Primary Reconstructive Procedures Research Articles

구강악안면 영역의 재건을 위한 대흉근피판의 임상적 평가

Purpose: Well vascularized pectoralis major myocutaneous flap (PMMF) had been a commonly used versatile flap in reconstructive oromaxillofacial surgery since the 1970s. However, after the advent of microvascular surgery in the 1980s, the PMMF was used less frequently. But, to date, PMMF has been useful and has some advantages such as covering wide defects, covering vital structures, back-up procedure in cases of free flap failure, and reconstruction for radiotherapy patients. The purpose of this study is to evaluate the role, indication, complications, functional, and aesthetic results of this flap in the era of free flap with a literature and chart review. Methods: A retrospective study was conducted of 16 oral cancer patients undergoing reconstructive surgery with PMMF for reconstruction of defects from 2001 to 2012 at Kyungpook National University Hospital. The male to female ratio was 10:6, with a mean age of 63 years (16~79 years). Basic demographic data, previous treatment history, indications, dimension of the flap, site of reconstruction, postoperative complications, and patients' final status were systemically analyzed from chart review. Results: The pathology of the disease included squamous cell carcinoma in the majority of cases (n=14). The remaining cases were fibrosarcoma and mucoepidermoid carcinoma. Of the 16 PMMF reconstructions, 13 flaps were applied as primary reconstructive procedures, whereas three flaps were; salvage; procedures (vascularized free flap failure). Twelve patients had complications such as wound dehiscence, infection, hematoma, fistula, flap bulkiness, and partial flap necrosis. The higher complication rates showed an association with utilization of the flap in preoperative radiotherapy cases. However, all patients were discharged without failure. Conclusion: In reconstructive oromaxillofacial surgery, the PMMF is still a useful flap for huge defects. In addition, the PMMF can be used as a salvage procedure after vascularized free flap failure and reconstruction for patients with a history of preoperative radiotherapy.

Increased Risk of Revision After Anteromedial Compared With Transtibial Drilling of the Femoral Tunnel During Primary Anterior Cruciate Ligament Reconstruction: Results from the Danish Knee Ligament Reconstruction Register

The goal was to study revision rates and clinical outcome after anterior cruciate ligament (ACL) reconstruction using the anteromedial (AM) technique versus the transtibial (TT) technique for femoral drill hole placement. A total of 9,239 primary ACL reconstruction procedures were registered in the Danish Knee Ligament Reconstruction Register between January 2007 and December 2010. The failure of the 2 different femoral drilling techniques was determined using revision ACL reconstruction as the primary endpoint. As secondary endpoints, we used the pivot-shift test and instrumented objective test as well as patient-reported outcome, registered in the Danish Knee Ligament Reconstruction Register. Relative risks (RRs) with 95% confidence intervals (CI) were calculated. We identified 1,945 AM and 6,430 TT primary ACL procedures. The cumulative revision rates for ACL reconstruction after 4 years with the AM and TT techniques were 5.16% (95% CI: 3.61%, 7.34%) and 3.20% (95% CI: 2.51%, 4.08%), respectively. The adjusted overall RR for revision ACL surgery in the AM group was 2.04 (95% CI: 1.39, 2.99), compared with the TT group. Use of the AM technique increased from 13% of all operations in 2007 to 40% in 2010. AM technique was further associated with increased RRs of positive pivot shift of 2.86 (95% CI: 2.40, 3.41) and sagittal instability of 3.70 (95% CI: 3.09, 4.43), compared with the TT technique. This study found an increased risk of revision ACL surgery when using the AM technique for femoral drill hole placement, compared with the TT technique, in the crude data as well as the stratified and adjusted data. Our finding could be explained by technical failures resulting from introduction of a new and more complex procedure or by the hypothesis put forward in prior studies that compared with a nonanatomic graft placement, a greater force is carried by the anatomic ACL reconstruction and, hence, there is a concomitant higher risk of ACL rupture. Level II, prospective comparative study.

Surgical treatment and prognosis in patients with high-grade soft tissue malignant fibrous histiocytoma of the extremities

Malignant fibrous histiocytoma (MFH) of soft tissue is one of the most common sarcoma in adulthood. However, only a few series have separately studied the clinical behavior and prognosis of this malignancy. We retrospectively reviewed 61 patients treated for extremity soft tissue high-grade MFH. Four patients had a history of another malignancy and were excluded from analysis. In 12 referred patients with incomplete excision, re-excision of the tumor bed was offered. Clinical and treatment variables were analyzed for their impact on treatment complications, local recurrence (LR), metastatic disease (MD) and overall survival (OS). Four patients underwent primary amputation. Twenty-three patients necessitated a primary reconstructive procedure for wound closure. Wound healing complication (WHC) developed in 28.3% of the limb sparing group of patients. LR developed in 11 patients (19.3%), while 6 of them had second LR. Eighteen patients (31.5%) developed MD, involving lung at least. Patients who developed MD <12 vs >12months, died within 19.3 vs 8months mean time (p<0.05). Overall survivorship was 66.7% at 5years. No statistically significant variables were identified for LR, while multivariate analysis for MD revealed tumor size >5cm as the only statistically significant variable. For OS, development of MD and age >70years emerged as independent prognostic factors. The overall prognosis is poor. LR, although can be managed with tumor re-excision, has high second recurrence rate. Increased tumor size is associated with shorter metastasis-free interval which significantly decreases survival.

Anterior Shoulder Instability Associated with Coracoid Nonunion in Patients with a Seizure Disorder

An association between coracoid fracture and glenohumeral instability with both a seizure disorder and the subsequent development of coracoid nonunion has not previously been recognized. This is clinically important as patients with a seizure disorder and glenohumeral instability frequently require a primary osseous reconstructive procedure, such as coracoid osteotomy and transfer to the anterior glenoid rim (the Bristow-Latarjet procedure), to address glenoid osseous deficiency. We report on coracoid fracture nonunion in five patients with a seizure disorder and anterior glenohumeral instability and discuss the implications for surgical treatment. Coracoid fracture was specifically sought on three-dimensional reconstructions of computed tomography scans in a consecutive series of 234 patients presenting to our unit with recurrent anterior instability. In addition to demographic data, we specifically sought information on any history of shoulder injury, the mechanism of injury, or previous seizure activity in these patients. In patients with a coracoid fracture or nonunion viewed to be at high risk of failure with a soft-tissue procedure, an open osseous reconstructive procedure was performed. The type of operative procedure was determined by the location of the nonunion. We identified six coracoid fracture nonunions in association with anterior glenohumeral instability in five patients (mean age, 26.8 years; range, twenty-four to thirty years). All patients had instability occurring in association with seizures. In the four shoulders with the anatomic location of the coracoid nonunion at its so-called elbow, a standard Bristow-Latarjet procedure was performed. In the two shoulders in which the nonunion was more distal, an Eden-Hybbinette procedure was performed. We recommend having a high index of suspicion of coracoid fracture when treating patients with a seizure disorder who have anterior glenohumeral instability. In these patients, preoperative computed tomographic images allow the diagnosis of a coracoid nonunion to be made prior to surgery and help to determine whether there is sufficient intact coracoid bone to allow a Bristow-Latarjet procedure to be performed.

Lip and oral commissure reconstruction with the radial forearm flap

Introduction:The radial forearm free flap has been a workhorse flap for lip reconstruction due to its pliability, color match, and ability to incorporate the palmaris longus tendon for support. We report our experience with the use of the radial forearm free flap in three patients post-tumor resection.Materials and Methods:Between 2009 and 2010, three patients had undergone resection of squammous cell carcinoma of the oral region and simultaneous reconstruction with the radial forearm free flap. The average patient age was 51 years and the average defect size was 4 × 3 cm2. In two patients, anterograde radial forearm free flap was used with a fascia lata free tendon graft for support and in one patient, a retrograde radial forearm flap was used without the use of tendon as support.Results:All three patients were satisfied with the initial management of tumor clearance. All three surgical margins were clear. Out of three, two patients complained that the flap was unsightly and were dissatisfied with the appearance and bulk of the flap.Conclusion:Although the radial forearm flap is recognized as a gold standard for lip reconstruction, there always appears to be a need for secondary revision procedures to further improve both the functional as well as esthetic appearance of the lip reconstruction procedure. As a primary reconstructive procedure, the flap does not satisfy patient expectations. A comprehensive questionnaire as well as objective assessment follow-up study is warranted.

Indications and Outcomes for Pedicled Pectoralis Major Myocutaneous Flaps at a Primary Microvascular Head and Neck Reconstructive Center

The pectoralis major musculocutaneous (PMMC) flap has been a useful technique for head and neck reconstruction since its first description by Ariyan in 1979. However, techniques in microvascular surgery have since evolved and recently free tissue transfer has played an important role in head and neck reconstruction. Although we use free flaps as the first choice for head and neck reconstruction, similar to many other institutions, some patients at our hospital have undergone reconstruction with PMMC flaps. We retrospectively analyzed the indications and outcomes of this reconstructive technique from our experience with 12 patients. The medical records of all patients who underwent PMMC flaps at Hokkaido Cancer Center from 2001 to 2010 were reviewed. Data concerning diagnosis, main indication, site of reconstruction, previous treatment, and postoperative complications were analyzed. Of the 12 PMMC flap surgeries performed, 3 were carried out as primary reconstructive procedures, whereas 9 were done as “salvage” procedures. Flap-related complications were observed in 6 cases. Partial flap loss developed in 4 patients, although there were no cases of total flap loss. There were 3 recurrent fistulae following reconstruction with PMMC flaps. The preoperative goals of performing PMMC flap surgery were met in 83% of our cases. The authors conclude that while free flap transfer is usually the first choice for head and neck reconstruction, PMMC flaps can produce acceptable results in certain situations.

The Use of a Pedunculated, Extended Latissimus Dorsi Flap in Primary and Secondary Breast Reconstruction Procedures - Case Report

The extended latissimus dorsi flap (LD) is used in breast reconstruction since the 70's. LD flap is often used in corrective surgery in cases of unsatisfactory cosmetic results after breast-conserving therapy. In our department LD flap has several uses. In addition to free microvascular flaps - which applies in breast reconstructive surgery is routine, there are clinical situations where the use of pedicled LD flap is justified. The main indications for its use are: the inability to apply microvascular flap, the general condition (diabetes, advanced atherosclerosis), smoking, previous surgery of abdominal wall, abdominal obesity, patient preferences. Approximately 30% of patients after breast reconstruction require corrective procedures. Group which uses extended LD flap account for 24 patients. In 16 cases it was used for elective breast reconstruction. In the remaining eight cases it was used in the corrective procedures symmetry and shape of the previously reconstructed breast. Based on our own experience it can be concluded that the LD flap with an alternative to microvascular techniques. Complication rate when using the LD flap is relatively low and includes: seroma and slight motor disability of the shoulder girdle.

HEAD AND NECK RECONSTRUCTION

Background: The pectoralis major myocutaneous pedicle flap (PMMPF) has been considered to be the "workhorse" of pedicled flaps in head and neck reconstruction. Despite the use of free flaps, this flap is still considered the mainstay of head and neck reconstruction. The flap is usually associated with a high incidence of complications compared with the free fasciocutaneous flaps yet its size, viability, and versatility make it a valuable tool for extending the limits of resectability and reconstruction. It is type V muscle flap with the dominant vascular supply from the pectoral branch of thoracoacromial artery. Objective: To share our experience of pectoralis major myocutaneous pedicle flap in selected cases of head and neck reconstruction. The indications, type of reconstruction and complications of the flap utilization were evaluated. Patients and Methods: Between March 2005 and August 2010, a 37 head and neck reconstructive procedures using the PMMPF were carried out. The indications for the flap use were defects due to resection of stage II-IV cancer in the head and neck region. The site, stage of the disease and the postoperative complications were all documented. Results: Pectoralis major myocutaneous pedicled flap reconstructions were used to reconstruct defects in the following sites: oral cavity (25 patients); oropharynx/ hypopharynx, (7 patients); and neck or face (5 patients). Of the 37 PMMPF reconstructions, 30 flaps were carried out as primary reconstructive procedures, whereas 7 flaps were "salvage" procedures. Twentyfive patients (67.59%) had complications. A higher complication rates were associated with the utilization of the flap as a salvage procedure, number of co- morbidities, and in oral cavity reconstructions. Conclusions: The pectoralis major myocutaneous pedicled flap is still an acceptable method of head and neck reconstruction. It is fast, reliable, provides safe repair and is indicated especially where bulk is needed.

Simple ligation versus arterial revascularisation of femoral pseudo aneurysms in intravenous drug users; a systematic review

Simple ligation versus arterial revascularisation of femoral pseudo aneurysms in intravenous drug users; a systematic review

Management of Horse and Donkey Bite Wounds: A Series of 24 Cases

Sir: Although horses are the animals most commonly involved with fatalities,1 reports about horse bites are very rare. Comparing animal bite wounds, cat bites result in punctured deep wounds, dog bites cause rather superficial abrasion and laceration type wounds,2 and horse and donkey bites provoke tissue loss wounds.3 We have performed a retrospective evaluation of 24 patients presenting with animal bites (19 horse and five donkey bites) and treated at the department of plastic surgery from 2003 to 2009. The head and neck were the most frequent bite sites (14 cases), followed by the extremities (eight cases) and the trunk (two cases). All patients were operated on within 24 hours after admission. Wounds were first cleansed with only saline in all patients, because irrigation with antibiotic or iodine solution may increase tissue irritation. Although half of the patients' wounds were closed with primary suture after surgical débridement of crushed wound edges, the other half required surgical treatment (Table 1). Besides the patient transferred from another clinic on the seventh day after the event, in whose hand there was tissue necrosis and infection (Fig. 1), no other patient had infection. On subsequent follow-up, three patients developed minor scar complications on the cheek and the chin.Table 1: Reconstructive Procedures in Patients with Tissue LossFig. 1.: Patient presented with the fifth finger of the right hand amputated and tissue necrosis in the hypothenar area.Our initial therapy in all animal bites includes copious irrigation with saline by means of a syringe with a 19-gauge needle, careful débridement of devitalized tissues, antibiotic prophylaxis with amoxicillin and clavulanic acid, tetanus and rabies prophylaxis, and early repair. Antimicrobial therapy is indicated for bite wound infections, but the role of antibiotics in the treatment of uninfected animal bite wounds is still a subject of debate. Controversy exists regarding the use of antibiotic prophylaxis in avoiding infections after an animal bite. The indications for antibiotic prophylaxis depend on the time between the bite and its medical treatment, the type of animal, the anatomical structures involved, and the extent of the bite.2 Although wounds on hands with exposed cartilage or delayed therapy are considered at high risk for infection in animal bites and delayed primary closure is recommended, we preferred early repair by immediate primary closure in horse and donkey bites, and no infection developed (Fig. 2).Fig. 2.: Crush injury of the right ear.A case of anaphylaxis after a horse bite is reported.4 A deep lesion (crush injury) producing severe hematoma, fat necrosis, and muscle rupture, without an external wound, in a woman bitten on her thigh by a horse could be diagnosed only through ultrasound examination, which can be useful for evaluating the extent of crush injuries after horse bites.5 We have not seen such cases in our series. Our experience shows the safety of primary closure for horse and donkey bite wounds, provided that careful débridement and good cleansing with antibiotic prophylaxis are also performed. An acceptable aesthetic outcome can be achieved only with early primary repair and reconstructive procedures. Rüştü Köse, M.D. Department of Plastic and Reconstructive Surgery Özgür Söğüt, M.D. Department of Emergency Medicine Cengiz Mordeniz, M.D. Department of Anesthesiology and Intensive Care Harran University Medical School Sanliurfa, Turkey

Chirurgische Korrektur des paralytischen Lagophthalmus

Impairment of the peripheral or central part of the facial nerve causes an ipsilateral peripheral facial nerve paresis. It is quite a common syndrome and affects 20-35 persons per 100,000 per year in Western Europe and the United States. A possible complication of facial palsy is paralytic lagophthalmos with aesthetic and functional impairment for the patient. Beside primary nerve reconstructive procedures plastic-reconstructive procedures play a major role in correcting paralytic lagophthalmos. The eyebrow, upper and lower lids, medial and lateral lid angle as well as the lacrimal system need to be seen as functional units and can be corrected with local surgical procedures. Restoration of eye closure is the most important goal in treating the affected eye. Due to the significant aesthetic limitations and resultant psychological stress for the patient cosmetic aspects must be included in the surgical concept.

Abdominal aortic coarctation: Surgical treatment of 53 patients with a thoracoabdominal bypass, patch aortoplasty, or interposition aortoaortic graft

Abdominal aortic coarctation is uncommon and often complicated with coexisting splanchnic and renal artery occlusive disease. This study was undertaken to define the clinical and anatomic characteristics of this entity, as well as the technical issues and outcomes of its operative treatment. Fifty-three patients, 34 males and 19 females, underwent surgical treatment of abdominal aortic coarctations from 1963-2008 at the University of Michigan. Patient ages in years ranged from 2-4 (n = 4), 5-8 (n = 17), 9-14 (n = 16), 15-20 (n = 11) and 25-49 (n = 5). The mean age was 11.9 years. Developmental disease (n = 48), inflammatory aortitis (n = 4), and iatrogenic trauma (n = 1) were suspected etiologies. Aortic coarctations were suprarenal (n = 37), intrarenal (n = 12), or infrarenal (n = 4). Patients often had coexisting occlusive disease of the splanchnic (n = 33) and renal (n = 46) arteries. Major clinical manifestations included: aortic and renal artery-related secondary hypertension (n = 50), symptomatic lower extremity ischemia (n = 3), and intestinal angina (n = 3). Primary aortic reconstructive procedures included: thoracoabdominal bypass (n = 26), patch aortoplasty (n = 24), or an aortoaortic interposition graft (n = 3). Primary splanchnic (n = 19) or renal (n = 47) arterial reconstructions were performed as simultaneous (n = 45) or staged (n = 13) procedures in relation to the aortic surgery. Benefits existed regarding improved control of hypertension (n = 46), as well as elimination of extremity ischemia (n = 3) and mesenteric angina (n = 3). Secondary renal or splanchnic arterial reoperations (n = 8) were performed without mortality 5 days to 12 years postoperative for failed primary procedures. Secondary aortic procedures, 5 to 14 years postoperative, were performed for patch aortoplasties that became stenotic (n = 2) or aneurysmal (n = 1), and when thoracoabdominal bypasses developed an anastomotic narrowing (n = 1) or proved inadequate in size with patient growth (n = 1). No perioperative mortality accompanied either the primary or secondary aortic reconstructive procedures. Abdominal aortic coarctation represents a complex vascular disease. Individualized treatment changed little over the period of study, remaining dependent on the pattern of anatomic lesions, patient age, and anticipated growth potential. This experience documented salutary outcomes exceeding 90% following carefully performed operative therapy.

HS01 MANAGEMENT OF OBSTETRIC BRACHIAL PLEXUS PALSY AT MIDDLEMORE HOSPITAL

In the year 2000 a surgical service for infants with obstetric brachial plexus palsy commenced at Middlemore Hospital in Auckland. This remains the only service available in New Zealand with the two founding surgeons remaining as its current providers. We present the seven‐year history of this service, the lessons learned from both primary and secondary reconstructive procedures and consider the direction for future treatment.

Atypical Fibroxanthoma of the Head and Neck: Report of 5 Cases

Atypical fibroxanthoma (AFX) is a solitary, nodular ulcerative neoplasm that mostly appears on the sun-damaged skin of elderly people. It usually appears in the forehead, cheeks, nose, and ears. Appearance in the scalp is uncommon. Differential diagnosis must be done with other exophytic lesions of the skin to make an adequate management. Although different treatment modalities have been reported, we recommend wide surgical excision with primary reconstructive procedures in most of the cases.

Synchronous Reconstruction of the Exenterated Orbit with a Pericranial Flap, Skin Graft and Osseointegrated Implants

Reconstruction of the exenterated orbit remains a surgical challenge. Here, the authors present a case in which orbital exenteration was performed for an extensive, infiltrating medial canthal basal cell carcinoma; the resulting defect was reconstructed with osseointegrated implants and a pericranial flap onto which a split thickness skin graft was placed. The second stage of the aesthetic rehabilitation of this patient (placement of the transcutaneous abutments) was completed under local anaesthetic 16 weeks later. Subsequently, the patient was fitted with an oculoplastic prosthesis four weeks later. The above technique accelerates the prosthetic rehabilitation of the patient by performing the primary reconstructive procedures simultaneously with the exenteration and by removing the need for secondary surgical procedures under general anaesthetics. The whole process from orbital exenteration to the fitting of an ocular prosthesis was completed in just five months.

Outcome of Continence Procedures in the Pediatric Patient: A Single Institutional Experience

Achieving continence remains a major goal in the treatment of children with neurogenic and/or anatomical voiding dysfunction. We reviewed our experience with continence procedures in pediatric lower urinary tract reconstruction. We reviewed the records of all pediatric patients who underwent continence procedures at our institution since July 1993. We reviewed the diagnosis, type of primary reconstructive procedure, concomitant procedure(s) and initial success rate. In cases of primary failure we noted the type of secondary continence procedure performed and the ultimate success rate. Success was defined as dry intervals of at least 4 hours when the patient was compliant with a catheterization or voiding regimen. Primary continence procedures were performed in 43 cases and secondary procedures were performed in 6 for a total of 49 continence procedures. The diagnoses included myelomeningocele in 22 patients, exstrophy in 12, epispadias in 3, bilateral single system ureteral ectopia in 3 and spinal cord injury in 3. A total of 32 primary procedures were performed concomitantly with or were preceded by bladder augmentation with creation of a catheterizable stoma. The remaining 11 patients underwent a continence procedure only. The diagnosis in these 11 patients was exstrophy in 5, epispadias in 3, with spinal cord injury in 2 and myelomingocele in 1. Mean followup was 35 months (range 1 to 95). Initial continence procedures included Young-Dees-Leadbetter bladder neck repair in 14 cases, of which 11 (79%) were initially successful, a urethral sling in 9 with 7 initial successes (78%), bladder neck division and closure in 7 with all successful (100%), collagen in 5 with 1 success (20%), other urethral lengthening procedure (eg Pippi Salle or Kropp) in 4 with 3 successes, (75%), combined urethral sling and Young-Dees-Leadbetter in 2 with 1 success (50%), and an artificial sphincter and fascial wrap in 1 each, which were successful. Of the 6 secondary procedures performed for primary failure collagen was injected in 4 and the bladder neck was divided and closed in 2. All were successful. Various lower urinary tract procedures can be performed to achieve successful continence in the pediatric population. At our institution all procedures had a reasonable success rate except primary collagen injection. Collagen injection and bladder neck division/closure proved to be reliable secondary procedures in cases of primary failure.

Use of transpelvic rectus abdominis musculocutaneous flap for anal cancer salvage surgery.

Perineal wounds following abdominoperineal resection (APR), for persistent or locally recurrent anal cancer, are associated with poor healing secondary to irradiation therapy. The results of APR combined with a vertical rectus abdominis musculocutaneous (VRAM) flap transposed transpelvically to cover the perineal defect are presented. Between 1994 and 2000, 105 patients were diagnosed and treated for anal cancer. Twenty-two (21 per cent) underwent a salvage operation owing to persistent or locally recurrent disease. In eight patients, before 1996, the perineum was closed primarily with serious wound complications in five. In the final 14 patients, primary perineal reconstruction with a VRAM flap was performed. Median age was 65.5 (range 45-78) years. Median follow-up was 14.5 (range 3-41) months. There were no flap-related complications and primary healing was achieved in all patients. Median hospital stay was 17 (range 14-72) days. There were two major complications related to the laparotomy and abdominal closure. Combining the salvage operation with a VRAM flap facilitates primary healing after surgical treatment for persistent or locally recurrent anal cancer. A single-stage primary reconstructive procedure is feasible, with an acceptable complication rate and high level of patient satisfaction.

Therapeutic angiogenesis with vascular endothelial growth factor in peripheral and coronary artery disease: a review.

Therapeutic angiogenesis constitutes an alternative treatment for patients with extensive tissue ischaemia in whom primary vascular reconstruction procedures are not feasible or have previously failed. At present vascular endothelial growth factor (VEGF) has been the most widely used angiogenic factor in experimental and human clinical trials. Early clinical data provide evidence that gene transfer of the VEGF gene can achieve beneficial angiogenesis, with minimal side-effects. Ongoing phase III clinical studies will reveal definitive efficacy.

Outcome of tarsoconjunctival flap dehiscence after eyelid reconstruction

PURPOSE: To report the outcome of eyelid reconstruction with a tarsoconjunctival flap complicated by premature flap dehiscence. DESIGN: Interventional case series. METHODS: In eight of approximately 100 patients who underwent unilateral lower eyelid reconstruction with a tarsoconjunctival (Hughes) flap during a 15-year interval, the procedure was complicated by premature flap dehiscence resulting from accidental trauma 1 to 11 days after the reconstructive procedure. Immediate surgical repair of the dehiscence was attempted in one case, but the tissues reopened within 1 day. Otherwise, the eyelids were permitted to heal spontaneously with the application of erythromycin ophthalmic ointment as the sole therapy. RESULTS: Although the reconstructed eyelids healed satisfactorily in each case, one patient, who had dry eyes from Sjögren syndrome, required secondary surgery to treat mild lagophthalmos and lower eyelid retraction. CONCLUSIONS: The ultimate functional and esthetic outcomes after premature, traumatic dehiscence of a Hughes flap were generally satisfactory, suggesting that elective division of the conjunctival pedicle in uncomplicated cases may be performed relatively soon after the primary reconstructive procedure.

Intervention in the critically ill neonate and infant with hypoplastic left heart syndrome and intact atrial septum.

Neonates that present with hypoplastic left heart syndrome (HLHS) and intact atrial septum (IAS) pose a major management problem for the pediatric cardiac team. They are critically ill newborns with profound hypoxemia and acidosis that require immediate attention. Controversy exists as to the most appropriate management strategy. In one series where a primary and emergent surgical-staged reconstructive procedure was performed, the in-house hospital mortality was 65% and the overall survival was 17%. With equal abysmal results, transcatheter creation of an atrial septal defect (ASD) using conventional balloon atrial septostomy (BAS) with or without the combination of blade atrial septotomy had an unacceptable high risk of cardiac perforation leading to tamponade and death. However, using more modern transcatheter techniques of transseptal perforation of the atrial septum followed by progressive and serial balloon septoplasty, creating an ASD, significantly reduced the risk of the procedure. In one series, 16 consecutive neonates underwent this type of interventional procedure without procedural mortality. The management strategy of creating an ASD in the catheterization lab followed by Stage I reconstructive surgical repair 3-5 days after the initial catheterization procedure improved the in-house survival to 57%. Unfortunately, there continues to be significant attrition of these patients undergoing Stage II and III reconstructive repair, which supports cardiac transplantation as an alternative strategy. There have been echocardiographic and histopathologic studies of these neonates, and an important echo classification of left atrial morphology has been described with perhaps some prognostic implication. In addition, autopsy specimens have demonstrated significant "arterialization" of the pulmonary venous architecture that likely dooms the patient with single ventricle physiology to a poor outcome. Future improvement in transcatheter techniques and materials offer promise in palliating these critically ill neonates. The concept of radiofrequency energy perforating catheters has great merit and may reduce the risk of cardiac perforation as compared with the rigid and long transseptal needle. Echocardiographic imaging at the time of entry through the IAS may improve the safety as well. The novel concepts of "butterfly" or "dog-bone" stents placed across the atrial septum creates a precisely sized ASD that may be more conducive to effectively lower left atrial hypertension, yet avoids excessive pulmonary blood flow associated with large atrial communications. In addition, new materials, such as the Cutting Balloon Catheter, may offer promise in creating ASDs in these patients. A more aggressive approach would be to consider intrauterine fetal transcatheter opening of the IAS using modified techniques that have been attempted for left ventricular outflow tract obstruction. Unfortunately to date, the results of attempted relief of aortic valve stenosis have been extremely poor. Finally, we as interventionalists need to continue to improve our skills to help in the complex management of these critically ill neonates and infants. Only through continued efforts of the entire cardiac team of intensivists, cardiologists, cardiothoracic surgeons, and interventionalists will our management strategy be defined to maximize the future outcome in this group of patients.