Histopathologic changes after tracheobronchial reconstruction with costal cartilage graft for congenital tracheal stenosis

BACKGROUND/PURPOSE: Congenital tracheal stenosis is an uncommon, life-threatening condition. Recently, tracheoplasty using costal cartilage grafts to enlarge the lumen was used successfully in such cases. In this study, we evaluated postoperative changes of costal cartilage grafts after tracheoplasty. METHODS: Costal cartilage patch tracheoplasty was used for surgical correction of long-segment congenital tracheal stenosis in 18 infants. Six patients whose tracheal specimens were obtained at autopsy are included in this study. The mean age at the time of repair was 4.8 months, and the mean period after operation was 7.5 months. Cartilage graft survival and epithelialization of inner layer was evaluated in each case. RESULTS: The mean width and length of grafts was 6.3 x 35 mm at operation and 4.0 x 22 mm at autopsy. The graft size was diminished gradually after operation and was replaced completely by mature scar tissue 2 years after operation. However, diameter of the reconstructed site was not reduced. Reepithelialization of the graft site with ciliated columnar epithelium was found in every case. Chondrocyte numbers were reduced and remaining cartilage was rather eosinophilic, suggesting that the degenerative process was ongoing in the graft. CONCLUSIONS: The costal cartilage grafts established a functional tracheal lumen, and reepithelialization with ciliated columnar epithelium was found at the graft site. The costal cartilage grafts continues to be an important option as graft material for tracheal reconstruction in infants with long segment congenital tracheal stenosis.     

Reconstruction of tracheal defects with dehydrated human costal cartilage: an experimental study in rats.

Reconstruction of tracheal defects continues to be a difficult problem in head and neck surgery. In this study, to evaluate the outcomes of tracheal reconstruction with a nonautogenous material, we used solvent-dehydrated human costal cartilage in 3 different forms: graft, neovascularized graft, and prefabricated free flap. Thirty-five Sprague-Dawley rats were distributed into 3 groups with 10 animals in groups 1, 10 in group 2, and 15 in group 3. Surgically created tracheal defects were repaired with a free cartilage graft in group 1, and a piece of cartilage was neovascularized for 3 weeks in the inguinal region and then used as a fibrovascular tissue-coated cartilage graft in group 2. In group 3, the neovascularized cartilage was transferred to the defect as a prefabricated free flap based on a vascular pedicle containing femoral vessels. Four weeks later, the tracheal reconstruction specimens were evaluated with light microscopy to determine cartilage survival, infection, and epithelial regrowth. The most favorable outcomes were obtained in group 3, where the material was used as a prefabricated neovascularized free flap.     

An alternative procedure for conjunctivodacryocystorhinostomy: supratrochlear artery-based island flap combined with buccal mucosal graft

Reconstruction of the total canalicular obstruction with destroyed medial canthal area is a challenging procedure for ophthalmic, plastic, and reconstructive surgeons. In the case presented, a supratrochlear artery--based island flap combined with a buccal mucosal graft was used for reconstruction of the medial canthal area. The medial canthal area was scarred significantly and demonstrated a medial ectropion and complete canalicular obstruction.To our knowledge, it is the first time for combined reconstruction of the medial canthal area and lacrimal drainage system in 1 stage, with island median forehead flap based on supratrochlear artery and buccal mucosal graft. During the 2-year follow-up period, no complication was encountered and the patient healed uneventfully.     

Complex partial nasal reconstruction using free prelaminated temporoparietal fascial flap

The reconstruction of nasal defects together with nasal lining, skeletal support, and skin loss constitutes difficulty to plastic surgeons. We present a single‐stage reconstruction of the defect formed on the nasal tip, columella, septum, and upper lip after tumor excision by performing free temporoparietal fascial flap, costal cartilage, and skin graft. In this case, cartilage support was created by the graft taken from costal cartilage, and free temporoparietal fascial flap was wrapped around this cartilage scaffold. Skin graft taken from scalp was placed on the skin surface, and skin graft taken from the thigh was placed on the mucosal surface. Vascular anastomoses were performed on the labial artery and the concomitant vein. In consequence of this operation, a nasal reconstruction with acceptable esthetic and functional results was provided in a complex nasal defect. Internal lining, skin, and cartilage structures were replaced in one single stage and with single flap and graft. © 2012 Wiley Periodicals, Inc. Microsurgery, 2013.     

Vascular-pedicled costal cartilage graft for the treatment of subglottic and upper tracheal stenosis

Background/purpose

Free costal cartilage graft for the treatment of subglottic and tracheal stenosis is widely used, but postoperative granulation formation is a problem. To reduce the risk of granulation formation after free costal graft, a new operation of costal cartilage graft with vascular pedicle was introduced.

Methods

A vascular pedicled fifth costal cartilage graft is prepared using internal thoracic artery and vein and intercostal artery and vein as a vascular pedicle. The prepared graft is brought to the upper trachea. The anterior wall of cricoid is split, and the costal cartilage graft is implanted to the split part and tracheostomy. Extubation on the next day is possible if the general condition of the patient permits.

Results

In 3 cases of subglottic or upper tracheal stenosis, this operation was performed. All the patients had tracheostomy made during early infancy. The postoperative course was uneventful, and all the patients were extubated soon after the operation. No granulation tissue was obserbed by postoperative bronchoscopic examinations.

Conclusions

Costal cartilage graft with vascular pedicle is a safe and useful new operation for the treatment of subglottic and upper tracheal stenosis. There also is a possibility of using this procedure for the treatment of long segment tracheal stenosis.     

Elevation of a constructed auricle using the anteriorly based mastoid fascial flap.

Two-stage methods for reconstruction of congenital microtia have been widely utilised. To obtain a desirable auriculocephalic angle and provide a nutrient support to the constructed auricle, elevation of reconstructed ears using a costal cartilage graft, the anteriorly based mastoid fascial flap transfer and a skin graft was performed as the second operation for nine microtia patients. In this procedure, the mastoid fascial flap was used instead of the temporoparietal fascial flap. Following the elevation of the reconstructed ear the anteriorly based mastoid fascial flap was harvested. A carved costal cartilage was grafted at the posterior wall of the concha and covered with the mastoid fascial flap, followed by a full-thickness skin graft from the inguinal region. The skin grafts took well and the appropriate auriculocephalic angle was preserved in all cases. This method was easy to perform and did not leave any scar in the temporal hair-bearing area.     

Eyelid reconstruction using a hard palate mucoperiosteal graft combined with a V-Y subcutaneously pedicled flap.

Full-thickness eyelid defects after tumour ablation require the reconstruction of two layers, the anterior and posterior lamellae. Eyelids were successfully reconstructed after removal of malignant tumours in four patients using a hard palate mucoperiosteal graft combined with a curved V-Y subcutaneously pedicled flap. Although there have been some reports of hard palate mucosal grafts for reconstruction of the posterior lamella, the graft is not sufficiently rigid to support the reconstructed eyelid without the aid of supporting materials such as cartilage grafts. The hard palate mucoperiosteal graft seems to be rigid enough to support the reconstructed eyelid without the use of cartilage or other supporting materials. The subcutaneously pedicled V-Y advancement flap is useful for reconstruction of the anterior lamella in partial eyelid defects. We used it with a modified curved design to allow easy advancement and to make postoperative scars inconspicuous.     

Is the deltopectoral flap born again? Role in postburn head and neck reconstruction

After extensive use for head and neck reconstruction, the deltopectoral flap has been supplanted by alternative methods of reconstruction and relegated to historical references. However, it remains a very valuable skin flap and should keep its place in the armamentarium of reconstructive surgeons for postburn head and neck reconstruction. We report here five cases of head and neck reconstruction using the deltopectoral flap: one case of perioral reconstruction after ballistic trauma, one case of nasal reconstruction after burn and three cases of neck reconstruction after burn contracture. Technical simplicity and reliability are the main features of this flap. The skin paddle is thin and pliable, and its surface can be extended after a flap delay. Previous tissue expansion can minimize donor site morbidity. The flap division necessitates a second surgical procedure. The major burn contractures of the neck are, in our opinion, an excellent indication of the deltopectoral flap.     

耳后延迟皮瓣自体肋软骨支架法外耳再造术

目的 探讨耳后延迟皮瓣自体肋软骨支架法外耳再造术的临床效果.方法 手术分3期进行：Ⅰ期为耳后皮瓣延迟术,术后3周左右进行Ⅱ期手术;Ⅱ期为自体肋软骨支架再造、延迟皮瓣覆盖及自体中厚皮片移植外耳再造术,术后半年据情进行Ⅲ期手术;Ⅲ期行耳屏再造、耳甲腔加深和再造耳局部修整术等.结果 对先天性小耳畸形28例,31只耳,分次完成Ⅰ～Ⅲ期手术23只耳,余8只耳只完成Ⅰ、Ⅱ期手术.术后外耳位置、大小及形态良好,并发症少,患者及家属基本满意.结论 应用皮瓣延迟术不但可获取足够面积富有血运保障的菲薄皮瓣,而且方法简单、安全,所需时间短.耳后延迟皮瓣自体肋软骨支架法外耳再造术,是一种良好的外耳再造术方法.     

The periosteal-cutaneous chimeric medial femoral condyle free flap for subtotal ear reconstruction: A case report

When costal graft is contraindicated or refused by the patient, autologous total/subtotal auricular reconstruction represent a real challenge as limited surgical options has been described. Aim of present report is to offer a novel possible autologous reconstruction of the ear frame using a chimeric free medial femoral condyle (MFC) flap. We present a case of a 29 years old patient who had total loss of the upper 2/3 of the right ear after bombing in Somalia and secondary infected condritis (considered a relative contraindication for costal cartilage graft). The MFC flap was harvested with a chimeric skin paddle (7 × 5 cm), a thin sheet of femoral cortex (6.5 × 8 cm) was used as basal ear frame, while part of the contralateral concha was trimmed as support for the helix, with the periosteal component of the flap wrapping around the whole framework. The chimeric skin paddle assured the retroauricular skin coverage, while the anterior part of the construct was covered by a thinned dermal flap. Postoperative course was uneventful. A defatting procedure of the posterior skin paddle was performed at 2 months post-op. At 6 months post-op, the patient was satisfied with the result, could wear glasses and was socially integrated. This new application of the free chimeric MFC flap, despite being not the primary choice for ear reconstruction, guaranteed satisfactory results in terms of ear shape and infection prevention and may be considered when ordinary cartilage rib reconstruction is refused, contraindicated, or failed.     

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.     

The elevation of the constructed auricle with a temporoparietal fascial flap wrapping a resorbable plate.

During the second stage reconstruction of the auricle in patients with microtia, we modified Nagata's method and two technical improvements were possible. After the implanted auricle was separated from the bed, we harvested the temporoparietal fascial flap through helical rim incision instead of incising the temporal scalp. So the surgical scar over the temporal region was avoided. Thereafter, a costal cartilage wedge was carved and grafted to the posterior aspect of the conchal region to get a firm projection. But in cases of unavailable costal cartilage wedge graft, we used a resorbable plate composed of polylactic and polyglycolic acid as a substitute for the former so that we could create firm elevation and sufficient ear projection. Between June 2002 and May 2004, 28 patients underwent this operation with the temporoparietal fascial flap and resorbable plating system. There was no complication resulting from our technique. It was possible to create firm elevation and good frontal projection even if there was no available cartilage wedge. Additionally, by harvesting the temporoparietal fascia through helical rim incision, we avoid creating additional scars on the scalp.     

Maxillary reconstruction using a free deep inferior epigastric perforator (DIEP) flap combined with vascularised costal cartilages.

In this article, we describe a case of maxillary carcinoma requiring reconstruction in which we used a free deep inferior epigastric perforator (DIEP) flap combined with vascularised costal cartilages. The DIEP flap was harvested with a rectus abdominis muscle in its cranial side. Eighth and ninth costal cartilages were harvested and connected with the muscle. The Zygomaticomaxillary buttress was reconstructed using vascularised costal cartilages. Nasal and oral lining were reconstructed with a DIEP flap. The viability of grafted bone was proved in bone scintigraphy and three-dimensional computed tomography after six months. Cosmetically the result was good. Compared with other methods, this flap can be thinned easily to match a defect and vascularised cartilages connected with rectus muscle can be nourished by the same vascular pedicle. This is a first report of perforator flap combined with vascularised cartilage. This flap has a possibility to be used for a lot of reconstruction that needs bone reconstruction with perforator flap.     

Simultaneous reconstruction of cervical esophagus and oral cavity with one free jejunal graft

A case of simultaneous reconstruction of the cervical esophagus and oral cavity with one free jejunal graft is described. A 36-year-old patient had suffered from stricture of the cervical esophagus after reconstruction with a deltopectoral flap and, at the same time, had developed cancer of the anterior floor of the mouth. Both defects were simultaneously reconstructed with one free jejunal graft pedicled on one pair of jejunal vessels. A segment of jejunum was divided into three portions leaving the mesenterium intact. The middle portion was discarded; one portion was used for cervical-esophageal reconstruction and the rest was split longitudinally and used for resurfacing the oral cavity.     

The use of omental pedicle flap for tracheobronchial reconstruction in infants and children

For the surgical repair of long-segment tracheal stenosis, costal cartilage graft or extensive resection with end-to-end anastomosis has often been used. Both procedures have a risk of developing anastomotic leakage, which is potentially a lethal complication, or stenosis resulting from compromised blood supply to the tissue at the anastomosis. We have used omental pedicle flap (OPF) to seal the anastomotic line and to restore the vascularity of the graft and the trachea in an attempt to avoid fatal complications. During the period between 1986 and 1990, OPF technique was used in tracheobronchial reconstruction in six patients aged 4 months to 3 years; cartilage graft for extensive tracheal stenosis (4), tracheal resection and anastomosis (1), and bronchial resection and anastomosis (1). The omentum was separated from the colon to form an OPF with the right gastroepiploic vessels preserved. The OPF was brought to the upper trachea in the mediastinum through the retrosternal space. There was no immediate postoperative death due to anastomotic leak. Endotrachial tubes were removed in all patients. Four of the six are totally free of airway problems. One patient showed persistent stridor because of remaining stenosis at the cervical trachea. The remaining one patient who underwent bronchial resection developed anastomotic stenosis probably due to the compression of the floppy left main bronchus by adjacent aorta. The OPF seems to be an important surgical adjunct in order to eliminate fatal complications in tracheobronchial reconstruction.     

乳突区皮瓣法在先天性中重度杯状耳三维重建中的应用

目的 探讨中重度杯状耳三维立体重建的有效方法及临床效果.方法 采用乳突区皮瓣及自体肋软骨切取的Ⅱ期再造方法对中重度杯状耳进行三维重建.Ⅰ期行外耳皮肤脱套、乳突区皮瓣分离;切取肋软骨与耳轮软骨桥接重建耳上极及乳突区皮瓣包盖.Ⅱ期行再造耳上极掀起,耳后筋膜瓣覆盖及植皮重建.结果 18例中重度杯状耳畸形患者,1例桥接处糜烂,软骨部分坏死,其余均Ⅰ期成活,随访3～26个月,外形满意.结论 应用乳突区皮瓣法重建中重度杯状耳,强调细节亚单位构建,再造耳更加安全、美观,手术成功率和医患满意率高,并发症少.     

Nipple reconstruction using the modified top hat flap with banked costal cartilage graft: long-term follow-up in 58 patients

The long-term projection of nipple reconstruction is a challenge. Fifty-eight consecutive female patients underwent 58 nipple reconstructions with modified top hat flap with cartilage graft following breast reconstruction in 54 autologous tissues and 4 implants, respectively.The average neonipple size was 11.5 mm initially and 8.5 mm at a mean follow-up of 44.9 months (range, 24-65 months), with a mean decrease in projection of 26.1%. Thirty-three patients achieved an excellent result, 20 patients a good result, 3 patients a fair result, and 2 patients a poor result, respectively. The complication rate was 12.1% (7 of 58 cases), and there was no statistically significant difference between the immediate and delayed groups; the revision rate was 8.6% (5 of 58 cases).The modified top hat flap with banked costal cartilage graft provides a sustainable solution to the gradual loss of nipple projection, with few complications.     

Reconstruction of a full-thickness alar wound using an auricular conchal composite graft

Nasogastric intubation has become a frequently used method for alleviating gastrointestinal symptoms. Necrosis from alar pressure during prolonged nasogastric and nasotracheal intubation is common, and can result in considerable deformity if it is unrecognized. The reconstruction of full-thickness alar wounds often requires multiple challenging surgical procedures. Difficult full-thickness alar defects often require nasal mucosal replacement for lining, cartilage batten graft support for the preservation of nasal function, and skin coverage for the restoration of an aesthetically correct appearance. Free composite conchal grafting can offer a single-staged, one-step repair of difficult full-thickness alar wounds that are no larger than 1.5 cm in size. A thorough explanation of the graft design and execution is presented, as well as a case report and literature review. Free composite conchal grafting can produce aesthetic and functional results that rival the most sophisticated flap reconstructions of the lateral ala.     

Temporoparietal Fascia Flaps for Surgical Treatment of Cartilage Exposure After the First-Stage Microtia Reconstruction

Significant improvements have been achieved in microtia reconstruction using an autogenous costal cartilage framework. However, complications such as skin necrosis and cartilage exposure often destroy the final contour of the reconstructed auricle. Local fascia flaps are commonly used in salvage surgery because of their reliability and satisfactory results. Here, we report the case of a 26-year-old woman with multiple skin necroses and cartilage exposure on day 21 after the first-stage microtia reconstruction. The exposure area was covered by a temporoparietal fascia flap as a single-stage procedure. The most essential subunits survived, and the esthetic concours were harmonious and natural at 12 months postoperatively. Temporoparietal fascia flaps are recommended as the surgical treatment for multiple skin necroses and cartilage exposure in microtia reconstruction. The axial-pattern temporoparietal fascia flap is reliable for salvage auricular reconstruction and ensures satisfactory results at long-term follow-up.     

多孔高密度聚乙烯支架在皮肤破溃感染的全耳廓再造术中的应用

目的对于先天性小耳患者，在应用扩张法行外耳再造术的过程中，当耳后皮肤软组织在扩张阶段发生扩张皮肤破溃，以致继发感染后，探索一种较为可行的外耳再造方法。方法对26例耳后扩张皮肤发生破溃感染的先天性小耳患者，经过积极的全身抗感染和适宜的局部换药处理，在感染得到有效控制后，应用多孔高密度聚乙烯（porous high density polyethylene，Medpor）材料做支架，外包蒂在前的耳后乳突区皮下组织筋膜瓣、扩张皮肤及移植皮片，行外耳再造术。结果26例外耳再造手术均获成功，耳形态令人满意，轮廓清晰。结论在耳后皮肤软组织扩张阶段，当扩张皮肤发生破溃继发感染后，用Medpor支架代替自体肋软骨支架行外耳再造术，是一种较为安全可行的手术方法。