Secondary Revision Research Articles

Endoscopic Posterior Cordotomy with Microdissection Radiofrequency Electrodes for Bilateral Vocal Cord Paralysis

The purpose of this study is to evaluate the results of endoscopic posterior cordotomy using microdissection electrodes in patients with bilateral vocal cord paralysis. Eleven patients underwent endoscopic posterior cordotomy using a radiofrequency Arrowtip monopolar needle. Preoperative-postoperative exercise tolerance, airway, and voice evaluation were performed in all patients. Two patients required a secondary revision operation due to granulation and crust formation and respiratory problems. No other complications were encountered. Two patients with tracheotomy cannulas were decannulated on the third postoperative day. All patients had an adequate functional airway and good exercise tolerance compared with poor preoperative exercise tolerance. There was no significant difference between preoperative and postoperative Voice Handicap Index values (P > .05). The data indicated the safety, easy use, and efficiency of the microdissection radiofrequency electrodes in patients with bilateral vocal fold paralysis. This technique provides a reliable alternative to laser procedures.

Outcomes after shoulder arthroplasty revision with glenoid reconstruction and bone grafting

Extensive glenoid bone loss after failed shoulder arthroplasty represents a challenge for revision arthroplasty. Treatment options vary widely and have been a source of controversy among experts. Between 2004 and 2010, a total of 17 patients underwent glenoid reconstruction surgery using an autologous iliac crest bone graft and secondary revision arthroplasty due to extensive glenoid bone loss after failed previous total shoulder arthroplasty. The outcomes were assessed by means of clinical examination, Constant score, and bi-plane radiography as well as pre-, postoperative and follow-up CT. Before the revision surgery, the mean Constant score was 24 ± 17 and improved to 40 ± 13 after the glenoid rebuilding and revision arthroplasty. CT imaging revealed adequate glenoid bone stock restoration with no relevant graft resorption or loosening of the glenoid. The average postoperative antero-posterior diameter of the glenoid was 28 ± 3 mm which had decreased to 25 ± 3 mm at follow-up. The average postoperative version of the glenoid was 95.7° ± 6° and had decreased to 98.5° ± 4° at follow-up. Both the glenoid version and diameter had changed significantly (P < 0.001) comparing postoperative and follow-up CT-scans. Glenoid reconstruction surgery using an iliac crest bone-block autograft prior to revision arthroplasty represents a valuable salvage procedure in cases of extensive glenoid bone loss after primary shoulder arthroplasty. Sufficient glenoid bone stock restoration is indispensable for reliable fixation of glenoid components and in turn a satisfactory clinical outcome.

The Role of Frontalis Orbicularis Oculi Muscle Flap for Correction of Blepharoptosis With Poor Levator Function

On the basis of the close anatomical interdigitation between the longitudinal-oriented frontalis muscle and the horizontal-oriented orbicularis oculi muscle (OOM), frontalis OOM (FOOM) flap was developed to treat blepharoptosis. Retrospective study during an 11-year period, 66 patients with 81 poor levator function ptotic eyelids accepted FOOM flap shortening (65 lids; 80.2%) or double-breasted FOOM flap advancement (16 lids; 19.8%) to correct blepharoptosis. There were 51 (77.3%) patients with unilateral ptosis and 15 (22.7%) patients with bilateral ptosis. Severity of blepharoptosis included severe type in 72 (88.9%) lids, moderate type in 5 (6.2%) lids, and mild type in 4 (4.9%) lids. The underlying etiology included congenital origin in 43 (65.1%) patients, involutional change in 19 (28.8%) patients, and neurologic origin in 4 (6.1%) patients. Marginal reflex distance 1 and lid slit distance improved from -1.6 (2.0) to 3.3 (1.2) and 3.2 (2.0) to 7.2 (1.4) mm, respectively, after operation. The postoperative outcome includes good results in 54 (81.8%) patients, fair results in 10 (15.2%) patients, and poor results in 2 (3.0%) patients. The undercorrection or recurrence rate is 14.8%, and secondary revision rate is 11.1%. Positive Hering law is 17.6% among patients with unilateral ptosis. Overall patients' satisfaction rate is 95.1%. Both FOOM flap shortening and double-breasted FOOM flap advancement are effective to treat poor levator function blepharoptosis. Double-breasted FOOM flap advancement is highly recommended because of the more natural contour and minimal lagophthalmos postoperatively, because of the maximal preservation of OOM.

Recurrent breast cancer in the subpectoral space after implant reconstruction

Breast reconstruction after mastectomy is most commonly performed with a prosthetic implant placed beneath the pectoralis major. Recurrence may rarely be identified in the subpectoral space where the implant was placed. We report a case of recurrent breast cancer after implant-based reconstruction with isolated subpectoral recurrence discovered 5 years later during secondary revision of her reconstructed breast.

Lappenplastiken bei Weichteildefekten nach endoprothetischem Kniegelenkersatz

Due to the marginal periarticular soft tissue envelope and the high risk of concomitant soft tissue or periprosthetic infection with the presence of exposed metal or bone, soft tissue defects after total knee arthroplasty are always a relevant surgical problem. Specific patient-related, intra- and postoperative risk factors have been identified and need to be considered during the course of treatment. Often a profound management of underlying infection must accompany the staged defect treatment which could require a prosthesis explantation with secondary revision in the case of a deep infection and involvement of the prosthesis. Four stages of soft tissue defects have been introduced (types A-D) and criteria for differentiation are the overall soft tissue coverage, the exposure, respectively, necrosis of the extensor mechanism, preservation or involvement of the joint capsule and/or an accompanying septic loosening of the prosthesis. The concept of plastic coverage follows a stage-adapted algorithm and includes secondary wound healing and mesh coverage for superficial defects, fasciocutaneous flaps for moderate defects and pedicled or free muscle flaps for deep defect situations with extension into the joint capsule. Crucial factors for a successful therapy include the early identification and precise analysis of defect characteristics, the careful preparation of the wound bed with serial debridements and the diligent flap coverage with early consultation of plastic-surgical expertise.

Tratamiento de heridas por mordeduras de perro en región craneofacial

Patients arriving with dog bite lesions in the craniofacial region are treated at the Maxillofacial Surgery Service. These patients require inter-consultation with the maxillofacial surgery service. Patients wounds are cleansed with a three-fold (solution in thirds) solution for 30 minutes, to then proceed to wound closure. Other protocols are restricted to wound closure and cleansing and antibiotic administration. Wounds caused by animal bites are complicated. These wounds can be macerating, sharp, lacerating or avulsive. Antibiotic, tetanus and rabies prophylaxis are indispensable. The most important aspect is cleansing and primary closure of the wound. Post-surgical treatment includes tight control to prevent or control infection and when needed, secondary revision of the scar with reconstruction purposes. In the present study, data from 58 patients were gathered. The following variables were examined: data on existing or non-existing infection according to region, age, gender, exposition time from the moment of aggression to hospital treatment, as well as anatomical region of the lesion.

Extremity nonunion treated by modified autologous iliac grafting

Objective To observe the efficacy of treating extremity nonunions by modified autologous iliac grafting.Methods Included in this study were 60 patients who had been treated for extremity nonunion in our department between May 2010 and May 2011.They were 45 men and 15 women,with an average age of 39.2 years (range,13 to 68 years).There were 7 humeral nonunions,19 tibial nonunions,27 femoral nonunions,4 radial nonunions,and 3 clavicle nonunions; by Weber classification,there were 3 hypertrophic nonunions,15 atrophic nonunions,37 ischemic nonunions and 5 pseudarthroses.The mean disease course of nonunion was 12.5 months (from 6 to 25 months).Before this revision,42 patients had one operation,17 had 2 operations and one patient had 3 operations; 45 patients had been treated with plate,8 with intramedullary nail and 7 with external fixator.This revision was performed using modified autologous iliac grafting followed by bridging fixation with locking plate.All patients were followed to document fracture healing and complications.Results The average follow-up was 12.8 months (range,6 to 24 months).The secondary revision led to bone union in 59 cases after a mean time of 5.3 months (range,4 to 8 months).One case of femoral nonunion suffered plate breakage 6 months postoperation which had to be revised by re-grafting and reconstruction plating augmented in the grafting area.No complications like infection,deformity,leg length discrepancy and pain at the bone donating area occurred in this series.Conclusion The modified autologous iliac grafting is highly efficient in curing extremity nonunions,because it can greatly activate the bone graft and increase the conductive and osteoinductive capabilities of the bone graft. Key words: Fractures, ununited; Extremities; Bone transplantation

Splitted Posterior Auricular Muscle Flap Combined With Traditional Otoplasty

This article presents a modified technique to split and reposition the posterior auricular muscle flap as an adjunct to traditional otoplasty. Although numerous techniques have been described for the correction of prominent ear deformity, there is still a continuing debate on which operative method achieves the best results. Recurrence of the deformity or the need for secondary revisions is still among the common problems. We aimed to focus on a technical modification of the use of the postauricular muscle flap to strengthen the effect of otoplasty and to obtain more prominent results. Twelve patients with prominent ears (total, 24 ears) were operated on and followed up at least 6 months. To determine the efficacy of the technique on the different parts of the ears, 2 distances of each ear to the scalp for both the superior and middle third of the ears were measured and compared before the surgery, early after the surgery, and late after the surgery. The mean distances for both the upper and middle third of the ears were significantly lower (P < 0.05) at the end of the first month after the surgery. Although a millimetric slight rise was observed, there was no statistically significant difference between the mean postoperative results of the first and sixth months (P > 0.05). The splitted posterior auricular muscle flap repositioning to the upper and middle third of the ear may be successfully performed adjunct to the conventional corrective otoplasty. According to the late postoperative results, it seems to be that a stronger and more permanent otoplasty may be obtained with the addition of a splitted and reinserted postauricular muscle flap to the traditional otoplasty.

Nasal Tip Projection: Asymmetries after Rhinoplasty

Background: Nasal tip projection has been defined as the distance along a perpendicular line from the vertical facial plane to the most anterior projecting point of the nasal tip. The tripod concept, although an oversimplification of nasal tip dynamics, highlights the intimate relationship between projection and rotation. Aim: The aim of the study was to evaluate the rate of nasal tip irregularities after the medial crura overlay procedure, and following the Tripoid concept. Methods: We completed a retrospective review of patients who have been admitted at ENT Clinic, Skopje from the period of 2008-2012. Operative technique rhinoplasty was prepared in 36 patients. Procedures included full-transfixion incision, release of tension septum, lateral crural overlay (LCO), dome truncation, medial crural overlay (MCO), and combinations of them. We reviewed major and minor secondary revision procedures that patients underwent, postoperative complications, and any functional complaints. Results: Of the remaining 36 patients: one (2.5%) required minor revision of dorsal irregularities, 3 (3.0%) required tip revision, 33 patients (93.3%) were satisfied without qualification, 3 patients (3.5%) were not satisfied and wont for revision surgery. Three patients (2.5%) underwent radix grafts. 5 (13.3%) of the patients had had previous rhinoplasty performed by another physicians. Seven patients (18.3%) were classified as having tension nose. One patient had postoperative epistaxis, and there were no cases of postoperative functional complaints. Conclusion: Our revision rate of 4.2% for tip irregularity and our finding that no patients had postoperative functional complaints allows us to feel confident that this algorithmic paradigm can be used to accomplish tip deprojection in almost any circumstance.

External Mustarde suture technique in otoplasty revisited: A report of 82 cases

In otoplasty surgery the antihelical fold is frequently created using Mustarde sutures. When using the Mustarde suture technique it is important to insert the needle through the cartilage at right angles. This technical objective is easily achieved with an external Mustarde suture technique. A review of 82 patients who underwent otoplasty between 2005 and 2011 was conducted. All patients underwent external Mustarde suture otoplasty without conchal cartilage resection. The cartilage had been softened by rasping and conchomastoidal sutures had been used to correct conchal excess if necessary. In one patient, a secondary revision was performed for inadequate superior pole correction. In three patients sutures were visible after 1 year postoperatively and the sutures were removed under local anaesthesia without any recurrence. In one patient blister formation occurred due to inaccurate packing, but healed without any problem in a few days. No other complications, such as bowstringing of the internal sutures, haematoma, or infection, were observed. The patients expressed a high degree of satisfaction with their results. The risk of technical error is minimal. It is easy to perform and not time-consuming. Due to these advantages, this method is a reliable technique in otoplasty.

Interdisziplinäre, primäre Rekonstruktion des Perineums zur Vermeidung von Wundkomplikationen nach abdominoperinealer Rektumexstirpation

Multimodal treatment options for ultra-low neoplasms of the rectum or anal cancer include chemotherapy, radical abdominoperineal resection and/or radiation. Primary wound closure increases the risk of perineal wound complications that require secondary revision. Perineal wound complications may trigger delay of adjacent tumor therapy and thus have an impact on rate of local recurrence and long-term survival for rectal cancer. Simultaneous primary reconstruction of the perineal defect has been shown to reduce the incidence of perineal wound complications as well as hospital stay which enables timely adjacent therapy and may improve prognosis. This study was designed to retrospectively evaluate wound complications after abdominoperineal resection by comparing a group with and one without primary perineal reconstruction. Between 2005 and 2011, patients were analysed and divided into cohorts 1 and 2. Cohort 1 included n = 33 patients without primary perineal reconstruction. Cohort 2 included n = 4 patients with primary perineal reconstruction. Risk factors were identified for increased wound complications and delay of adjacent therapy. Subgroup analysis revealed that 18 out of 33 patients of cohort 1 had wound complications. In five cases, prolonged wound healing resulted in a delay of adjacent therapies. Four patients suffered from progression of tumour, 2 out of these 4 patients had a history of delayed adjacent therapy. The main risk factor for prolonged wound healing due to postoperative complications was a history of neoadjuvant treatment resulting in a rate of 64.7 %. Cohort 2 undergoing primary reconstruction presented without wound complications or delay in adjuvant therapy. A primary perineal reconstruction after APRE can reduce the rate of perineal wound complications. Furthermore, neoadjuvant treatment was shown to carry a major risk for wound complications. Patients after radio-/chemotherapy should undergo a primary reconstruction to prevent procedure-related perioperative morbidity. Subsequently, delays in adjuvant therapy, and prolonged hospital stay can be inhibited. Moreover, quality of life can be increased. The interdisciplinary approach aims at identifying high-risk patients for perineal wound complications who may benefit from primary reconstruction in order to reduce rate of wound complications with potential impact on rate of local recurrence. All these measures contribute to an optimized surgical standard.

Efficacy of Acellular Dermal Matrices in Revisionary Aesthetic Breast Surgery: A 6-Year Experience

Augmentation mammaplasty and augmentation mastopexy are associated with a substantial primary and secondary revision rate. Capsular contracture (CC), implant malposition, ptosis, asymmetry, and rippling are the main reasons for revisionary surgery in these patients. Traditional corrective techniques have not been completely reliable in preventing or treating these complications. Recently, acellular dermal matrices (ADM) have been used to assist with revisionary surgery with promising results. The authors review their 6-year experience using ADM for revisionary surgery in aesthetic patients and evaluate long-term outcomes with this approach. Patients who underwent revisionary breast augmentation or augmentation mastopexy with ADM in conjunction with standard techniques over a 6-year period between October 2005 and December 2011 were retrospectively reviewed. Only patients with at least 1 year of follow-up were included in the analysis. A total of 197 revisions were performed (197 patients). Reasons for revision included CC (61.8%), implant malposition (31.2%), rippling (4.8%), ptosis (4.8%), implant exposure (1.6%), and breast wound (0.5%). The mean ± SD follow-up period was 3.1 ± 1.1 years (range, 0.1-6.1 years). The complication rate was 4.8%, including Baker grade III/IV CC (1.6%), infection (1.6%), implant malposition (0.5%), hematoma (0.5%), and seroma (0.5%). Most (98%) revisions were successful, with no recurrence of the presenting complaint. The use of ADM in conjunction with standard techniques for the reinforcement of weak tissue in revision augmentation and augmentation mastopexy patients appears to be effective.

Total nasal reconstruction with total rib cartilage framework

To investigate a new technique for nasal reconstruction with total rib cartilage framework. The expanded frontal flap was fabricated by skin expansion and flap delay to cover the reconstructed nose. The dorsal flap was reversed as the lining of reconstructed nose. The whole framework was made by rib cartilage. Secondary revision operation was also performed to make the reconstructed nose more natural. Total nasal reconstruction was performed successfully in 37 cases. Each patient underwent 4-7 operation during a period of 6-8 months. 32 patients were followed up for 12-24 months. The reconstructed nose had a natural skin color and symmetric appearance with good ventilation and less scar. Both doctors and patients were satisfied with the results. Satisfactory cosmetic result and ventilation function can be achieved by nasal reconstruction with total rib cartilage framework.

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Salvage procedures in reconstructive urology.

This is an interesting evaluation of a group of extremely complicated patients, who developed non reconstructible bladder outlets either due to injury, trauma or surgical misadventure. In my personal experience, this is one of the most difficult groups of patients to reconstruct and often requires heroic measures to salvage their quality of life and continence status. The authors are to be congratulated on their perseverance and well–planned care of this devastating patient group. As the study implies, this type of injury can occur from a variety of causations, including post prostatectomy incontinence, bladder neck stenosis, neurogenic dysfunction, urethral tumor recurrence and patients with neobladders and post–tension–free vaginal taping (TVT) or colposuspension incontinence. Because this study includes both men and women, the authors have used a variety of techniques for purposes of closing the bladder neck. However, they have provided all patients with continent vesicostomy using an ileal segment that provides not only an augmentation but also a catheterizable stoma. Their results are emblematic of their technical skill and their intensive care of these individuals with an overall primary incontinence rate of 86.7. Bladder neck closure, in and of itself, is a complicated procedure. The use of interposition grafts is a critical consideration, especially in women. Unfortunately, bladder neck closure can result in persistent fistulization, which can be very problematic for subsequent management purposes. The authors are to be commended regarding their results with this as well. As the authors note, patients will require subsequent revisions for a variety of techniques and in fact, two of these series did demonstrate the need for secondary revisions. Complications are also common; both related to the use of bowel as well as the related issues of perineal breakdown and wound problems associated with bladder neck closure. Due to mesh related complications in North America, bladder neck injury is being increasingly encountered. The primary efforts for these individuals are related to urethral reconstruction with autologous bladder neck slings, in an effort to salvage them. However, in some cases where mesh has been present for long periods, fixation and fibrosis in the peri–vesical and peri–bladder neck area results in substantive difficulties in management of these individuals. This can cause the ability to fall back to a bladder neck closure with an adequate pop off mechanism, in this case catheterizable stoma, to be a critical surgical technique. Again, I wish to personally congratulate the authors on the results and their care of this particularly bothered group of individuals.

Technical Considerations in Abdominoplasty of Huge Abdomen

In abdominoplasty, the surgeon aims to contour the abdominal wall and create a balanced relationship with the lower body contour. The condition huge abdomen is characterized by severe lipohypertrophy; marked laxity of the abdominal skin, which almost overlaps the mons pubis and upper thighs; divarication of the recti; and ptosis of the mons pubis. Abdominoplasty of huge abdomen carries a higher risk of postoperative complications and unaesthetic results. This study presents certain technical considerations in liposuction: preservation of the vascular perforators and subumbilical scarpa fascia, undermining/resection of the abdominal skin, performance of umbilicoplasty, and lifting of the mons pubis. From June 2009 to June 2011, abdominoplasty were performed on 112 patients with the condition huge abdomen. Body weights ranged from 89 to 105 kg, with a mean of 92 kg. Body mass index ranged from 32.7 to 37.4, with a mean of 35.2. After an average follow-up period of 1 year, 93 patients (83%) achieved good aesthetic results and had no major or local postoperative complications. In 4 patients (3.6%), seroma was an early postoperative complication. Six patients (5.4%) developed long-term unfavorable aesthetic results, which required secondary revisions. This study focuses on certain type of abdominal wall obesity that requires abdominoplasty and provides some technical considerations to achieve a safe and aesthetic outcome.

Focus on Technique

Prosthetic-based breast reconstruction commonly involves device placement in either a total submuscular pocket or a partial subpectoral position for just superior pole coverage, with various possible strategies for inferior pole coverage. Historically, the pectoralis major muscle is managed either by suturing the muscle to the inferior flap or with marionette sutures; alternatively, the device is placed under total muscle/fascia coverage (under the pectoralis major, plus the serratus anterior and rectus abdominis muscles or fascia). For many plastic surgeons, acellular dermal matrix is now used instead to function as a sling or "hammock" supporting the periprosthetic pocket and thus covering the inferior pole of the device, attached to the pectoralis major muscle above and to the inframammary fold below. In addition to its added soft-tissue support in the inferior pole, acellular dermal matrix may help to stabilize the pectoralis major muscle along its inferolateral margin, create a well-defined inframammary fold, provide the opportunity to significantly increase intraoperative fill volume of the tissue expander, and reduce the incidence or severity of significant or symptomatic capsular contracture, particularly in a patient whose breast has been treated with radiation. In addition to its indications in primary breast reconstruction, acellular dermal matrix has been increasingly used in secondary revision reconstruction cases. It can be used to buttress capsulorrhapy and capsulotomy sites and it can be used to replace periprosthetic capsule following capsulectomy. While clinical experience is accruing for these indications, acellular dermal matrix continues to be used in primary and secondary breast reconstruction.

Rhinoplasty in the Black Sea Region

We have retrospectively evaluated the charts of 120 patients who had undergone rhinoplasties. The noses were divided into 2 types. Type 1 (42 cases) was characterized by a normal radix, high dorsum, and prominent vault. These noses were corrected by dorsal reduction, lateral osteotomy when needed, and caudal septal resection. Type 2 (78 cases) was characterized by a dependent tip with inadequate projection and a low radix with an excessive projected dorsal hump. These noses were corrected by tip support with cartilage graft and/or various suturing techniques and dorsal reduction. Secondary revision was necessary in 26 patients (21.6% of the total number) mostly due to inadequate septal correction in the first operation and irregularities of the dorsum. The postoperative result was considered as good in 88 (81%), fair in 27 (15%), and poor in 5 (4%) by the patients. Although the cases presented in this series were mostly difficult ones, experience was found to be the major determinant in success while dealing with the challenging noses of the Black Sea Region.

Immediate Osseous Genioplasty With Kirschner Wire Fixation for Revision of Infected Alloplastic Chin Implant

Genioplasty is a useful tool for correction of congenital abnormalities, as well as for aesthetic improvements of the lower face. Both alloplastic implantation and osseous genioplasty techniques have long been used successfully to achieve satisfactory outcomes. However, alloplastic implantation can be associated with several known complications, including infection, bone resorption, and secondary soft tissue deformities. Typically, these issues arise in the early postoperative period, but there have been reported instances of late infectious complications and the associated sequelae. These cases are generally treated with removal of the implant and secondary revision at a later date. We present here the unique case of a 65-year-old woman who presented with an infected silicone chin implant 25 years after her initial surgery. In this case, we chose to perform an immediate osseous genioplasty at the time of implant removal to avoid the problems that can arise from unpredictable soft tissue healing, as well as an untoward aesthetic result from the significant bone resorption that had occurred in this patient. To minimize the presence of exposed hardware in this contaminated field, we used intraosseous Kirschner wire fixation for osteosynthesis of the advanced genial segment. Our patient experienced no complications from this procedure, the infection cleared, and a successful aesthetic outcome was achieved with this technique.

The Forked Liposuction Cannula

Cicatricial contracture deformities in breast reconstruction can result from delayed wound healing, fat necrosis, or chest wall radiation. Secondary revision can be difficult as these contour deformities compromise the final result. The authors describe correction of these scar deformities with a forked liposuction cannula in 38 breast reconstructions (32 patients). Mean follow-up time was 6 months, and no complications resulted from the use of the forked cannula. In 33 reconstructions (86.8%), autologous fat grafting was performed simultaneously. Multiple revisions were required in 8 reconstructions (23.7%). Three patients had a residual contracture after treatment; all 3 had a history of radiation therapy. This early experience demonstrates that use of a forked liposuction cannula for cicatricial breast deformities is both easy and safe. This technique can be a useful adjunct, especially in patients undergoing autologous fat grafting; however, residual contracture may be observed in patients with a history of radiation therapy.