Placement Of Flaps Research Articles

REPAIR OF ARTICULAR CARTILAGE DEFECTS WITH OSTEOGENIC PROTEIN-1 (BMP-7) IN DOGS

Articular cartilage injury has a poor prognosis for repair. Mesenchymal cells, when exposed to osteogenic proteins and other cytokines, can differentiate into cells that behave phenotypically as chondrocytes. In this study, we examined the ability of recombinant human osteogenic protein-1 (rhOP-1 or rhBMP-7) to elicit the repair of osteochondral defects in dogs. Bilateral osteochondral defects that were 5 mm in diameter by 6 mm deep were surgically created in the medial femoral condyles of sixty-five adult dogs. rhOP-1-treated (100 mg of a 3.5-mg rhOP-1/g bovine bone-derived Type-I collagen device) and control defects (untreated or treated with 100 mg bovine bone-derived collagen implants) were evaluated grossly and histologically at six, twelve, sixteen, twenty-six, and fifty-two weeks postoperatively. The influence of protected initial weight-bearing and surgical placement of periosteal flaps was also evaluated. Gross and histologic grading of the defect repair indicated improvement in the rhOP-1-treated defects compared with that in the controls. Grossly, the repair tissue in the rhOP-1-treated defects was continuous with the adjacent intact cartilage and appeared translucent. By comparison, the repair tissue in the control defects was discontinuous and opaque or inhomogeneous in nature. Histologically, maturing cartilage similar in appearance to the intact articular cartilage was present in the rhOP-1-treated defects. Cartilage at the defect interface was minimally degraded. The control defects were filled primarily with fibrous tissue and fibrocartilage. Significant differences based upon treatment type were observed at twelve weeks, sixteen weeks, and for all time-periods combined (p = 0.0385, p = 0.0070, and p = 0.0026, respectively). rhOP-1 (rhBMP-7) induced hyaline cartilage-like repair of full-thickness osteochondral defects in a dog model. Differences in cartilage repair were maintained at fifty-two weeks postoperatively with no significant degradation of the rhOP-1-induced repair tissue.

Radio Frequency Fistulotomy: An Effective Modification Of The Conventional Technique

Background: The techniques in vogue for treating fistula are fistulectomy, fistulotomy, curettage of fistula, and placement of flaps of mucosa or skin, placement of medicated Setons, insertion of antibiotic beads, and injection of commercial or autologous fibrin glue. Of all these procedures, majority of the surgeons continue to prefer the classical technique [fistulotomy] as the procedure of choice in 90% of anal fistulae. Materials & Methods: In this retrospective study, the conventional lay open technique, or has been performed by employing the radio frequency surgical device as an alternative to the traditional knife and scissors. In a span of 18 months starting from July 1999 to December 2000, 210 cases of fistula in ano of low variety were operated exclusively applying the radio frequency device. Observations: A follow up of the operated patients with radio frequency surgery over a period of 15 months, i.e. from December 2000 to March 2002 could be summarized as below. A] Average time taken by the patient to resume routine 7 days. B] None of the patient had any interference with anal continence. C] The wounds were found healed within an average time of 47 days. D] Delayed wound healing was noticed only in 7 patients. E] Recurrence/ failure rate was as low as 1.5 percent. Conclusion: This technique has been found superior to the conventional fistulotomy in the sense that the time taken for the whole procedure was reduced to almost half, amount of bleeding was minimum, the post operative pain was less compared to conventional method and return to work was much quicker.

Treatment of the Aging Face Using the “Round-lifting” Technique

Background: Characteristics of the aging face include not only senescence and flaccidity of the skin, but also sagging of deeper tissues, especially in the fascial and fatty layers. Objective: This study was undertaken to evaluate the different surgical approaches to the aging face, specifically the techniques available for correction of the prominent nasolabial fold, which is a significant sign of facial aging. Methods: Through a total of 7446 cases in more than 40 years of experience in the surgical correction of the aging face, the senior author has emphasized the importance of the repositioning of the skin and the facial soft tissues. After appropriate treatment of the superficial musculoaponeurotic system (SMAS) and the malar fat pad has been completed, adequate placement of the skin flaps is done by rotation, as described in the round-lifting technique, rather than by direct traction. The anatomic basis of this correction is discussed. Results: Traction of the SMAS was found to soften the appearance of the nasolabial fold to varying degrees, but other complementary procedures such as collagen injection or fat grafting often were necessary to achieve a more satisfactory correction. Durability of nasolabial fold correction with simple SMAS traction varied with each individual and his or her unique aging process. Simple traction of the SMAS did not include treatment of the fascial fatty layer. The senior author has included the treatment of the fascial fatty layer in his standard rhytidectomy over the last 2 years, with improved aesthetic results. Again, long-term correction by this technique is related to the aging process, and the final result was deemed superior to treatment of the SMAS alone. Direct excision of the nasolabial fold was performed in patients ranging from 35 to 60 years of age who had extremely prominent folds. In these very select cases, the results were considered satisfactory to both the surgeon and patient, with correction of the fold and acceptable scars. Conclusions: There is as yet no ideal solution for the surgical correction of the naso-labial fold component of the aging face. However, all of the techniques described are considered safe and have precise indications. It should be stressed to the patient that the nasolabial fold is part of the anatomy of the face and that the goal of treatment is to soften the appearance of the fold, not to eliminate it completely.

Treatment of Mediastinitis: Early Modified Robicsek Closure and Pectoralis Major Advancement Flaps

Background. The treatment of sternal wound complications is controversial. It is our practice to combine early aggressive debridement, a modified Robicsek sternal closure, and bilateral pectoralis major advancement flaps with or without closed irrigation in a single procedure. We reviewed our experience to determine the efficacy of this approach. Methods. Grade II to IV mediastinitis (dehiscence and infection) developed in 47 patients 3 to 14 days after routine open heart operations between 1990 and 1995. Culture-positive infection was identified in 60% (n = 28); 62% (n = 29) had septicemia. Thirty patients underwent incision, drainage, and surgical assessment of the wound. Once systemic signs of infection were under control (no pyrexia, normal white blood cell count), formal single-stage debridement of all infected soft tissues and bones was performed. Sternal stability was achieved using a modified Robicsek closure and bilateral pectoralis major advancement flaps. Seventeen patients were treated with staged procedures. Results. Early sternal closure and coverage with pectoralis major advancement flaps can be associated with a low mortality (0%), low morbidity (13%; n = 4: three superficial wound infections, one seroma), and shortened hospital stay (median, 22 days, compared with a median of 82 days in patients managed with conservative staged treatment; p < 0.05). Sternal stability with excellent functional and aesthetic results has been achieved in all patients. Conclusions. The combination of aggressive early surgical debridement, sternal closure, and the placement of bilateral pectoralis major advancement flaps is a simple procedure associated with a low mortality and morbidity and a short hospital stay.

Regional Flaps in Maxillofacial Reconstruction

SUMMARY Soft tissue maxillofacial reconstructive surgery has been elevated to new levels by virtue of a great number of available regional flaps. These flaps present a diverse set of donor sites, possible skin paddle sizes, and arcs of rotation that allow predictable immediate or delayed soft tissue reconstruction of the maxillofacial complex. The introduction of the pectoralis major myocutaneous flap in 1979 preceded the popular and frequent use of mandibular reconstruction bone plates and our understanding of the biology of radiation necrosis of the mandibular bone and concomitant soft tissue radiation necrosis requiring reconstruction. The oral and maxillofacial surgeon's responsibility for cancer patients who will be irradiated postoperatively, as well as for patients who have sustained soft and hard tissue radiation injury, therefore, has resulted in the modification, the further development, and the placement of myocutaneous flaps in these patients. Larger muscle volumes with preservation of secondary pedicles have proved useful in treating patients with these dilemmas. Furthermore, patients who undergo extirpation of oral malignancies and neck dissections that sacrifice the sternocleidomastoid muscle benefit from myocutaneous flap surgery, not only from the provision of oral lining by the skin paddle but also from coverage of the exposed carotid artery by the muscle. Moreover, an increased awareness of flap pedicles and their potential sacrifice during cancer neck dissections has led to sophistication in selection of myocutaneous flaps in head and neck cancer patients. An understanding of donor site anatomy, as well as the use of good judgment on the part of the reconstructive surgeon, allows for predictable and successful flap reconstruction of the maxillofacial complex.

Regional exposure of cerebral convexity lesions

The utility and reliability of a simple technique for the localization of cerebral convexity lesions are retrospectively analyzed in 83 intracranial procedures. The technique is based on data obtained from preoperative computed tomography (CT) scans, and on a few anthropological landmarks which usually can be identified on both the patient's head and skull radiograms. This method allowed precise placement of small craniotomy flaps (3 to 7 cm in diameter) in 94% of the patients studied. In the remaining, localization errors were corrected either by enlarging the craniotomy opening (3 cases), or by rescanning during the operative procedure (2 cases). Due to its technical simplicity and reliability in the vast majority of cases, the bony landmark method constitutes a recommendable alternative for the localization of convexity lesions, being particularly useful when highly sophisticated equipment is not available.

The morbidity and benefits of concurrent gracilis myocutaneous graft with pelvic exenteration

This study was undertaken to evaluate the morbidity and potential benefits of concurrent gracilis myocutaneous graft with exenteration. All patients undergoing exenteration from 1962-1986 were reviewed, of whom 24 had concurrent grafts. The mean operative time, blood loss, and hospital stay were not different in patients with versus without grafts. The rate of fistula formation in the hospital was less in the graft group (P = .004) but was not different when compared with contemporary patients only. The total infection rate (wound and pelvic) was decreased in the graft group (P = .04) when graft infections were excluded. The major problem with the graft was significant necrosis of the flap(s) in nine of the 24 patients. There were no life-threatening complications attributed to concurrent placement of gracilis myocutaneous flaps. Experience with the technique is improving the cosmetic and functional outcome of the neovagina formed with the graft. Patients most likely to benefit from this procedure include those requiring immediate reconstruction or those with potentially poor healing due to high-dose pelvic radiation, including intraoperative radiation.