harvest of an extended flap. Forty-three consecutive patients who had had breast reconstruction with an autologous latissimus dorsi flap were assessed by a surgeon and a physiotherapist for muscular strength and shoulder mobility. Patient opinion was studied through a questionnaire. Mean delay between the operation and the evaluation was 19 months. Early complications, mainly dorsal seromas, were frequent after the harvest of an extended flap (72 percent). There was no late morbidity and, especially, no flap loss or partial necrosis. As for functional results, 37 percent of the patients had complete adjustment and 70 to 87 percent demonstrated no change in shoulder strength. Sixty percent of the patients experienced no limitation in everyday life, and 90 percent said they would undergo this procedure again. The authors show that dorsal sequelae after an extended latissimus dorsi flap are minimal and that this technique compares favorably with the transverse rectus abdominis muscle flap.     

Medial epicanthoplasty combined with plication of the medial canthal tendon in Asian eyelids

The authors present a new technique for the correction of the medial epicanthal fold using the Y-W-plasty or inverted Y-V-plasty combined with plication of the medial canthal tendon. From January of 1996 to April of 2001, 10 patients with epicanthal folds received a medial epicanthoplasty combined with plication of the medial canthal tendon. The patients ranged in age from 20 to 49 years (average, 27.3 years). Eight patients with epicanthal folds received the Y-W-plasty with plication of the medial canthal tendon. Two patients were operated by inverted Y-V-plasty. The follow-up period ranged from 5 months to 2 years. Neither injury of the lacrimal apparatus nor asymmetry of the eyes was noted. Fibrosis and redness of the operated scar was noted in the first 2 to 3 months. However, the scar maturated by 3 months in all patients, and the hypertrophic scar was unnoticeable in all patients. Two key modifications of this technique are plication of the outer leaflet of the medial canthal ligament and lateral advancement of the central triangular flap. These modifications remarkably reduce the tension along the skin suture line. This method is very effective for the correction of the moderate-to-severe epicanthal fold. In addition, these modifications can be applied in most other medial epicanthoplasty techniques.     

Upper lip measurements at the time of surgery and follow-up after modified rotation-advancement flap repair in unilateral cleft lip patients

The purpose of this prospective study was to determine whether unilateral cleft lip repaired by the rotation-advancement flap will grow short on the repaired side. This study involved 56 patients with nonsyndromic unilateral cleft lip (31 with complete and 25 with incomplete cleft lip) who underwent a rotation-advancement flap repair by a single surgeon between 1989 and 1997. Eleven patients were lost to follow-up. Forty-five patients have been followed for a varying period of between 8 and 84 months (mean = 37 months). The upper lip was measured immediately after the lip repair and follow-up using calipers. The growth ratios of vertical, horizontal, and nostril sill dimensions were compared between the cleft side and the noncleft side of the same face. Statistical analysis was performed to compare the growths between the cleft and noncleft sides. There was not a significant difference in the growth ratios of vertical (Wilcoxon signed rank test, p = 0.85) and horizontal dimensions (Student's t test, p = 0.18) between the cleft and noncleft sides. There was, however, a statistically significant difference in the growth ratios of nostril sill width between the cleft and noncleft sides (Student's t test, p = 0.02). Our findings indicated that a repaired unilateral cleft retained the vertical and horizontal dimensions determined at the time of the initial repair.     

Management of secondary soft-tissue deficits following microsurgical head and neck reconstruction by means of another free flap

Secondary soft-tissue deficits may develop following a microsurgical reconstruction in the head and neck region because of inadequate planning or chronic effects of radiotherapy. Although most cases could be managed with alternative methods, free flaps might be necessary in difficult cases. Herein are described 11 cases of microsurgical head and neck reconstruction in which secondary soft-tissue deficits required transfer of another soft-tissue free flap. All patients had malignant tumors treated with surgical resection, and their defects were reconstructed with free flaps. Seven patients received either preoperative or postoperative adjunctive radiotherapy. These patients gradually developed signs and symptoms of soft-tissue deficiency in the reconstructed area, and a soft-tissue free flap transfer was required for treatment within an average of 21.5 months of their initial reconstruction. Five rectus abdominis, one rectus femoris, one latissimus dorsi, one tensor fasciae latae myocutaneous, one radial forearm, one medial arm, and one dorsalis pedis flap were used for this purpose. All flaps survived completely. The average follow-up time was 32 months. Significant improvement was achieved in all cases, and no further major surgical procedures were required. Secondary soft-tissue deficits that could not be predicted or prevented during the initial microsurgical reconstruction may be treated successfully by a subsequent free soft-tissue transfer in selected cases.     

Muscle Union Procedure in Patients with Paralytic Strabismus

To present the surgical outcomes of a muscle union procedure in patients with paralytic strabismus, this retrospective study included 27 patients with paralytic strabismus who underwent a muscle union procedure. In this procedure, the two vertical rectus muscles are united with the paralytic horizontal muscle without splitting the muscles. Postoperative ocular deviations, complications, surgical success rates, and reoperation rates were obtained by examining the medical records of the patients. Seventeen patients had a sixth cranial nerve palsy, seven patients had a third cranial nerve palsy, and three patients had a medial rectus muscle palsy after endoscopic sinus surgery. The mean preoperative angle of horizontal deviation in the primary position was 56 ± 21 prism diopters. The mean follow-up period was 12 ± 9 months. The mean final postoperative ocular deviation was 8 ± 13 prism diopters. The success rate was 74%, and the reoperation rate was 0%. No significant complications, including anterior ischemia, occurred in any of the patients. One patient exhibited an increase in intraocular pressure in the immediate postoperative period, but this resolved spontaneously within 1 week. Our muscle union procedure was effective in patients with paralytic strabismus, especially in patients with a large angle of deviation. This muscle union procedure is potentially a suitable option for muscle transposition in patients with paralytic strabismus who have large-angle deviation or a significant residual angle after conventional surgery.     

Quality of life changes after inguinal hernia repair using anterior rectus sheath--a preliminary study

Chronic pain is the most serious long-term complication after groin hernia repair. The aim of this preliminary research was to assess the quality of life before and after standard tension-free mesh repair and new method of tension-free inguinal hernia repair using anterior rectus sheath. Total of 62 patients were evaluated. Anterior rectus sheath method was performed in 29 patients and in 33 patients standard mesh repair was used (Lichtenstein repair). Quality of life was assessed before and after the surgery using short-form SF-36 questionnaire (QualityMetric Inc.), adjusted for Croatian language. There were statistically significant improvements in bodily pain and general health scores in both groups. Patients operated using mesh technique also demonstrated statistically significant improvements in social functioning and emotional role. Similarly, patients in whom inguinal hernia was repaired using anterior rectus sheath had significantly better postoperative scores for physical functioning and role physical scores. Quality of life assessment demonstrated good ability to differentiate between several independent aspects of quality of life. Anterior rectus sheath repair significantly improved quality of life and was shown to be similar to mesh repair in the aspect of physical functioning.     

Surgical Responses of Medial Rectus Muscle Recession in Thyroid Eye Disease-Related Esotropia

We evaluate the surgical outcomes and surgical responses of medial rectus muscle (MR) recession patients with thyroid eye disease (TED)-related esotropia (ET). The surgical dose-response curves 1 week postoperatively and at the final visit were analyzed. Univariable and multivariable linear regression analyses were applied to investigate factors influencing surgical dose-response. A total of 43 patients with TED-related ET that underwent MR recession were included. The final success rate was 86.0% and the rate of undercorrection was 14.0%. The surgical dose-response curves of TED-related ET showed a gentle slope compared with those of standard surgical tables. In the univariable model, simultaneous vertical rectus muscle recession was the only significant factor influencing surgical dose-response of MR recession in TED-related ET (β = -0.397, P = 0.044). In a model adjusted for age, sex, type of surgery, and preoperative horizontal angle of deviation, simultaneous vertical rectus muscle recession showed marginal significance (β = -0.389, P = 0.064). The surgical dose-response curve of TED-related ET was unique. Simultaneous vertical rectus muscle recession was associated with increased surgical dose-response in TED-related ET.     

Soft-tissue flap coverage maximizes limb salvage after allograft bone extremity reconstruction

Limb salvage after extremity tumor ablation may include the use of allograft bone. The primary complication of this method is infection of the allograft, which can lead to limb loss in up to 50 percent of cases. The purpose of this study is to evaluate the efficacy of primary muscle flap coverage in the setting of allograft bone limb salvage surgery. This study is a prospective review of all patients with flap coverage of extremity allografts over the 10-year period 1991 to 2001. There were 20 patients (11 male and nine female patients) with an average age of 28 years (range, 6 to 72 years). Flap coverage was primary in 16 patients and delayed in four. Delayed coverage was performed for failed wounds that did not have a primary soft-tissue flap. Pathologic findings included osteosarcoma in nine patients, Ewing sarcoma in five patients, malignant fibrohistiocytoma in two patients, chondrosarcoma in two patients, synovial sarcoma in one patient, and leiomyosarcoma in one patient. Allograft reconstruction was performed for the upper extremity in 12 patients and for the lower extremity in eight patients. Flap reconstruction was accomplished with 20 pedicle flaps in 17 patients (latissimus dorsi, 12; gastrocnemius, four; soleus, three; and fasciocutaneous flap, one) and four free flaps (rectus abdominis, three; latissimus dorsi, one) in four patients. All pedicled flaps survived. There was one flap failure in the entire series, which was a free rectus abdominis flap. This case resulted in the only limb loss noted. The follow-up period ranged from 1 to 50 months (average, 12.35 months). At the time of final follow-up, three patients were dead of disease and 17 were alive with intact extremities. The overall limb salvage rate in the setting of bone allograft and soft-tissue flap coverage was 95 percent (19 of 20). Reoperation for bone-related complications was required in 50 percent (two of four) of cases receiving delayed flap coverage compared with 19 percent (three of 16) of patients with primary flap coverage (statistically not significant). The results of this study support the use of soft-tissue flap coverage for allograft limb reconstruction. In this series, no limb was lost in the setting of a viable flap. Reoperation was markedly reduced in the setting of primary flap coverage. Pedicled or microvascular transfer of well-vascularized muscle can be used to wrap the allograft and minimize devastating wound complications potentially leading to loss of allograft and limb.