The use of local muscle flaps in foot and ankle reconstruction

Pedicled muscle flaps always should be considered as a reconstructive option when evaluating possible options to filling a defect around the foot and ankle. To gain confidence in using this option, multiple anatomic dissections with special attention to the vascular anatomy are necessary. These dissections also should give the surgeon a feel for the reach of the various flaps and their applicability in various circumstances. For optimal results, the interoperative dissections should be performed with loupes and the Doppler. This allows the surgeon to identify and protect the dominant pedicle. When insetting the flap, special attention is directed to avoid placing excessive torsion or tension on the pedicle so that the blood flow is not compromised. The flow, both arterial and venous, should be assessed after insetting the muscle with a Doppler. Pedicled muscle flaps offer a rapid and easy solution to difficult soft tissue problems around the foot and ankle. The operation can be performed with a regional block in under two hours. The postoperative stay is short, and the donor defect is minimal. Pedicled muscle flaps offer a great alternative to microsurgical free flaps, especially in the sick patient. They should be considered more often when looking at how to fill small defects with exposed bone or osteomyelitis around the foot and ankle.     

Traction suture modification to tongue-in-groove caudal septoplasty

Caudal septal deviation leads to unfavorable esthetic as well as functional effects on the nasal airway. A modification to the tongue-in-groove (TIG) technique to correct these caudal septal deformities is described. With placement of a temporary suspension suture to the caudal septum, manual traction is applied, assuring that the caudal septum remains in the midline position while it is being secured with multiple through-and-through, trans-columellar and trans-septal sutures. From 2003 to 2016, 148 patients underwent endonasal septoplasty using this modified technique, with excellent functional and cosmetic outcomes and a revision rate of 1.4%. This modified TIG technique replaces the periosteal suture that secures the caudal septum to the midline nasal crest in the original TIG technique. This simplifies the procedure and minimizes the risk of securing the caudal septum off-midline when used in endonasal septoplasty.     

Factors related to non-compliance with active tuberculosis treatment in Montreal 1992-1995

OBJECTIVE: To determine the extent of non-compliance with antituberculosis treatment in Montreal and whether it is influenced by the characteristics of the health care setting. METHODS: Retrospective medical and public health chart review of tuberculosis patients reported to the Montreal-Centre Department of Public Health between 1992-1995. A non-compliant patient is defined as one who has taken less than 80% of prescribed antituberculosis medication. RESULTS: Among patients for whom the compliance status was available, 19.8% were non-compliant. In univariate analysis, risk factors significantly associated with non-compliance included: living alone, birth in an endemic country for tuberculosis, side effects related to the medication, and follow-up in a clinic not specialized for tuberculosis. In multivariate analysis, increase of age by one unit (OR: 1.1; 95% CI: 1.02-1.1), and risk factors such as alcoholism (OR: 33.8; 95% CI: 5.8-194.4) and being HIV positive (OR: 8.9; 95% CI: 2.9-26.6) were independently associated with non-compliance. CONCLUSION: Non-observance seemed to be associated with patients' characteristics rather than health care system characteristics.     

The split orbicularis myomucosal flap for lower lip reconstruction

OBJECTIVES: To describe the split orbicularis myomucosal flap and to review our center's experience with this technique for large defects of the lower lip. METHODS: All patients presenting to the senior author (Y.D.) for lower lip reconstruction using this flap were reviewed in a retrospective fashion. RESULTS: A total of 14 patients with a minimum follow-up of 6 months (mean, 3.4 years; range, 6 months to 5 years) underwent lower lip reconstruction using the split orbicularis myomucosal flap from May 1999 to May 2004. Twelve of the defects arose as a result of cancer resection (squamous cell carcinoma [n = 8], basal cell carcinoma [n = 3], and melanoma [n = 1]), and 2 arose secondary to trauma. The defect crossed the vermilion in two thirds of the cases, extending for a variable distance onto the cutaneous portion of the lower lip. The defect size varied from 50% to 80% of the transverse dimension of the lower lip (mean, 68%) and involved the commissure in 4 patients. There were no flap failures, facial nerve palsies or paralyses, oral incompetence, or need for scar revision in any of our study population. CONCLUSION: The split orbicularis myomucosal flap is a reliable method of reconstructing significant defects of up to 80% of the lower lip with minimal risks of microstomia or functional impairment.     

Safety and risk factors for breast reconstruction with pedicled transverse rectus abdominis musculocutaneous flaps: a 10-year analysis

BACKGROUND: The purpose of this study is to examine the effect of various risk factors on complications in patients undergoing pedicled transverse rectus abdominis musculocutaneous (TRAM) flap breast reconstruction. METHODS: A retrospective review of 224 pedicled TRAMs in 200 patients over a 10-year period was carried out. Patients were divided into subgroups based on smoking history, weight, radiation status, and pedicle type. Complication rates were calculated and logistic regression analysis was used to identify risk factors. RESULTS: Logistic regression identified active smoking as a statistically significant risk factor for developing multiple (2 or more) flap complications (P = 0.0061) and TRAM infection (P = 0.0255), while former smoking was a risk factor for multiple flap complications (P = 0.01) and TRAM-delayed wound healing (P = 0.0433). Obesity (body mass index > or =30) was found to be a statistically significant risk factor for overall (1 or more) donor-site complications (P = 0.0281), overall flap complications (P = 0.0375), multiple flap complications (P = 0.0002), TRAM-delayed wound healing (P = 0.0334), and minor flap necrosis (P = 0.0075). CONCLUSIONS: This study identified that active or former smoking and obesity contribute to a significant complication rate, while overweight body habitus, use of double-pedicled flaps, and pre-TRAM radiation do not. This second decade "look-back" on pedicled TRAM flap breast reconstruction emphasizes the need for appropriate patient selection to achieve successful results with pedicled TRAM breast reconstruction.     

Elective transcervical superior mediastinal lymph node dissection for advanced laryngeal and level 4 N3 squamous cell carcinoma

OBJECTIVES: To review our results with elective superior mediastinal lymph node dissections in patients with advanced laryngeal squamous cell carcinoma (SCCA) and overt level 4 adenopathy. STUDY DESIGN: Retrospective review. METHODS: We searched operative case logs for all patients treated with an elective superior mediastinal dissection by the senior author (Y.D.) during a 7-year period. Charts were reviewed for demographic information, prior treatment with chemotherapy or radiotherapy, and pathologic results. RESULTS: Fifty-six patients who underwent elective superior mediastinal lymph node dissection for advanced laryngeal SCCA and overt level 4 adenopathy were reviewed, and superior mediastinal disease was present in 15 of 56 (26.8%) patients. Superior mediastinal nodes were positive in 11 of 42 (26.2%) patients with advanced laryngeal SCCA and 4 of 14 (28.6%) patients with N3 SCCA involving level 4. Patients with SCCA receiving prior chemotherapy and radiotherapy had a significantly higher rate of positive superior mediastinal nodes (10/21 patients, 47.6%) compared with patients without prior therapy (5/35 patients, 14.3%, P = .01, Fisher's exact test). There were no stomal recurrences in 42 patients treated for advanced laryngeal cancer. CONCLUSIONS: Elective transcervical superior mediastinal dissection was positive in 26.8% of patients with advanced laryngeal cancer or N3 disease in level 4. A transcervical superior mediastinal dissection may be safely performed without a sternotomy.