One-stage reconstruction for defects of the mouth using a sternomastoid myocutaneous flap.

The sternomastoid muscle has 3 blood supplies: the occipital artery superiorly, the superior thyroid artery in the middle, and the thyrocervical trunk below. We report the use of a myocutaneous flap consisting of a "paddle" of skin on the end of a pedicle of sternomastoid muscle--with the latter based either on its superior or inferior blood supply. Fourteen such flaps have been used successfully in 13 consecutive patients for one-stage reconstructions of defects of the oral cavity and oropharynx. Although there was partial epithelial loss of the skin "paddle" in 7 cases, in each case the surviving dermis became resurfaced with epithelium.     

One-stage reconstruction of the postburn nailfold contracture

Dorsal digital burn contractures cause unsightly eponychial retraction and proximal nail exposure. These areas are subject to breakdown with minor trauma. These deformities are often ignored as trivial. Many surgeons are unaware that simple reconstruction is possible. Correction is a worthwhile undertaking. This report illustrates a new modification: one-stage reconstruction with bilateral proximally based flaps, dorsally transposed and interdigitated. Donor sites are closed primarily. This technique has been successfully applied to 14 affected fingertips in 4 patients with no complications and no revisions. Patients have been gratified by the resultant restoration of the nailfold. Contractures have not recurred.     

A new surgical technique for phalloplasty in patients with exstrophy of the bladder

Posterior pelvic osteotomy has not been a satisfactory operation to provide penile length in the repair of defects associated with bladder exstrophy. The authors are proposing a new technique based on the movement of the halves of the symphysis and pubic rami (en bloc with the attached corpora cavernosa) to the midline. This is accomplished by osteotomies of the superior and inferior rami and bone grafting of the resulting defects in the superior rami only. The hip joints are not disturbed, risk of complications appears to be reduced, and increased effective penile length is obtained. Cadaver dissections confirmed the practicality of this operation and a successful case is reported. The anatomy and physiology of penile function that is important to surgeons is reviewed.     

One-stage reconstruction of a large upper lid defect in a newborn

Full-thickness defects of the upper eyelids require immediate reconstruction to ensure protection of the cornea. A technique is described for a one-stage reconstruction of a large congenital defect of upper eyelid in a newborn. The reconstruction was composed of a mucosa-lined transpositional musculocutaneous flap. The advantages of this method over previous methods are discussed.     

One-stage reconstruction of composite bone and soft-tissue defects in traumatic lower extremities

Management of bone loss that occurs after severe trauma of open lower extremity fractures continues to challenge reconstructive surgeons. Sixty-one patients who had 62 traumatic open lower extremity fractures and combined bone and composite soft-tissue defects were treated with the following protocol: extensive debridement of necrotic tissues, eradication of infection, and vascularization of osteocutaneous tissue for one-stage bone and soft-tissue coverage reconstruction. The mechanism of injury included 49 motorcycle accidents (80.3 percent), five falls (8.2 percent), three crush injuries (4.9 percent), two pedestrian-automobile accidents (3.3 percent), and two motor vehicle accidents (3.3 percent). The bone defects were located in the tibia in 49 patients (79 percent; one patient had bilateral open tibial fractures), in the femur in seven patients (11.3 percent), in the calcaneus bone in four patients (6.5 percent), and in the metatarsal bones in two patients (3.2 percent). The size of soft-tissue defects ranged from 5 x 9 cm to 30 x 17 cm. The average length of the preoperative bony defect was 11.7 cm. The average duration from injury to one-stage reconstruction was 27.1 days, and the average number of previous extensive debridement procedures was 3.4. Fifty patients had vascularized fibula osteoseptocutaneous flaps, six had vascularized iliac osteocutaneous flaps, and five patients had seven combined vascularized rib transfers with serratus anterior muscle and/or latissimus dorsi muscle transfers. One patient received a second combined rib flap because the first combined rib flap failed. The rate of complete flap survival was 88.9 percent (56 of 63 flaps). Two combined vascularized rib transfers with serratus anterior muscle and latissimus dorsi muscle flaps were lost totally (3.2 percent) because of arterial thrombosis and deep infection, respectively. Partial skin flap losses were encountered in the five fibula osteoseptocutaneous flaps (7.9 percent). Postoperative infection for this one-stage reconstruction was 7.9 percent. Excluding the failed flap and the infected/amputated limb, the primary bony union rate after successful free vascularized bone grafting was 88.5 percent (54 of 61 transfers). The average primary union time was 6.9 months. The overall union rate was 96.7 percent (59 of 61 transfers). The average time to overall union was 8.5 months after surgery. Seven transferred vascularized bones had stress fractures, for a rate of 11.5 percent. Donor-site problems were noted in six fibular flaps, in two iliac flaps, and in one rib flap. The fibular donor-site problems were foot drop in one patient, superficial peroneal nerve palsy in one patient, contracture of the flexor hallucis longus muscle in two patients, and skin necrosis after split-thickness skin grafting in two patients. The iliac flap donor-site problems were temporary flank pain in one patient and lateral thigh numbness in the other. One rib flap transfer patient had pleural fibrosis. Transfer of the appropriate combination of vascularized bone and soft-tissue flap with a one-stage procedure provides complex lower extremity defects with successful functional results that are almost equal to the previously reported microsurgical staged procedures and conventional techniques.