肿瘤切除后鼻腔复合缺损的重建:作者经验及疗效评价(英文)

Objective:The aim of the study was to present our experience in reconstruction of complex defects of the nose.Methods:Fourteen patients presenting with large composite defects of the nose were anatomically reconstructed after full tumor clearance of a skin cancer.The aesthetic outcome was assessed subjectively and objectively while the functional outcome was only assessed subjectively in 13 patients.Results:Basal cell carcinoma(BCC),represented the tumor excised in 10 patients while the remaining 4 patients suffered from squamous cell carcinoma(SCC).One patient died of extensive local recurrence of SCC after 6 months.The commonest flap used for inner lining was the septal flap while the forehead paramedian flap provided the external coverage for the majority of patients.All flaps survived completely except in one patient who developed distal paramedian forehead flap necrosis.Two patients developed multiple abscesses and sinuses discharging parts of cartilage grafts through the flaps’skin with one patient suffering from total extrusion of the costal cartilage grafts.Two other patients suffered from severe nostril stenosis.All patients had variable degree of difficulty in airway passage,while most patients were satisfied with the total nasal appearance.The objective assessment of the overall appearance of the nose scored less than the subjective satisfaction.Conclusion:Reconstruction of complex nasal defects has a high learning curve.Intranasal flaps are usually of limited size and nostril asymmetry is likely to occur.Local or regional skin flaps if available are still considered a good choice for inner as well as outer lining.     

Résultats oncologiques de la reconstruction immédiate après mastectomie pour cancer du sein: à propos de 38 cas

Objective

The purpose of this study is to analyze the oncologic outcome of immediate reconstruction after mastectomy for breast cancer and the impact of adjuvant treatments on cosmetic results.

Patients and methods

This retrospective study concerns 38 consecutive advanced abdominal flap with breast prothesis, realized immediately after mastectomy for breast cancer by one surgeon between 1997 and 2008.

Results

The average retrospective period was 34.5 months. Recurrence was observed in three caseswithout late diagnosis. It was local in two cases and systemic in one case resulting in death 18 months after reconstruction. Breast tumor in these cases had several initial poor prognostic factors. Delayed scarring was noted in one case due to post-radiation cutaneous necrosis. Capsular contracture was also observed in two women who received postoperative radiotherapy. In our study, esthetic results were considered poor in three cases because of prothesis removal in these cases, acceptable in 10 cases, good in 20 cases, and excellent in 5 cases.

Conclusion

Immediate breast reconstruction using advanced abdominal flap associated to a prothesis doesn’t affect neither local and systemic recurrence rates nor overall survival. Cosmetic results are overall good.     

Reconstruction of scalp defects with the radial forearm free flap

Background

Advanced and recurrent cutaneous squamous cell carcinoma of the scalp and forehead require aggressive surgical excision often resulting in complex defects requiring reconstruction. This study evaluates various microvascular free flap reconstructions in this patient population, including the rarely utilized radial forearm free flap.

Patients and methods

A retrospective review of patients undergoing free flap surgeries (n = 47) of the scalp between 1997 and 2011 were included. Patients were divided primarily into two cohorts: a new primary lesion (n = 21) or recurrence (n = 26). Factors examined include patient demographics, indication for surgery, defect, type of flap used, complications (major and minor), and outcomes.

Results

The patients were primarily male (n = 34), with a mean age of 67 years (25?C91). A total of 58 microvascular free flap reconstructions were performed (radial forearm free flap: n = 28, latissimus dorsi: n = 20, rectus abdominis: n = 9, scapula: n = 1). Following reconstruction with a radial forearm free flap, duration of hospitalization was shorter (P = 0.04) and complications rates were similar (P = 0.46). Donor site selection correlated with defect area (P < 0.001), but not with the extent of skull defect (P = 0.70). Larger defect areas correlated with higher complications rates (P = 0.03) and longer hospitalization (P = 0.003). Patients were more likely to require multiple reconstructions if referred for a recurrent lesions (P = 0.01) or received prior radiation therapy (P = 0.02).

Conclusion

Advanced and recurrent malignancies of the scalp are aggressive and challenging to treat. The radial forearm free flap is an underutilized free flap in the reconstruction of complex scalp defects.     

带蒂额肌帽状腱膜裂层颅骨瓣修复前颅底(英文)

Objective:The aim of our study was to reconstruct soft and hard tissue perforating defects of the anterior skull base in a 1-stage surgical procedure with a combined craniofacial approach. Methods:Soft and hard tissue defects of the anterior skull base were successfully reconstructed in 43 patients during a 1-stage surgery through the use of frontalis muscle galea aponeurotica skull flaps with 1 or 2 vascularized pedicles. The skull flap areas were up approximately 7cm × 14cm. Results:Intracranial infection and cerebrospinal fluid leakage were not observed in the 43 patients, and all incisions healed. Of 33 malignant tumor patients, 25 patients received follow-up examinations for longer than 2 years, and 18 patients survived for 2 years. Conclusion:Frontalis muscle galea aponeurotica skull pedicle flaps provided a constant blood supply and resulted in soft and thin tissue. The pedicle flaps, together with the external cranial bone plate, strengthened the support, but still allowed for bending and shaping. In addition, the flap harvesting approach was consistent with surgery approach, without aesthetic compromises.     

Indications du lambeau du grand pectoral en carcinologie cervicofaciale: à propos de 37 cas au CHU de Dakar

Introduction: The use of pectoralis major myocutaneous flap in head and neck oncology allowed the excision of large tumors

Materials and methods

It is a retrospective study which concerns a period of 13 years in the course of which, 37 pectoralis major myocutaneous flaps were performed at the private hospital of ENT of Dakar.

Results

The mean age of our patients was 51 years with a sex ratio of 5.16. To the clinical plan, the pharyngo-laryngeal tumors prevailed in 64.87% of cases. The cancers of larynx expanding into the skin and requiring a square laryngectomy were our main indication (37.86%). It was followed by the surgical cure of pharyngostoma (18.92%). To the anatomical plan, we obtained a healing of first intention in more than half of our patients (54.05%).

Conclusion

Thanks to its qualities, the pectoralis major myocutaneous flap has already supplanted the other flaps and it finds its main use in the reconstruction after square laryngectomy.     

Temporal lobe necrosis: a dwindling entity in a patient with nasopharyngeal cancer after radiation therapy

Purpose

The pectoralis major myocutaneous flap (PMMF) is a commonly used flap in reconstructive head and neck surgery, but in literature, the flap is also associated with a high incidence of complications in addition to its large bulk. The purpose of the study is the evaluation of the reliability and indication of this flap in reconstructive head and neck surgery.

Patients and methods

The records of all patients treated with a PMMF between 1998 and 2009 were systematically reviewed. Data of recipient localization, main indication, and postoperative complications were analyzed.

Results

The male to female ratio was 17:3, with a mean age of 60 years (45-85). Indications in 7 patients were recurrence of a squamous cell carcinoma, in one case an osteoradionecrosis and in 12 cases an untreated squamous cell carcinoma. In 6 male patients (30%), a complication appeared leading to another surgery.

Conclusion

The PMMF is a flap for huge defects in head and neck reconstructive surgery, in particular when a bulky flap is needed in order to cover the carotid artery or reconstructive surgery, but the complication rate should not be underestimated in particular after radiotherapy.     

Therapie des Rezidivs beim Vulva- und Vaginalkarzinom

Objective

In this retrospective analysis,186 patient cases of recurrent vulvar or vaginal carcinoma were examined regarding pretreatment, surgical therapy, plastic reconstruction, and postoperative disease course.

Results

Therapy was individualized according to tumor status using the complete spectrum of surgical interventions. Plastic reconstruction led to improvements with respect to operability, wound healing, and survival. For minor defects, local (fasciocutaneous) flaps proved to be reliable operative techniques. In cases exhibiting larger wounds, the use of regional (myocutaneous) flaps produced satisfactory results. For posterior defects, gluteal thigh flaps were the safest procedures, whereas for anterior defects, flaps from the rectus abdominis muscle proved to be most successful.

Conclusion

Our analysis shows that individualized reconstructive surgery leads to good local control and satisfactory patient outcome in patients with recurrent vulvar cancer. Surgical procedures for recurrent vulvar carcinoma require the same principles of radicality as for primary tumors. To an even greater extent than for primary therapy, plastic surgery enlarges the spectrum of feasible surgical alternatives, especially after radiotherapy.     

Möglichkeiten der plastischen Chirurgie in der Behandlung von Weichteilsarkomen

Background

The therapy of choice for locally limited soft tissue sarcomas involves complete surgical resection of the tumor. The goal of surgical therapy is the achievement of negative surgical margins (R0 resection). In locally advanced soft tissue sarcomas that have already infiltrated critical anatomical structures, the achievement of R0 status can be associated with a high surgical morbidity and result in functional impairment of the affected extremities or truncal wall. Plastic surgery can reduce this surgical morbidity by using a variety of modern techniques.

Objective

The aim of this article is to illustrate the various treatment options of plastic surgery in the multimodal therapy of patients with soft tissue sarcoma.

Material and methods

This article is based on a review of the current literature and evaluation of an in-house patient database.

Results

Several plastic surgery treatment options can be implemented in the curative and palliative therapy of patients with soft tissue sarcoma of the extremities and truncal wall. Large soft tissue defects can be covered by local pedicled or free flaps, whereas bone defects can be reconstructed by free bone transfer. Motor reconstruction surgery can partially restore functional impairment of extremities after nerve or muscle resection. In palliative disease stages soft tissue coverage after surgical debulking of exulcerated tumors can improve the quality of life of affected patients.

Discussion

Reconstructive plastic surgery techniques can restore functional impairments and cover soft tissue defects so that amputation of extremities can be avoided or complete tumor resection from the truncal wall can be made possible. In palliative disease situations plastic surgery can improve the quality of life.     

Breast reconstruction using free medial circumflex artery perforator flaps: intraoperative anatomic study and clinical results

Background

A free fascioadipocutaneous flap obtained from the medial thigh is suitable for breast reconstruction in Asian women with a small-to-moderate breast size. In this region, both a medial circumflex femoral artery perforator flap (MCFAp flap) and a posterior medial thigh perforator flap (PMTp flap) are options, based on perforators from the deep femoral vessels. Here, we evaluated the anatomic basis of the medial circumflex femoral artery (MCFA) perforators from the medial circumflex femoral vessels.

Methods

Between July 2010 and June 2014, 53 patients (55 flaps) underwent breast reconstruction using a fascioadipocutaneous flap from the medial thigh. MCFA perforators larger than or equal to 0.5 mm in this region were investigated. The following parameters were recorded intraoperatively: number of perforators, perforator locations, distance of the perforating point from the proximal thigh crease and anterior border of the gracilis muscle.

Results

The total number of perforators was 131, with a mean of 2.4. The number of perforators coursing through the gracilis muscle (gracilis perforators) was the largest, followed by septocutaneous perforator coursing between the adductor longus and gracilis muscle. The average perforating point was located 6.5 cm below the proximal thigh crease and 2.2 cm from the anterior border of the gracilis muscle. Of the 102 procedures performed since 2006, 15 flaps were elevated as MCFAp flaps and there was no major complication.

Conclusions

In some cases, MCFA perforators are dominant in this region compared to PMT perforators. A perforator map can be helpful for identifying adequate MCFA perforators intraoperatively.

     

Endonasal endoscopic dacryocystorhinostomy: our experience

Objectives

To study the outcome of endonasal endoscopic dacryocystorhinostomy (DCR) with or without mucosal flap preservation, without mitomycin local application, silicon tube stenting or laser assistance. To determine the duration of the surgical procedure of DCR, influence of simultaneously performed endonasal endoscopic procedures for concomitant sinonasal diseases.

Methods

Combined retrospective and prospective study in our tertiary referral center. 24 patients with chronic dacryocystitis underwent 25 standard endonasal endoscopic DCR procedures, 10 with and 15 without mucosal flap preservation. 6 of these had concomitant sinonasal diseases for which they underwent septoplasty or functional endoscopic sinus surgery (FESS) or both, simultaneously or as staged procedures. Relief from epiphora and patency of the nasolacrimal fistula was assessed by nasal endoscopy and syringing of the lacrimal apparatus at 1 week, 3 weeks and 3 months postoperatively.

Results

Out of 18 patients who underwent only DCR, 17 patients (94.44%) had complete relief from epiphora. Out of 6 patients who underwent 7 DCRs with concomitant sinonasal surgery, 5 patients (85.71%) had complete relief from epiphora. Overall 23 out of 25 DCRs (92%) had complete relief. In 15 of the 25 procedures, mucosal flap was excised completely. In remaining 10 procedures, flap was trimmed, repositioned to cover exposed bone around the newly created nasolacrimal fistula. In either situation, only one patient each had partial block of the nasolacrimal fistula. Average duration of the surgical procedure of DCR was 18 min.

Conclusion

Endonasal endoscopic DCR is a viable alternative to external DCR, co-existing sinonasal diseases can be managed simultaneously, as may be required in 25% of cases. It can be performed under 20 min without mucosal flap preservation, mitomycin local application, silicon tube stenting or laser assistance and can still provide a good success rate (92%) with less complications.     

Tongue flap in oral submucous fibrosis

A perspective study of role of lateral tongue flap operation in cases with trismus due to oral submucous fibrosis has been carried out. This study includes pre and post-operative evaluation of 21 cases. The results of this procedure have been discussed. The findings of the present study can be summarised as follows :

1. In all 21 cases have been treated with follow-up of maximum 3 years and minimum 2 months.
2. Two types of lateral tongue flaps i.e. anteriorly based and posteriorly based are tried.
3. The relief of trisums in all cases was satisfactory.
4. No handicap in the form of restricted mobility of tongue or distortion of speech etc. was noted.

     

Reconstruction of the Irradiated Extended Abdominoperineal Excision (APE) Defect for Locally Advanced Colorectal Cancer

Purpose

There is substantial evidence for neoadjuvant chemoradiotherapy and extended abdominoperineal excision (APE) for improving local recurrence rates and overall survival for rectal carcinoma. While oncologic outcomes are improved, the large irradiated defect in the pelvic floor can potentiate poor operative outcomes. We describe a reconstructive option, the inferior gluteal artery myocutaneous (IGAM) transposition flap, which can enable wide tumour resections by providing substantial non-irradiated tissue bulk.

Methods

Ten consecutive patients underwent either standard APE with direct primary closure or extended APE with IGAM transposition flap reconstruction between 2007 and 2009 for mStage I–IIIC disease. Patients underwent staging computed tomography and pelvic magnetic resonance imaging, and neoadjuvant chemoradiotherapy after multi-disciplinary team discussion. Eight patients underwent extended APE and IGAM transposition flap reconstruction due to locally advanced stage of their carcinoma. Oncologic, reconstructive and post-operative outcomes were assessed.

Results

All cases demonstrated good closure of the APE defect, with no intra-operative perforations and no immediate operative complications. Histological margins were clear (R0) in all specimens, with mean closest distance to margin 10.8 mm (range 4–20 mm). Mean follow-up was 11.3 months, with no locoregional recurrences. There was no donor site morbidity and no perineal hernia; patients reported high degrees of satisfaction with aesthetic outcome.

Conclusion

As the extended APE becomes increasingly utilized for rectal carcinoma, a reliable reconstructive option is increasingly important. The IGAM island transposition flap imports well-vascularized, non-irradiated tissue to reconstruct the defect, provides tissue bulk and potentiates good oncologic and reconstructive outcomes.     

The script concordance test in radiation oncology: validation study of a new tool to assess clinical reasoning

Purpose

To retrospectively evaluate the results after a regimen of surgery, IORT (intraoperative radiotherapy), and EBRT (external beam radiotherapy) for soft-tissue sarcomas

Methods

38 consecutive patients underwent IORT for soft-tissue sarcoma; 29 were treated for primary tumours, 9 for recurrences. There were 14 cases with liposarcomas, 8 with leiomyosarcomas, 7 with malignant fibrous histiocytomas. 27/38 tumours were located in the extremities, the remaining ones in the retroperitoneum or the chest. Radical resection was attempted in all patients; a R0-resection was achieved in 15/38 patients, R1 in 12/38 pats and R2 in 4/38 pats. IORT was performed using a J-125 source and a HDR (high dose rate) afterloading machine after suturing silicone flaps to the tumour bed. The total dose applied ranged from 8–15 Gy/0.5 cm tissue depth measured from the flap surface. After wound healing external beam radiotherapy (EBRT) was applied in 31/38 patients with total doses of 23–56 Gy dependent on resection status and wound situation. The mean duration of follow-up was 2.3 years.

Results

A local recurrence was found in 10/36 patients, lymph node metastases in 2/35, and distant metastases in 6/35 patients. The actuarial local control rate was 63%/5 years. The overall survival rate was 57%/5 years. There was no statistically significant difference between the results after treatment for primaries or for recurrences. Late toxicity to the skin was found in 13/31 patients, wound healing problems in 5/31 patients. A neuropathy was never seen.

Conclusion

The combination of surgery, IORT, and EBRT yields favourable local control and survival data which are well within the range of the results reported in the literature. The complication rates, however, are considerable although the complications are not severe, they should be taken into account when therapy decisions are made.     

National trends in immediate and delayed post-mastectomy reconstruction procedures in England: A seven-year population-based cohort study

Introduction

Little is known about post-mastectomy reconstruction procedural trends in women diagnosed with breast cancer in England. Our aim was to examine patterns of immediate and delayed reconstruction procedures over time and within regions.

Cervicopectoral rotation flap for primary closure of lateral face and neck defects

Objective

To recount our experience with the cervicopecloral flap (clavipfcmral flap, herein after referred to as CVF) fur reconstruction of large lateral cervicofacial defects in fifteen patients, which has been underutilized and has not received due recognition in world literature pertaining to reconstructive surgery.

Study Design

Retrospective case review

Setting

Tertiary care regional cancer referral center.

Patients

Those with lateral cervicofacial defects resulting from extirpative cancer surgical resection.

Results

A 100% &#x2018;take rate&#x2019; was observed at the primary defect. In 7% there was full thickness, distal loss that was successfully managed by split thickness skin grafting. Three cases (20%) shaved superficial epidermolysis, which healed by full epithelization within three weeks.

Conclusion

This flap provides satisfactory primary closure of surface defects that do not extend beyond an arbitrary line extending from the angle of mouth to tragus and posteriorly beyond the mastoid.     

Secondary breast reconstruction after mastectomy using the DIEP flap

Introduction

Breast reconstruction is an important element in the successful therapy of breast cancer [1]. Thereby, autologous microvascular breast reconstruction has been shown to be a reliable technique. The use of a deep inferior epigastric perforator (DIEP) flap or a muscle-sparing (MS) free transverse rectus abdominis musculocutaneous (TRAM) flap is recognized in many centres as gold standard for reconstructive options [[2], [3], [4]]. Based on our experiences with 137 patients over a 5-year period we want to highlight the technical aspects of the free microsurgical autologous breast reconstruction using a DIEP flap.

Mastectomy with immediate breast reconstruction after neoadjuvant chemotherapy and radiation therapy. A new option for patients with operable invasive breast cancer. Results of a 20 years single institution study

Purpose

To evaluate the feasability of immediate breast reconstruction (IBR) following mastectomy after neoadjuvant chemotherapy (NACT) and radiation therapy (RT) for operable invasive breast cancer (OIBC), in terms of incidence of local complications, locoregional control and survival.

Patients and methods

From 1990 to 2008, 210 patients were treated by NACT, RT and mastectomy with IBR for OIBC. One hundred and seven patients underwent a latissimus dorsi flap with implant (LDI), 56 patients a transverse rectus abdominis musculocutaneous (TRAM) flap, 25 an autologous latissimus dorsi flap (ALD) and 22, a retropectoral implant (RI) reconstruction.

Results

Forty-six (21.9%) early events were recorded: 20 necrosis, 9 surgical site infections and 6 haematomas, requiring further surgery in 23 patients. More necrosis were observed with TRAM flap reconstructions (p = 0.000004), requiring more surgical revision than LD reconstructions. Seromas represented 42% of early complications in LD reconstructions. Fifty-five patients presented with late complications (26.2%) with mainly implant complications (capsular contracture, infection, dislocation, deflation) (23.6%), requiring reintervention in 14 cases. There were more delayed surgical revisions in RI reconstructions (p = 0.0005). The 5 years overall and disease-free survival rates were respectively 86.7% and 75.6%. Sixty-four patients presented at least one recurrence (30.5%) with 5 local, 9 locoregional and 54 distant relapses.

Conclusion

This therapeutic sequence does not seem to increase the IBR morbidity nor alter disease-free and overall survival.     

Radiation-induced microenvironments - The molecular basis for free flap complications in the pre-irradiated field?

Background and purpose

The effect of preoperative radio- or radiochemotherapy on the survival of free flaps used for head and neck reconstruction is reported in a contradictory way. Although there is a lot of knowledge on radiation-induced wound healing disorders from animal models there are no investigations on human patients so far. Our prospective study aimed at clarifying the effect of radiotherapy on clinically apparent free flap complications and on correlating them with radiation-induced extracellular matrix (ECM) remodeling.

Materials and methods

Healing of 114 free flaps was monitored in a prospective study and correlated with different anamnestic features, such as diabetes and radio- or radiochemotherapy using multivariate regression. During the operation connective tissue biopsies were harvested from the graft beds and analyzed for Transforming Growth Factor (TGF)-β₁-expression by means of Western blotting as well as Tissue Inhibitor of Matrix-Metallo-Proteinase (TIMP)-1 and Matrix-Metallo-Proteinase (MMP)-1 by immunohistochemistry.

Results

History of radio- or radiochemotherapy was the only factor significantly predicting free flap complications. Radiochemotherapy resulted in a significant increase in TGF-β₁- and TIMP-1-expression, while MMP-1-expression was not significantly altered. Radiotherapy alone significantly increased TIMP-1-expression without detectable effects on TGF-β₁ and MMP-1.

Conclusions

Radio- and radiochemotherapy alter graft bed ECM organization prior to surgery. This alteration impacts significantly on free flap survival in the pre-irradiated field.     

Intracranial complications of otitis media: In retrospect

Objective

Evaluating intracranial complications of otitis media.

Design

An Evaluative study of 106 cases of intracranial complications secondary to otitis media.

Intervention

Diagnosis is based on history, clinical exam (general, systemic and ENT), investigations hemogram, X-ray mastoid CT scan brain and mastoid.

Treatment

1. Medical management:

1. IV Higher Antibiotics.

1. Surgery for complicating pathology:

1. Pus (in Abscesses)-bram canula aspiration.
2. Lateral sinus thrombosis (thrombus removal),
3. Otitic hydrocephalus (epidural catheterization).

1. Primary disease eradication:

1. Exploration of mastoid.

Results

Fully recovered patients without residual neurodeficit (85%), Morbidity (6%) CSF otorrhoea secondary to otitic hydrocephalus (9%) Mortality: preoperative (3%) and postoperative (6%).

Conclusion

Otological approaches for management of cases of intracranial complications of otitis media are equally comparable with results by neurosurgical approaches of management. Therefore, holding promise if applied in the rural and peripheral parts of India with limited resources even with absence of the expertise of Neurosurgical Department.     

Assessment of the perforators of anterolateral thigh flaps using 64-section multidetector computed tomographic angiography in head and neck cancer reconstruction

Background

The anterolateral thigh (ALT) flap is a frequent choice for free flap transfer in head and neck cancer reconstruction because of its versatility. Preoperative mapping of the perforator pedicles of an ALT flap is still a challenge because of variations in vasculature. Although computed tomographic angiography (CTA) is used increasingly to evaluate the peripheral vasculature, the use of this method for evaluating the perforators of an ALT flap has not been described in detail.

Methods

From September 2008 to March 2009, 32 patients underwent preoperative CTA before free ALT flap transfer for head and neck cancer reconstruction. The perforators were marked on a 64-section multidetector CT image for each patient. The preoperatively mapped perforators were compared with the actual intraoperative findings. Flap success rates and associated morbidity and complications were recorded.

Results

Preoperative CTA identified major variations in perforators. Eighty-four were found by preoperative CTA; 64 of these were mapped to be explored during the operation, and 13 additional perforators were identified during surgery. The accuracy rate of identifying the branching origin of the ALT perforators was 98% (63/64). All of the ALT flaps survived except for one with necrosis (survival rate 97%). There was no donor site morbidity.

Conclusions

Preoperative mapping of perforators by CTA proved valuable in free ALT flap transfer and shortened the operation time significantly. This modality provides useful information for head and neck cancer reconstruction in difficult cases, especially in patients with large or through-and-through defects that might need multiple perforators in flap design.