The new reconstruction technique in the treatment of the skin cancers located on the eyelid: Posterior temporalis fascia composite graft

BACKGROUND: Difficulty of reconstruction of the eyelids arises from the need to reconstruct different supporting and covering structures in a single operation. Defects in the anterior lamella of the eyelids can be readily repaired with skin grafts or flaps but posterior lamellar reconstruction needs more complex applications. METHODS: We performed posterior lamellar eyelid reconstruction with posterior parts of the temporalis fascia, since their anatomical and histological features are very similar to the defects. Nine patients with skin tumors located on the periorbital region were treated with local skin flaps and deep layer of the temporalis fascia. RESULTS: Grafts were harvested very easily. There was no complication related with graft or donor site. Biopsy was performed in three cases and normal conjunctival elements were seen. Functional and acceptable aesthetically results were achieved in all patients. CONCLUSION: Ideal reconstructive material for replacement of the posterior lamina is still lacking. Tarsal reconstruction can be made with deep temporalis fascia with success since the thickness of the both tissues are very similar and also since the loose areolar layer of the temporalis fascia is very thin and highly vascularized, this layer can be used in reconstruction of the conjunctiva. According to our knowledge this is the first report of using of the posterior part of temporalis fascia as a composite graft in the literature.     

Palatal distraction in a canine cleft palate model

The purpose of this study was to determine whether the canine hard palate can be lengthened by distraction osteogenesis in a cleft palate model using a mostly submucosal distractor. Five mongrel dogs were used. After raising mucoperiosteal flaps, a midline strip of bone was removed from the hard palate of each dog to simulate the bony defect seen in a cleft palate. A transverse osteotomy was then made to separate the posterior segment of the hard palate from the anterior segment. Posterior osteotomies were also made laterally parallel to the teeth so that the 2 posterior segments (one on either side of the bony cleft) were mobile. An intraoral distractor that was mostly submucosal was attached to the anterior hard palate and both segments of the mobilized posterior hard palate. Radiopaque bone markers were placed, and x-rays were obtained. After a 10-day latency period, the distractor was expanded 0.675 mm per day until it had been lengthened 10.125 mm. Distractors were left in place for an additional 8 weeks. After distractor removal, animals were observed for an additional 8 weeks before euthanization. Follow-up x-rays and histologic examinations were performed. New bone formation was found at the site of distraction in all dogs at the time of death. This new bone was seen on the follow-up x-rays and on histologic examination of the hard palates using both hematoxylin and eosin staining and Masson's trichrome stain. Distraction osteogenesis using a mostly submucosal device is an effective technique for lengthening the hard palate in a canine cleft palate model. The technique may eventually provide an alternative treatment for velopharyngeal incompetence in humans that is more precise and involves less morbidity than existing treatments.     

A classification system and reconstructive algorithm for acquired vaginal defects

Although multiple flaps have been used for vaginal reconstruction, a logical approach to reconstruction of these often complex defects has not been described. The objective of this study was to establish a classification system for acquired vaginal defects and to develop a reconstructive algorithm derived from this system. This study is a retrospective review of a 7-year experience with 51 flaps in 37 consecutive vaginal reconstructions. Twenty-two partial defects and 15 circumferential defects were reconstructed in 35 patients. Average patient age was 48 years (range, 19 to 69 years). Of the 22 patients with partial vaginal defects, six involved primarily the anterior and lateral wall and 16 the posterior vaginal wall. Among the 15 patients with circumferential defects, four included only the upper two-thirds of the vagina and 11 encompassed the entire vagina. On the basis of these defects, a classification system was developed. Partial defects involving the anterior or lateral vaginal wall were classified as type IA defects and were reconstructed primarily with pedicled Singapore fasciocutaneous flaps. Partial defects involving the posterior wall were classified as type IB and were reconstructed with pedicled rectus abdominis myocutaneous flaps. Circumferential defects involving the upper two-thirds of the vagina were classified as type IIA defects and were reconstructed with a rolled rectus flap or, less commonly, sigmoid colon (one patient). Total circumferential defects, type IIB, were reconstructed largely with bilateral gracilis flaps. Six patients had major complications, including one perioperative death, one complete flap loss, one partial flap loss, and three pelvic abscesses. Three patients had minor complications that included delayed wound healing and donor-site infection. Vaginal defects can be categorized into one of four types on the basis of the location and extent of resection. Flap selection is determined on the basis of the type of defect. Using this algorithm, immediate vaginal reconstruction with pedicled regional flaps can be performed with minimal patient morbidity and few surgical complications.     

New buccinator myomucosal island flap: anatomic study and clinical application

The authors studied the vascular anatomy of the buccinator muscle by dissecting fresh cadavers. The anatomy of the buccal branches of the facial artery consistently confirmed the existence of a posterior buccal branch, a few inferior buccal branches, and anterior buccal branches to the posterior, inferior, and anterior portions of the buccinator. The buccal artery and posterior buccal branch anastomose to each other and ramify over the muscle. Several veins originate from the lateral aspect of the muscle, converge into the buccal venous plexus, and drain into the facial vein (from two to four tributaries) or into the pterygoid plexus and the internal maxillary vein (from the buccal vein). These vessels and nerves enter the posterior half of the buccinator posterolaterally. The facial artery and vein are located at variable distances from each other around the oral commissure and the nasal base. Two patterns of buccinator musculomucosal island flaps supplied by these buccal arterial branches are proposed in this article. The buccal musculomucosal neurovascular island flap (posteriorly based), supplied by the buccal artery, its posterior buccal branch, and the long buccal nerve, can be passed through a tunnel under the pterygomandibular ligament for closure of mucosal defects in the palate, pharyngeal sites, the alveolus, and the floor of the mouth. The buccal musculomucosal reversed-flow arterial island flap (superiorly based), supplied by the distal portion of the facial artery through the anterior buccal branches, can be used to close mucosal defects in the anterior hard palate, alveolus, maxillary antrum, nasal floor and septum, lip, and orbit. The authors have used the flaps in 12 patients. There has been no flap necrosis, and results have been satisfactory, both aesthetically and functionally.     

Clinical applications of the posterior rectus sheath-peritoneal free flap

Soft-tissue injuries involving the dorsum of the hand and foot continue to pose complex reconstructive challenges in terms of function and contour. Requirements for coverage include thin, vascularized tissue that supports skin grafts and at the same time provides a gliding surface for tendon excursion. This article reports the authors' clinical experience with the free posterior rectus sheath-peritoneal flap foil dorsal coverage in three patients. Two patients required dorsal hand coverage; one following acute trauma and another for delayed reconstruction 1 year after near hand replantation. A third patient required dorsal foot coverage for exposed tendons resulting from skin loss secondary to vasculitis. In all three patients, the flap was harvested through a paramedian incision at the lateral border of the anterior rectus sheath. After opening the anterior rectus sheath, the rectus muscle was elevated off of the posterior rectus sheath and peritoneum. When elevating the muscle, the attachments of the inferior epigastric vessels to the posterior rectus sheath and peritoneum were preserved while ligating any branches of these vessels to the muscle. Segmental intercostal innervation to the muscle was preserved. The deep inferior epigastric vessels were then dissected to their origin to maximize pedicle length and diameter. The maximum dimension of the flaps harvested for the selected cases was 16 X 8 cm. The anterior rectus sheath was closed primarily with non-absorbable suture. Mean follow-up was 1 year, and all flaps survived with excellent contour and good function in all three patients. Complications included a postoperative ileus in one patient, which resolved after 5 days with nasogastric tube decompression.     

Selection of the recipient vessel in the free flap around the knee: the superior medial genicular vessels and the descending genicular vessels

In reconstructions around the knee, the use of a free flap is indicated in a limited number of cases, but it plays a critical role in cases of extensive defects or unavailability of local flaps. The selection of the recipient vessel is an essential and challenging step for a successful free tissue transfer. Popliteal vessels and other small vessels around the knee have been reported to be used as recipient vessels, but the choice of recipient vessels around the knee has not been established. In this study, after a thorough investigation of the vascular anatomy at the knee region, the superior medial genicular vessels and the descending genicular vessels were considered to be the proper recipient vessels, and a clinical application was tried. From July of 1997 to July of 1999, a total of seven cases of soft-tissue defects around the knee-four cases in the posterior region and three cases in the anterior region-were reconstructed with free flaps, using the superior medial genicular vessels and the descending genicular vessels, respectively. All flaps survived completely, with no flap loss. The advantages of these vessels are their proximity to the knee and their reliability, versatility, simplicity, and size match. The outstanding characteristic of this combination of vessels is their versatility, because the combination can cover all defects around the knee. The clinical application and the versatility of the combination of the superior medial genicular vessels and the descending genicular vessels as the recipient vessels was confirmed for the reconstruction of posterior and anterior knee defects.     

The free thoracoumbilical flap for resurfacing large soft-tissue defects of the lower extremity

Both cadavers and living patients were studied regarding a method to resolve large skin defects with bone exposure in the leg, with long-distance thrombosis of the anterior tibial vessels or posterior tibial vessels resulting from traumatic lesions. Forty-six casting mold specimens of cadaveric legs were investigated. There were rich communication branches among the anterior tibial artery, posterior tibial artery, and fibular artery in the foot and ankle, which complemented each other well. Twenty-six patients with large skin defects with bone exposure in the proximal or middle segment of the leg were admitted to the authors' hospital. Among those patients, 19 demonstrated long-distance thrombosis of the anterior tibial vessels or posterior tibial vessels resulting from traumatic lesions. During treatment, a thoracoumbilical flap based on the inferior epigastric vessels was anastomosed to the distal stump of the anterior tibial vessels or the posterior tibial vessels, with reversed flow. All defects were successfully repaired, with good color and texture matches of the flaps. This method can be used for patients with normal anterior tibial vessels or posterior tibial vessels, normal distal stumps of the injured blood vessels, and good reversed flow. The method has the advantages of dissecting blood vessels in the recipient area during the débridement, not affecting the blood circulation of the injured leg, not sacrificing blood vessels of the opposite leg, and not fixing the patient in a forced posture. The muscles are less bulky in the distal one-third of the leg, and the blood vessels are shallow and can be dissected and anastomosed easily. When the flap is used for reconstruction in the proximal two-thirds of the leg, the blood vessel pedicle of the free flap is at a straight angle, without kinking.     

The effects of flexion and rotation on the length patterns of the ligaments of the knee

Measurements have been made of the lengths of the ligaments in human knee joint specimens. The ligaments considered were the lateral collateral, medial collateral, anterior cruciate and posterior cruciate. The ligament length patterns were determined for twelve specimens at flexions of 0, 30, 60, 90 and 120°, in neutral, internal rotation and external rotation at each angle. The collateral ligaments steadily diminished by about 20 per cent in length from 0 to 120° flexion, rotation having little effect. The anterior cruciate gradually increased 10 per cent from 0 to 120° flexion and the posterior cruciate, was 10 per cent longer at 0° flexion than at all other angles for which length was constant. The action of the cruciates was therefore somewhat reciprocal. Rotation had a significant effect on cruciate lengths, affecting the anterior more than the posterior cruciate. Computations were made of the change in length of the anterior and posterior fibres of each cruciate ligament, in relation to the central fibres. Reciprocal functions between fibres were demonstrated.     

A new extended external oblique musculocutaneous flap for reconstruction of large chest-wall defects

A new extended external oblique musculocutaneous flap utilized in the reconstruction of chest-wall defects is described. The flap is drawn as a V-Y rotation flap on the ipsilateral abdominal wall. It is laterally based, and its pedicle coincides with the five lowest costal insertions of the external oblique. The flap extends above the transiliac line, from the posterior axillary line to the linea alba, and includes the dynamic territory of the external oblique muscle. Vascular supply is provided by the musculocutaneous perforating arteries of the intercostal vessels and their subcutaneous branches. The flap is raised medially and includes the anterior sheath of the rectus. Undermining continues between the external and the internal oblique muscles as far as the posterior axillary line. The donor site on the abdominal wall is reinforced by the plication of the internal oblique sheath. This flap was used in 13 patients with major anterior chest-wall excisional defects. The mean chest-wall defect was about 390 cm2. Marginal necrosis with distal skin loss was observed in one patient. All other flaps healed without complications. The extended external oblique musculocutaneous flap differs from other external oblique flaps already described in several aspects that allow it to obtain better functional and aesthetic results.     

The mechanisms of the influence of the anterior and posterior hypothalamus on the electrical activity of the large hemispheres of the forebrain and on autonomic reactions in hens

Studies have been made of the effect of stimulation of the anterior and posterior hypothalamus on the electrical activity of the hemispheres, arterial blood pressure, heart and respiration rates. Mainly desynchronizing mechanisms were revealed in the ascending influences from both the anterior and posterior hypothalamus. Concerning the descending influences, it was found that stimulation of the anterior hypothalamus evokes depressor reactions, whereas stimulation of the posterior hypothalamus results in pressor reactions. Peculiarities of evolutionary development of the ascending and descending mechanisms of the posterior and anterior hypothalamus are discussed.     

Sex differences in dog corpus callosum.

Human studies reported sex differences in size and shape of the corpus callosum. These observations have been contested. The purpose of the present study is to investigate possible sex differences in the corpus callosum of dogs. The entire brains including the medulla from 12 female and 9 male adult mongrel dogs were removed and weighed. Total and partial area measurements of the callosum were made from photographic tracings of its outline. The callosum was partitioned into 3 regions; anterior half, posterior half, posterior one-fifth. The total corpus callosum, anterior half, posterior half, and posterior fifth or splenium areas were measured. Sex differences were found. The anterior half, the posterior half, the posterior fifth, and the total callosum were significantly greater in absolute area in males than in females.     

Differences in the sensory support of the anterior and posterior sections of the limbic cortex of the rat

Using retrograde axonal transport of horseradish peroxidase, studies have been made on the thalamic projections in the anterior and posterior parts of the limbic cortex with special reference to exterosensory system projections (visual, auditory and somatic). Projections of the retinorecipient nuclei of the anterior hypothalamus and classic thalamic visual relays (n. geniculatus lateralis dorsalis, n. lateralis posterior, pretectum) were found in the anterior and posterior limbic cortex. There are also inputs from the thalamic relays of the auditory (n. geniculatus medialis) and somatic (n. ventralis posterior) systems in the posterior limbic cortex The data obtained indicate: 1) that sensory supply of the limbic cortex in rats may be realized via direct pathways from sensory thalamic relays; 2) that thalamic sensory supply of the anterior limbic cortex differs from that of the posterior one. In the former, projections of the thalamic relays of the visual, auditory and somatic systems were found, whereas in the posterior cortex only visual system is presented. Topographic organization of the thalamic nuclear areas sending afferents to the anterior limbic cortex differs from that of the posterior limbic cortex.     

Reverse-flow island flap: clinical report and venous drainage

Twenty-two reverse-flow island flaps were transferred. These included peroneal, forearm, anterior tibial, and temporal flaps. Sixteen of 22 flaps survived completely. We encountered partial necrosis in 4 flaps and total necrosis in only 2 flaps. We credit this success to the reliability and availability of the peroneal, forearm, and temporal flaps; but we do not encourage use of the anterior tibial flap. The flaps that survived well did not show any signs of venous congestion. The advantage of the reverse-flow island flap is that it can be transferred from a proximal to a distal location. Using cadavers and fresh amputated limbs, studies on venous drainage of the reverse-flow island flap were performed. The venae comitantes had numerous venous valves and communicating branches, but more than sufficient reflux of the venous blood occurred through the valves at pressures of 90 to 105 cmH2O. We believe that the venous drainage of the reverse-flow island flap occurs as a result of reflux actions at the valve, communicating branches between the venae comitantes, and bypass vessels around the valves.     

Leg length preservation with pedicled fillet of foot flaps after traumatic amputations

Six patients with insufficient soft-tissue coverage after lower limb trauma were treated with pedicled fillet of foot flaps to achieve primary stump closure and to preserve leg length. The flaps used were all based on either the posterior tibial neurovascular pedicle, the anterior tibial neurovascular pedicle, or both. Five flaps survived; one patient required conversion of a through-knee to an above-knee amputation and debridement of the flap because of venous thrombosis of the pedicle. In three of the cases, a functional knee joint was preserved. The patients ranged in age from 21 to 54 years, the mean hospital stay was 55.5 days (range, 28 to 76 days), and the mean follow-up time was 14.5 months. Despite an average of 4.3 procedures from initial admission to first discharge and an average of 2.0 postamputation procedures to achieve primary stump healing, all patients have achieved independent mobility with their prosthesis. The advantages of preserving leg length and, where possible, preserving a functional knee joint compensate for repeated procedures on these patients. When planned well, a pedicled fillet of foot flap therefore achieves the aims of amputation, namely, providing primary healing of a sensate, durable, cylindrical stump that is pain-free and preserves maximal leg length. This is achieved with no donor-site morbidity and with no need for microvascular reconstruction.     

Restoration of the anterior neck surface in the burned patient by free groin flap

In treating extensive burn contractures of the anterior neck, we obtained good results using free flaps. Ninety-nine patients with neck contractures were treated with free flaps. The ages of the patients range from 2 to 64 years. We used 84 free groin flaps, 10 free latissimus dorsi musculocutaneous flaps, 2 free deltopectoral flaps, 2 free scapular flaps, and 1 free anterolateral thigh flap. In all patients, contractures were sufficiently released and no recurrences followed after a mean follow-up of 8.7 years. After defatting procedures, natural profiles and good appearances were restored, especially in patients in whom groin flaps were used.     

An analysis of the hypothalamic mechanisms regulating cold hypobiosis in the frog Rana temporaria]

Experiments were made on intact frogs and after removal the anterior or the posterior hypothalamus. Data of spectral analysis of the EEG as well as quantitative evaluation of activation phenomena occurring spontaneously during hypobiosis are presented. Removal of the anterior hypothalamus did not affect the EEG parameters investigated, whereas lesion of the posterior hypothalamus significantly decreased cold-resistance capacities in frogs.     

Pulmonary perfusion in the prone and supine postures in the normal human lung.

Prone posture increases cardiac output and improves pulmonary gas exchange. We hypothesized that, in the supine posture, greater compression of dependent lung limits regional blood flow. To test this, MRI-based measures of regional lung density, MRI arterial spin labeling quantification of pulmonary perfusion, and density-normalized perfusion were made in six healthy subjects. Measurements were made in both the prone and supine posture at functional residual capacity. Data were acquired in three nonoverlapping 15-mm sagittal slices covering most of the right lung: central, middle, and lateral, which were further divided into vertical zones: anterior, intermediate, and posterior. The density of the entire lung was not different between prone and supine, but the increase in lung density in the anterior lung with prone posture was less than the decrease in the posterior lung (change: +0.07 g/cm(3) anterior, -0.11 posterior; P < 0.0001), indicating greater compression of dependent lung in supine posture, principally in the central lung slice (P < 0.0001). Overall, density-normalized perfusion was significantly greater in prone posture (7.9 +/- 3.6 ml.min(-1).g(-1) prone, 5.1 +/- 1.8 supine, a 55% increase; P < 0.05) and showed the largest increase in the posterior lung as it became nondependent (change: +71% posterior, +58% intermediate, +31% anterior; P = 0.08), most marked in the central lung slice (P < 0.05). These data indicate that central posterior portions of the lung are more compressed in the supine posture, likely by the heart and adjacent structures, than are central anterior portions in the prone and that this limits regional perfusion in the supine posture.     

Use of the AO plate for immediate mandibular reconstruction in cancer patients

Free vascularized bone grafts have revolutionized mandibular reconstruction, yet their use in all mandibulectomy patients is not always necessary. A recently developed alternative to bony reconstruction has been the use of the AO reconstruction plate. We compared the use of the AO reconstruction plate with immediate free bone graft mandibular reconstruction in 31 patients. Reconstruction plates were used in 20 and immediate free bone grafts were used in 11 patients. The overall success rate for use of the plate was 15 of 20 (75 percent). There were 6 anterior reconstructions, of which only 2 (33 percent) were successful. This is opposed to 13 of 14 (93 percent) lateral reconstructions that were successful in lateral plate placements. There were 11 immediate composite free flaps: 4 iliac crest, 4 scapula, 2 fibula, and 1 composite radial forearm flaps. Six repairs were for anterior defects, and there were 5 full-thickness defects, 3 of which were in the anterior position. All 11 flaps were successful. In conclusion, we believe the reconstruction plates are a useful adjunct for mandibular replacement in the head and neck cancer patient but should be reserved for lateral defects. For anterior reconstructions, even in patients with locally advanced disease, free-tissue transfer of composite osteocutaneous flaps is the reconstructive method of choice.     

The tumbling concha-cartilage flap for correction of lop ear

This article presents a new surgical method that uses tumbling concha-cartilage flaps to correct lop ears. Through a posterior or anterior auricular skin incision, a rectangular or T-shaped cartilage flap is elevated from the concha and tumbled backward. After passing under the postauricular skin, the flap's tip is fixed to the lidded helix or scapha. The recoiling force of the flap's conchal side enables the lidded portion to be in a normal, erect, anatomic position. The method also increases the vertical height of the ear and creates a normally shaped scapha. Sixteen lop ears were corrected using this procedure, with most of them maintaining natural auricular features. Therefore, this method was considered effective for the correction of moderate lop ear deformity.