Reconstruction of the cervical esophagus with a free inferior rectus abdominis flap

An inferior rectus abdominis flap was transferred in an 83-year-old female patient with a cervical esophageal carcinoma. This flap can be a good option for pharyngoesophageal reconstruction when it is desirable to avoid laparotomy and to shorten the operating time in an elderly or high-risk patient.

[Recent advance in head and neck reconstruction]

The clinical application of microvascular free-flap transfers in reconstructive surgery has expanded tremendously since their introduction. Difficult reconstruction in the head and neck region can now be accomplished in a one-stage procedure using these techniques. Free flaps such as rectus abdominis, forearm, and scapular flap have been used frequently in this region because of their many advantages. They have a long vascular pedicle of a large-caliber vessel with anatomic stability and have ample blood supply. It is easy to harvest, and donor site morbidity in negligible. However, further improvement and refinement of surgical procedures are required to obtain better functional results and increase patients' quality of life. In this article, we describe the most recent concepts and techniques in head and neck reconstruction.

Free jejunal patch to reconstruct oral scar contracture following caustic ingestion

Reconstruction of oral scar contracture is often a challenging problem due to the complex structures and functions of the oral cavity. This report describes the treatment of a patient who sustained extensive oral scar contracture following caustic liquid soda ingestion. Surgical release of the scar contracture formed an S-shaped, thin, long defect that was difficult to cover with a conventional flap or skin graft. A jejunal segment was transferred microsurgically as a patch to reconstruct the defect. It sustained a sufficient oral space to provide full opening of the mouth and good movement of the tongue. A free jejunal flap, used occasionally for reconstruction following oral cancer resection, has significant advantages for restoration of function after release of an oral scar contracture.

Rescue of liver grafts from hepatic artery occlusion in living-related liver transplantation

BACKGROUND

Hepatic artery thrombosis after liver transplantation remains a significant cause of graft loss and death. Retransplantation is a difficult option after living-related liver transplantation in Japan.

METHODS

Twenty-seven patients underwent living-related liver transplantation with left-sided liver grafts donated from their relatives. The hepatic artery was anastomosed end to end under a surgical microscope. Anticoagulant therapy was maintained for 2 weeks after operation. Routine post-transplant Doppler ultrasonography together with serum blood tests were performed twice a day during the first 2 weeks.

RESULTS

Three patients developed hepatic artery occlusion, which was identified by routine Doppler ultrasonography before the serum transaminase values increased on days 7, 7 and 3 after surgery respectively. In two of the three patients, no apparent arterial thrombosis was recognized and vasospasm was therefore considered to be the cause of the occlusion. Arterial patency was restored by urgent revascularization with reanastomosis in all patients, but one patient with a functional graft died from a cerebral haemorrhage on day 47.

CONCLUSION

Early diagnosis of hepatic artery occlusion by routine Doppler ultrasonography and revascularization of the graft is an indispensable strategy for preventing graft loss after living-related liver transplantation.

Versatility of the inferior epigastric artery as an interpositional vascular graft in living-related liver transplantation

We have used the recipient inferior epigastric artery as an interpositional vascular graft in living-related liver transplantation cases with hepatic artery obstruction, enabling us to restore the arterial inflow sufficiently to the transplanted liver. The inferior epigastric artery is easy to access during abdominal surgery. Easy to harvest, it is anatomically constant and has a caliber equivalent to that of the hepatic artery. Donor site morbidity is negligible. There is no risk of rejection because of the autograft. There has been no report on the availability of the inferior epigastric artery for hepatic artery reconstruction. We consider this vessel as a good option for an arterial conduit in case of the inadequacy or thrombosis of the hepatic artery in living-related liver transplantation.

Congenital cheek fistula: a report of three cases

Three cases of the rare condition of congenital cheek fistulae are presented. These differ from preauricular fistulae in terms of their location and the direction in which the fistula is lying. Each cheek fistula seemed to be situated along the line of the junction between the mandibular and maxillary processes of the first branchial arch.

Anterolateral thigh flap for abdominal wall reconstruction

The free or pedicled anterolateral thigh flap was introduced for the reconstruction of large abdominal wall defects. This flap is superior to the tensor fasciae latae musculocutaneous flap in several respects. These include the wide, reliable skin territory (which can reach the level of the knee) and the long pedicle. Therefore, a pedicled anterolateral thigh flap with reliable blood circulation can easily be positioned above the umbilicus. In addition, the free anterolateral thigh flap has greater freedom of orientation and can be used to repair larger abdominal wall defects than can the tensor fasciae latae flap. Seven patients in whom abdominal wall defects had been reconstructed with pedicled or free anterolateral thigh flaps were reviewed. Their average age was 47.1 years (range, 21 to 74 years), and the average follow-up period was 10.7 months (range, 2 to 21 months). The size of the abdominal wall defects ranged from 12 x 12 cm to 18 x 24 cm, and the size of the transferred flap ranged from 10 x 20 cm to 20 x 20 cm. Three flaps were pedicled and four were free, of which three incorporated the tensor fasciae latae flap. All flaps survived completely, and no postoperative abdominal hernias developed. Despite some variations in vascular anatomy and technical difficulties in elevating the anterolateral thigh flap, the authors conclude that the pedicled or free anterolateral thigh flap is superior to the tensor fasciae latae flap for reconstruction of large abdominal wall defects.

Reorganization of the primary afferent termination in the rat spinal dorsal horn during post-natal development

To study the reorganization of the primary afferent input in the spinal dorsal horn during post-natal development, synaptic responses evoked by large Abeta and fine Adelta afferents were recorded from substantia gelatinosa (SG) neurons in slices obtained from immature (post-natal days 21-23) and mature rats (post-natal days 56-60). Threshold stimulus intensities and conduction velocities (CVs) of Abeta and Adelta afferents were determined by intracellular recordings of the antidromic action potentials from dorsal root ganglion (DRG) neurons isolated from immature and mature rats. In immature rats, excitatory postsynaptic currents (EPSCs) were elicited by stimulation sufficient to activate Abeta afferents in the majority of SG neurons (64.9%, 24 of 37 neurons), while most EPSCs observed in mature rats were elicited by stimulation of Adelta afferents (62.5%, 25 of 40 neurons). These observations suggest that the primary afferents innervating SG neurons were reorganized following maturation; Abeta afferents were the predominant inputs to the SG neurons in the immature state, thereafter Adelta afferents were substituted for the Abeta afferents to convey sensory information to the SG neurons. This relatively slow reorganization of the sensory circuitry may correlate with slow maturation of the SG neurons and with a delay in the functional connections of C afferents to the SG neurons.

Multi-bracket appliance in management of mandibular reconstruction with vascularized bone graft

BACKGROUND

The most commonly used tool for maxillo-mandibular fixation to the patient who underwent reconstruction using a vascularized bone graft after mandibular resection is a dental arch-bar. However, the occlusal relationship achieved by this method is not ideal. Different from the dental arch-bar, the multi-bracket appliance which is frequently used in orthodontic treatment can control the position of each individual tooth three dimensionally. Thus, this appliance was applied for maxillo-mandibular fixation to patients who underwent mandibular reconstruction using a vascularized bone graft.

METHODS

A multi-bracket appliance was applied to three patients. Prior to the surgery, standard edgewise brackets were bonded to the teeth in the maxilla and in the remaining mandible. After mandibular resection, wires for maxillo-mandibular fixation were applied. The harvested bone was then carefully fixed with miniplates to maintain the occlusion. The multi-bracket appliance was worn for 3 months when the wound contraction became mild.

RESULTS

All three cases demonstrated stable and good occlusion. They also demonstrated satisfactory post-surgical facial appearance.

CONCLUSIONS

Compared to conventional dental arch-bars, a multi-bracket appliance offers improved management of mandibular reconstruction. Firstly, its properties are helpful in maintaining occlusion of the remaining dentition accurately in bone grafting procedure as well as protecting against postsurgical wound contraction. Secondly, the multi-bracket appliance keeps the oral cavity clean without periodontal injury. As a result, stable occlusion of the residual teeth and good facial appearance were obtained.

Prefabricated free jejunal transfer: a new reconstructive technique for high pharyngeal defects

A new method that uses a prefabricated free jejunal transfer has been applied to three cancer patients with pharyngoesophageal defects with a high pharyngeal deficit extending up to the nasopharynx. In this method, the jejunum harvested in the usual manner is divided into two segments with a single vascular pedicle. Its distal segment is used to reconstruct the cervical esophagus, and its proximal segment is turned over to create a mucosal patch to cover the high pharyngeal defects. The two segments are then co-apted in a side-by-side anastomosis. The esophagus can be reconstructed in a naturally straight shape without a curved portion or blind loop formation, thus leading to good swallowing function. In our series, all grafts survived well and there was no complication directly related to jejunal transfer. All patients could tolerate a soft diet without difficulty. This method is easy to perform and applicable to any shape or size of very high pharyngeal defects that cannot be reconstructed properly by other methods. Although patients with an advanced hypopharyngeal cancer usually have a poor prognosis, this technique allows a better quality of life for a probable short life span.

Free adipofascial flap for scalp reconstruction: case report

The authors describe a case in which a large defect of the scalp was present after tumor excision. It was covered with a free adipofascial flap and a split-thickness skin graft, with satisfactory results. Numerous similar cases of scalp defects reconstructed with other free flaps have been described. But since donor-site morbidity is minimized with free adipofascial flaps, they should be used more often for reconstruction of scalp defects.

Anatomic variations and technical problems of the anterolateral thigh flap: a report of 74 cases

We have transferred 74 free or pedicled anterolateral thigh flaps, including those combined with other flaps, for reconstruction of various types of defects. We report several anatomic variations of the lateral circumflex arterial system and discuss some technical problems with this flap. Septocutaneous perforators were found in 28 of 74 cases (37.8 percent), and no perforators were found in 4 cases (5.4 percent). In the 70 cases with perforators, 171 tiny cutaneous perforators (an average of 2.31 per case) were found. Musculocutaneous perforators (81.9 percent) were much more common than septocutaneous perforators (18.1 percent). Perforators were concentrated near the midpoint of the lateral thigh, and the selection of perforators as nutrient vessels for the anterolateral thigh flap was related to the length of the pedicle and the thickness of the skin flap. Anatomic variations of the branching pattern of perforators were classified into eight types. Flaps with perforators that arise directly from the profunda femoris artery are difficult to combine with other free flaps. Because the perforators are extremely small and tend to thrombose soon after congestion develops, these flaps are difficult to salvage with recirculation surgery. Therefore, several perforators should be included with the flap, if possible. The descending artery of the lateral circumflex femoral artery was always accompanied by two veins with different back-flow strengths. Therefore, veins for microsurgical anastomosis must be chosen carefully. Because it is nourished by several perforators arising from the descending artery, the vastus lateralis muscle can be combined with the anterolateral thigh flap. However, splitting the muscle longitudinally without harvesting its blood supply is complicated because its fibers are oblique. The rectus femoris muscle can also be combined with the anterolateral thigh flap, but its pedicle is short and its origin is very near the site of anastomosis. When the anterolateral thigh flap is combined with the tensor fasciae latae musculocutaneous flap, the large skin area of the lateral part of thigh can be transferred to repair the massive defects. The anterolateral thigh flap has many advantages and can be used to reconstruct many types of defect. However, anatomic variations must be considered if the flap is to be used safely and reliably.

Comparative evaluation in pharyngo-oesophageal reconstruction: radial forearm flap compared with jejunal flap. A 10-year experience

We reviewed 109 consecutive patients with cancer of the hypopharynx or cervical oesophagus who underwent free flap transfer for immediate reconstruction after total pharyngolaryngo-oesophagectomy. The free flaps used were either free jejunal (n = 70) or radial forearm flaps (n = 39). Significantly more fistulas (3/70 compared with 15/39, p < 0.0001) and strictures (6/64 compared with 13/33, p = 0.0008) developed in the radial forearm than the jejunal flap group. However, functional donor site morbidity was minimal and there were no cases of total flap necrosis in the forearm flap group. We consider that the free jejunal flap should be the first choice for total reconstruction of pharyngo-oesophageal defects. However, the forearm flap is suitable for elderly, high risk patients, because it is less invasive and has minimal donor site morbidity, which facilitates early recovery.

Laryngeal preservation surgery using a free flap patch following resection of a carcinoma of the posterior wall of the oropharynx

A carcinoma originating from the posterior wall of the oropharynx is not common, and radiotherapy has been used for years in this event without acceptable success. A free flap patch was used in 4 patients to reconstruct the defect after resection of a T2 or T3 carcinoma on the posterior wall of the oropharynx without laryngectomy. The free flaps used were the radial forearm and the free jejunal patch in 2 patients each. There was no flap loss, and successful laryngeal preservation was obtained in 3 of 4 patients. Laryngeal preservation surgery using a free flap patch proved very useful in selected patients with carcinoma of the posterior wall of the oropharynx. Based on our clinical experience, the free jejunal patch seems superior to the free forearm flap with regard to postoperative functional results.

One-stage reconstruction of an upper part defect of the auricle

A one-stage procedure for the reconstruction of a defect of the upper auricle is described. The anterior surface of a carved costal cartilage graft was covered with an anterosuperiorly based skin flap, and the posterior surface was covered by the superficial mastoid fascial flap and a skin graft. This method can be performed easily, without leaving any scar in the hair-bearing area or visible postauricular region, and can be applied to cases in which the condition of the margin scar of an auricular defect is poor.

One-stage transfer of the latissimus dorsi muscle for reanimation of a paralyzed face: a new alternative

The two-stage method combining neurovascular free-muscle transfer with cross-face nerve grafting is now a widely accepted procedure for dynamic smile reconstruction in cases with long established unilateral facial paralysis. Although the results are promising, the two operations, about 1 year apart, exert an economic burden on the patients and require a lengthy period before obtaining results. Sequelae such as hypoesthesia, paresthesia, and conspicuous scar on the donor leg for harvesting a sural nerve graft also cannot be disregarded. To overcome such drawbacks of the two-stage method, we report a refined technique utilizing one-stage microvascular free transfer of the latissimus dorsi muscle. Its thoracodorsal nerve is crossed through the upper lip and sutured to the contralateral intact facial nerve branches. Reinnervation of the transferred muscle is established at a mean of 7 months postoperatively, which is faster than that of the two-stage method. In our present series with 24 patients, 21 patients (more than 87 percent) believed that their results were excellent or satisfactory, which also compares well with the results of the two-stage method combining free-muscle transfer with cross-face nerve graft.

Dumbbell type jugular foramen meningioma extending both into the posterior cranial fossa and into the parapharyngeal space: report of 2 cases with vascular reconstruction

Two cases with huge dumbbell type jugular foramen meningioma with extension into the parapharyngeal space are reported. A well co-ordinated surgical strategy for total resection to this high risk tumour with neurosurgeons, otolaryngologists and plastic surgeons is mandatory to minimise operative complications. Both of our patients presented with a cervical mass and lower cranial nerve palsies, and had huge dumbbell type masses extending from the posterior cranial fossa through the jugular foramen to the parapharyngeal space, encasing the cervical internal carotid artery. Gross total resection of the tumours was successfully achieved by basically a 2-stage operation. In the first stage, posterior fossa tumours were removed by the transjugular approach, combined with the petrosal approach in one case. In the second stage, cervical tumours were removed along with the cervical carotid artery by the transcervical and/or transmandibular approach, followed by vascular reconstruction from the ipsilateral carotid artery to the middle cerebral artery using saphenous vein graft. From these experiences, we recommend this 2-stage operation for large dumbbell type meningiomas extending to the infratemporal/parapharyngeal space. The intracranial tumour is removed at the first operation. The extracranial portion is resected at the second, and if necessary, the involved cervical carotid artery is resected and simultaneous revascularisation using saphenous vein graft is performed with a vascularised free muscle graft. This strategy could maximise the functional preservation on the one hand, and minimise the surgical risk, such as postoperative infection, on the other.

A new concept and technique for reconstruction of the lower pharyngeal space using the free jejunal graft

OBJECTIVE

To report on a new concept and simple operative procedure to conform the diameter of the oral end of free jejunal grafts to that of pharyngeal defects for reconstruction of the lower pharyngeal space.

DESIGN AND METHODS

A preliminary study showed that the jejunum is supplied by a highly vascular network and that longitudinal paramesenteric incisions can be made without disturbing the blood supply of the jejunum. We then developed the following operative procedure. The position of the highest point of the pharyngeal defect and the site of the recipient vessels are determined. The free jejunal graft is positioned with its mesentery in correspondence with the location of the recipient vessels. The position of a longitudinal incision 180 degrees to the highest point of the defect is then determined. After the oral border of the jejunum is opened with scissors, a pharyngojejunal end-to-end anastomosis is performed.

PATIENTS

Eighteen patients with defects of the lower pharyngeal space after cancer treatment.

RESULTS

We transferred jejunal grafts in 18 patients using this operative procedure. In 7 of these patients, paramesenteric incisions were made. The lengths of the incisions ranged from 2 to 8 cm. Transfer was successful in all 18 patients. Postoperative leakage occurred in 1 patient in whom an antimesenteric incision had been made; however, a fistula did not develop.

CONCLUSIONS

Our method allows defects of the lower pharyngeal space to be reconstructed with end-to-end anastomosis of free jejunal grafts regardless of the location of the defect or of recipient vessels. This method is simple and appropriate for correcting large pharyngeal defects.

Free forearm flap reconstruction of the posterior tracheal wall invaded by esophageal carcinoma

A patient with a locally advanced cervical esophageal carcinoma invading the trachea underwent total esophagopharyngolaryngectomy and resection of the posterior wall of the trachea. The esophagus was repaired with a gastric pull-up, and the posterior defect in the trachea was repaired with a free radial forearm flap, obtaining a satisfactory result.

Secondary lengthening of the reconstructed mandible using a gradual distraction technique--two case reports

We have performed mandibular lengthening to restore oral function in 2 cases after tumour resection. Both cases had already undergone a vascularised fibular graft for mandibular reconstruction and had severe contracture and absence of an alveolar ridge for dentures. Gradual distraction was applied after corticotomy of the fibular bone at 0.9 mm per day. After completion of bone lengthening of 20-30 mm, both patients underwent a split thickness skin graft to obtain a good alveolar ridge for dentures and implants. Osteointegrated implants have since been applied in one of these cases, and the other patient has been able to eat a normal diet using dentures. Gradual distraction is applicable for vascularised bone grafts and useful for restoration of the alveolar ridge to accommodate dentures in cases with severe contracture of the oral space after tumour ablation.

Immediate free flap reconstruction for head and neck pediatric malignancies

We performed six immediate free flap reconstructions after tumor ablation in 5 children under the age of 15 years presenting with head and neck malignancy. One patient underwent free flap transfer on two separate occasions because of tumor recurrence. There were no flap losses nor were there any complications related to microvascular surgery. Although a pediatric head and neck malignant tumor is rare, surgical resection is the primary therapeutic role for those that are amenable to complete excision. Pediatric microsurgery provides a safe and reliable procedure for reconstruction of head and neck defects after extirpation of the tumor.

Closure of large pharyngo-oesophageal fistulas with free flap transfer after resections for cancer

Postoperative salivary fistulas still remain a serious and potentially lethal problem in head and neck reconstruction particularly if the fistula is large and involving one half or more of the circumference of the pharyngo-oesophagus. Pedicled flaps have traditionally been the flaps of choice for closure of these fistulas, but the results are often disappointing. During the period 1982 to 1995, we have used either a radial forearm free flap or a jejunal free flap to close large and complex pharyngo-oesophageal fistulas after resection for cancer in 15 patients. Although two patients developed major fistulas that required additional operations for closure, successful closure was achieved in all but one case: the success rate was therefore 14/15 (93%). We consider that jejunal flaps are suitable for circumferential pharyngo-oesophageal reconstruction and forearm flaps for non-circumferential defects.

A second primary squamous cell carcinoma arising in a radial forearm flap used for reconstruction of the hypopharynx

A 63-year-old man had undergone hypopharyngectomy for hypopharyngeal carcinoma in 1985. A free radial forearm flap was used for reconstruction of the pharynx. Ten years after the surgery, a second primary squamous cell carcinoma occurred in the neopharynx. Persistent exposure to alcohol, saliva and foodstuffs was considered as a possible cause of second primary carcinoma. Long-term follow-up is indicated in patients undergoing reconstruction using cutaneous or musculocutaneous flaps.

Clinical value of computer-generated acrylic skull replicas produced by laser lithography

To determine for what deformity and utility the computer-generated acrylic (CGA) skull replica has the greatest value, we analyzed retrospectively a consecutive series of patients with craniomaxillofacial deformities (N = 54) whose treatment involved the utilization of CGA skull replicas. Application of the CGA skull replica was divided retrospectively into four groups: (1) use as an aid for preoperative analysis of osseous deformity, (2) use as material for preoperative surgical simulation, (3) use as a navigational aid during an operation, and (4) use as a negative template. Based on the aspects of these utilizations, we evaluated for what deformity the CGA skull replica was useful. Analysis of the data led us to conclude the following. First, the CGA skull replica is a valuable tool in craniomaxillofacial surgery, especially for patients with asymmetrical deformities and delicate convexities and concavities of the skull surface. Second, the largest function that CGA skull replicas can satisfy is standardization of craniomaxillofacial surgery. In carrying out preoperative surgical simulation utilizing a replica, drawing osteotomy lines on it, sterilizing it, and then bringing it to the operating table for consultation whenever required during an operation, we are able to proceed with greater precision and speed than if it was not available.