Problems associated with surgery of the heart and the great vessels; technical problems encountered in surgery for congenital abnormalities.
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Dubowitz syndrome is an autosomal recessive disorder of growth retardation, characteristic face, mild mental retardation, and eczema originally described by Dubowitz [1965]. Little information is available on natural history and adulthood in this disorder. We report on a 30-year-old woman who was one of the first patients to be diagnosed with the condition [Grosse et al., 1971, Z Kinderheilkd 110:175-187]. Microcephaly, short stature, leg length discrepancy, hyperextensible joints, spina bifida occulta, and absence of anterior cruciate ligaments were present. Her facial appearance had been modified by several plastic surgery procedures. Eczema resolved with age, with occasional flareups. Asthma, headaches, and seizures were additional medical findings. Speech delays, an unusually soft, high-pitched voice, submucous cleft palate, and velopharyngeal insufficiency were noted in childhood. Mild mental retardation was present. At age 30 years she is living independently in her own apartment and working full-time in a nearby sheltered workshop.
Tissue engineering is a relatively young field that combines engineering, clinical science, and life sciences to, in part, repair or regrow tissues. Adipose tissue has recently become a focus area for tissue engineering, encouraged by the large number of reconstructive, cosmetic, and correctional indications that could be addressed with clinically translatable adipose tissue engineering strategies. This review discusses the three aspects of an adipose construct, namely cell types, scaffold, and microenvironment, and presents current tissue engineering strategies under pursuit.
Tissue engineering (TE) is a new interdisciplinary field of applied research combining engineering and biosciences together with clinical application, mainly in surgical specialities, to develop living substitutes for tissues and organs. Tissue engineering approaches can be categorized into substitutive approaches, where the aim is the ex vivo construction of a living tissue or organ similar to a transplant, vs. histioconductive or histioinductive concepts in vivo. The main successful approaches in developing tissue substitutes to date have been progresses in the understanding of cell-cell interactions, the selection of appropriate matrices (cell-matrix interaction) and chemical signalling (cytokines, growth factors) for stimulation of cell proliferation and migration within a tissue-engineered construct. So far virtually all mammalian cells can be cultured under specific culture conditions and in tissue specific matrices. Future progress in cell biology may permit the use of pluripotent stem cells for TE. The blueprint for tissue differentiation is the genome: for this it is reasonable to combine tissue engineering with gene therapy. The key to the progress of tissue engineering is an understanding between basic scientists, biochemical engineers, clinicians, and industry.
The subgaleal fascia (SGF) is a distinct layer in the temporal fossa situated between the superficial fascia and galea aponeurotica and the temporal fascia covering the superficial surface of the temporal muscle. The SGF is used most frequently for otologic reconstruction. Reviewing the literature, however, showed many contradictory findings about dissection of an independent SGF layer, its blood supply, and the possibility of harvesting it as part of a combined flap. Our study, carried out on ten fresh cadavers, presents a detailed view of the blood supply of the SGF to develop a safe method of harvesting an inferior-based SGF. Our systematic plane-by-plane approach, associated with a transparent grid applied on each dissection, allowed us to quantify the branches from each plane and to localize precisely their entering sites from a reference "zygomatic point." The SGF had no ascending axial vascular supply entering from its base; according to our results, therefore, the SGF could not be harvested alone as an inferior pedicled flap down to the zygomatic arch. It may be feasible, however, to harvest a SGF flap when a strip of the superficial fascia is associated with its middle third. Therefore, we suggest that an average height of 5.4 cm of superficial fascia should be included in an inferior-based pedicle of a SGF.
BACKGROUND: The goal of reconstructive laryngectomy addressing glottic carcinoma, as described by Tucker, is twofold: achieve local control and preserve as much as possible the physiological laryngeal function. METHODS: The study consisted of long-term assessment of oncological, deglutitory, and vocal outcome in 34 patients following Tucker's reconstructive laryngectomy. Postoperative follow-up included fiberscopic examination, videoradiography, and voice assessment after speech rehabilitation. RESULTS: The 5-year overall survival rate was 92% +/- 5%. Fiberscopic examination and videoradiography contributed to observing and understanding the rehabilitation process and impairment to its progress. Two main compensatory movements were identified: the anticipatory backward movement of the tongue base (50%) and the anticipatory upward laryngeal motion (15%). Both movements occurred simultaneously at the beginning of the pharyngeal stage of the swallow (35%). The median duration prior to tracheostomy tube removal was 14 days. Swallowing of solids resumed on day 9 (median), and liquid intake (water and soup) resumed on day 12 (median). The median duration of hospitalization was 16 days. Following speech rehabilitation, the latest follow-up visit measured as follows: the mean conversational voice intensity at 64 dB (range, 57-79 dB); the mean maximum intensity at 87 dB (range, 78-96 dB); the minimum intensity at 54 dB (range, 45-65 dB); the mean maximum phonation time at 16 seconds (range, 10-29 seconds); and the mean phonation quotient at 284 mL/second (range, 205-341 mL/second). According to our classification, voice spectral analysis revealed 19 class-III patients, 12 class-II patients, and three class-I patients. CONCLUSION: Tucker's reconstructive laryngectomy is reliable in terms of both the oncological and functional outcome. Fiberscopic examination and videoradiography are two complementary methods for assessing postoperative deglutition.
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The ulnar forearm flap is not frequently utilized for oromandibular reconstruction. This study evaluated the usefulness of the ulnar free flap for reconstruction. A retrospective study of 32 patients was conducted. The ulnar forearm flap was combined with an osseous flap in 24 patients. Nine females and 23 males with a mean age of 58.15 years comprised our study population. Squamous-cell carcinoma was the diagnosis in 93.75% of cases (56.25% T4), of which 20% were recurrent. Functional evaluation of swallowing was based on the University of Washington Questionnaire (UWQ). The mean hospital stay was 9.8 days. The external carotid (100%) was the recipient artery, and the internal jugular (74.07%) was the main recipient vein. Overall flap survival was 96.8%. One flap was lost due to unsalvageable venous thrombosis. Major local complications were seen in 9.4% of cases and included partial flap loss, hematoma, and an orocutaneous fistula. At the time of this study, 21 patients were available for functional evaluation. Speech was rated excellent and good in 33.3% of patients. Swallowing was found good in 28.6% of patients. Chewing was rated excellent and good in 47.6% of patients. Cosmetic acceptance was rated good in 71.4% of cases. The ulnar forearm is a useful free flap in oromandibular reconstruction. It is available when the radial artery is the dominant artery of the hand. Being more hidden, it may be more cosmetically accepted. It affords pliable soft tissue for lining and/or covering of oromandibular defects, and can be used as a second choice after other free-flap failures.
Free flaps are regularly used in plastic and reconstructive surgery but have a significant failure rate due to vessel thrombosis in the re-established arterial or venous circulation. A monitor of flap perfusion and oxygenation would allow the early detection of progressing flap ischaemia, hastening the required intervention and maximising the chances of salvaging the flap. A dual wavelength spectrophotometer has been designed and constructed which can monitor haemodynamic events in flaps during surgery and postoperatively. Eleven patients undergoing free flap surgery were studied. Measurements were made during surgery before division of the vessels and during and after microvascular anastomosis. Significant changes in all parameters were observed on reperfusion of the flaps after anastomosis or tourniquet ischaemia. Abnormal reperfusion in one flap and subsequent ischaemic events in two others were identified.
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