Laparoscopically assisted full thickness skin graft for reconstruction in congenital agenesis of vagina and uterine cervix

In patients with agenesis of the vagina and cervix but with a functional endometrium, the traditional treatment is hysterectomy with construction of a neovagina. We report successful treatment by laparoscopically assisted full thickness skin graft for reconstruction in a patient with congenital agenesis of the vagina and uterine cervix concomitant with haematometra and ovarian endometrioma in a 12 year old girl. Postoperatively, the vaginal skin graft healed well, and menstruation first appeared 4 weeks later. In our opinion, a combined laparoscopic and vaginal procedure with full thickness skin graft is an efficacious alternative in managing such genital defects.     

Intraoperative internal mammary artery transit-time flow measurements: comparative evaluation of two surgical pedicle preparation techniques

Objects.

Myocardial revascularization is performed preferentially with internal mammary artery grafts. Pedicle preparation and pharmacologic vasodilatory treatment vary greatly. Objective measurements are difficult since peripheral and later coronary vascular resistance and possible competitive flow of the native bypassed coronary artery will influence the results significantly. Our objectives were: (1) measurement of internal mammary artery graft flow with the transit-time flow technique; (2) comparison of two surgical take-down techniques (skeletonizing vs standard pedicle preparation); (3) quantitation of transit-time flow compared to the free pedicle flow and (4) the vasodilatory effect of papaverine on internal mammary artery flow.

Method.

Consecutive elective cases of coronary artery bypass grafting, performed by two surgeons using routinely either skeletonizing of the internal mammary artery (group A, n=10) or classical pedicle preparation technique (group B, n=10), were studied prospectively. Anesthesia, cardiopulmonary bypass and operative data were otherwise comparable; likewise, hemodynamic parameters showed no statistical differences between the two groups. Transit-time flow (CardioMed, Medi-Stim, Norway) was measured at the following time points: beginning (1) and end of take-down (2); after papaverine soaking: before (3) and on cardiopulmonary bypass (4); free flow into a beaker (5); after anastomosis; on (6) and off cardiopulmonary bypass (7).

Results.

Measurement of mean flow showed the following results: (1) severe vasoconstruction of the internal mammary artery was detected in both groups regardless of the preparation technique (occurring earlier in group A); (2) papaverine soaking caused a moderate flow increase (up to 40%); (3) with corresponding cardiopulmonary bypass flow (4.4 vs 4.1 l/min in group B) a higher free flow in group A was evident (67.7 vs 50.7 ml/min); (4) after coronary grafting, transit-time flow showed no significant differences between the two groups and (5) using a 3 mm probe, a linear correlation was demonstrated between transit-time flow and simultaneously measured free flow (r=0.89).

Conclusion.

Intraoperative transit-time flow measurement is a reliable method for assessing internal mammary artery and coronary artery bypass flow; considering the simple technical application, the procedure may be regarded as a valuable instrument of quality control.     

Use of sclera and liquid collagen in the camouflage of superior sulcus deformities

The cosmetic deformities following enucleation are often unavoidable. Loss of orbital volume and atrophy of orbital fat create significant enophthalmos. The literature is filled with numerous procedures that add to the orbital volume of the anophthalmic socket. An outline of three procedures to the upper eyelid to camouflage an enophthalmic appearance are presented. These can be used alone or in conjunction with an "orbital volume increasing" procedure. Two procedures can be used in an office setting to alleviate small deformities; 19 patients have been treated in this manner with a follow-up period of up to 26 months.     

Syringe liposculpture: A two-year experience

Syringe liposcupture is a method that combines two relatively new techniques of plastic surgery: syringe liposuction and fat grafting. We can reshape the face and the body by removing localized fat deposits and reinjecting this fat where needed. When we do not reinject, we call the technique reduction liposculpture. In 1989 we introduced a new technique—superficial syringe liposculpture—to treat patients with flaccid skin, superficial irregularities or depressions, cellulite, and liposuction sequelae. The technique combines syringe liposculpture, superficial liposuction, and our method of treating skin irregularities by breaking the fibrous adherences and injecting fat superficially.     

Free muscle graft pharyngoplasty with palatal retroposition in the treatment of velopharyngeal incompetence

Summary The use of free skeletal muscle autografts in combination with a V-Y push back to the soft palate, in the treatment of velopharyngeal incompetence in 6 patients is reported. This pharyngoplasty offers a reconstruction of the anatomical elements of the region, and enhancement of the physiological functions of the velopharyngeal sphincter in speech production. Of the 6 patients treated, 4 were restored to essentially normal speech, and 2 salvage cases were improved; in all cases however, the anatomical mechanism for speech production was effectively augmented.     

截骨加楔形植骨术治疗创伤性踝成角并短缩畸形（附7例分析）

目的：对创伤性踝成角并短缩畸形行截骨加楔形植骨手术的治疗效果进行评价。方法：对7例因外伤致踝成角并短缩畸形患者行截骨加楔形植骨术矫形并延长肢体，术后进行平均39．7个月的随访，就疼痛，行走能力，活动度、日常生活能力等进行百分制评分。结果：术后患肢恢复或接近等长，疼痛，行走能力和日常生活能力均有改善，但踝关节活动度无改善。结论：本手术方法是治疗创伤性踝关节成角短缩畸形合并早期骨性关节炎十分有效的方法。     

Review of select transplant subpopulations at high risk of failure from standard immunosuppressive therapy

Despite improvements in short-term graft and patient survival rates for solid organ transplants, certain subgroups of transplant recipients experience poorer clinical outcome compared to the general population. Groups including pediatrics, African-Americans, diabetics, cystic fibrosis patients, and pregnant women require special considerations when designing immunosuppressive regimens that optimize transplant outcomes. Problems specific to pediatric transplant recipients include altered pharmacokinetics of immunosuppressive drugs, such as cyclosporine (CsA) and tacrolimus (poor absorption, increased metabolism, rapid clearance), the need to restore growth post-transplantation, and a high incidence of drug-related adverse effects. African-Americans have decreased drug absorption and bioavailability, high immunologic responsiveness, and a high incidence of post-transplant diabetes mellitus. Diabetics and cystic fibrosis patients exhibit poor absorption of immunosuppressive agents, which may lead to underimmunosuppression and subsequent graft rejection. Pregnant women undergo physiologic changes that can alter the pharmacokinetics of immunosuppressives, thus requiring careful clinical management to minimize the risks of either under- or overimmunosuppression to mother and child. To achieve an optimal post-transplant outcome in these high-risk patients, the problems specific to each group must be addressed, and immunosuppressive therapy individualized accordingly. Drug formulation greatly impacts upon pharmacokinetics and the resultant level of immunosuppression. Thus, a formulation with improved absorption (e.g., CsA for microemulsion), higher bioavailability, and less pharmacokinetic variability may facilitate patient management and lead to more favorable outcomes, especially in groups demonstrating low and variable bioavailability. Other strategies aimed at improving transplant outcome include the use of higher immunosuppressive doses, different combinations of immunosuppressive agents, more frequent monitoring, and management of concurrent disease states.     

Posterior Laryngeal Clefts: Preliminary Report of a New Surgical Procedure Using Tibial Periosteum As an Interposition Graft

Objective: To present the preliminary results of a new surgical procedure for posterior laryngeal cleft repair. Design: Retrospective study in an academic tertiary care center. Method: The study included three male patients (age at surgery, 2, 13, and 14 mo). One presented with severe aspiration and cyanotic attacks, the two others with aspiration and recurrent chest infections. The types of laryngeal clefts included complete cleft of the cricoid with varying degrees of tracheal involvement but not further than the first six tracheal rings. Associated malformations included one VATER syndrome, one esophageal atresia, and one tracheoesophageal fistula. Surgery was performed under general anesthesia with nasotracheaI intubation. A vertical anterior laryngofissure was performed. The mucosal margins of the clefts were incised and then repaired in two layers with polyglactin sutures. The original feature of this procedure was the interposition of a small piece of tibial periosteum between the two layers. This fascia graft is known to be strong and resistant in cleft palate surgery. Main Outcome Measure: Clinical and endoscopic follow-up was used for evaluation of results. Results: The three patients had successful laryngeal repair at a mean follow-up of 6 months (range, 4-14 mo). Conclusion: The anterior laryngofissure provides a good surgical access to the cleft. The interposition of tibial periosteum allows durability of the cleft repair. A longer follow-up is needed to confirm these preliminary results. A computed tomography scan study and a study on the rabbit are planned in order to evaluate the outcome of these periosteal grafts.     

前交叉韧带重建术后短期内移植体黏性变化

目的 研究前交叉韧带重建(anterior cruciate ligament reconstruction, ACLR)术后短时间内移植体黏性的变化规律。方法 选择6只雄性新西兰兔,以跟腱为移植体制作单侧膝关节ACLR动物模型。ACLR术后15 d将实验兔安乐死,取出移植体、健康的前交叉韧带(anterior cruciate ligament, ACL)和跟腱。测量移植体的截面积,分别进行0.1、1 MPa平衡条件的蠕变实验,并计算黏性系数,总结移植体的黏性变化规律,与健康ACL进行对比。结果 移植体的截面积在手术后15 d内缓慢上升。ACL与移植体的黏性呈非线性变化。在不同应力下,黏性系数有较大差异。移植体黏性系数随ACLR术后时间呈下降趋势,但在低应力下更明显。结论 本文建议,ACLR术后早期康复过程中,应使用助行器,降低步频,并避免踢、踹等对关节冲击的运动。     

Fibrin glue assisted amniotic membrane graft reconstruction of conjunctival fornix and canthus following excision of conjunctival tumours

Conjunctival tumors involving non-limbal locations, such as the fornix and canthus, are typically excised using a “non-touch” technique, often with a wide surgical margin. Reconstruction of these large defects can be difficult due to the contour of the ocular surface and are often complicated by shortening of the fornix, symblepharon formation, and restriction of eye movements. In our experience, the use of amniotic membrane grafts combined with the sealant properties of fibrin glue such as Tisseel® has improved our surgical outcomes during the reconstruction phase. We would like to highlight and describe our surgical technique using fibrin glue and squint hooks to aid amniotic membrane graft reconstruction for surgically challenging locations in the fornix and canthus following excision of conjunctival lesions, with excellent surgical outcomes.