Biomedical subjects
Publications and source records attributed to A G Batchelor.
The closure of a large palatal fistula with a free fascial forearm flap based on the radial vessels is described. The benefits of this flap are discussed with particular reference to this site.
A rare malignant tumour presented as a pathological fracture in the clavicle of an 11-year-old girl. This was resected and the defect reconstructed using a pedicled bilobed flap based on the thoracodorsal system with latissimus dorsi and serratus anterior with a rib to replace the clavicle. The innervation of both donor muscles was preserved. The reconstruction was cosmetically acceptable and maintained the function of the thoracohumeral articulation. Although the use of vascularised rib grafts in composite flaps is well documented, this is the first report of clavicular reconstruction using the technique.
The use of pretransfer tissue expansion of a free scapular flap is described. This technique allows coverage of large defects with good quality skin and tensionless closure of the donor site.
We describe our experience with the true island pectoralis major musculocutaneous flap in patients with high-volume defects for whom free-tissue transfer is unsuitable. Our operative technique is presented. We have modified the method of making a true island of the pectoralis major musculocutaneous flap on a muscle-free pedicle as first described by Wei et al. in 1984. This maintains maximal donor-site muscle function and facilitates closure of the donor-site defect. We present our results in 24 patients, in whom the flap has proved to be robust and reliable. The flap's advantages in terms of increased pedicle length, wider arc of rotation, decreased pedicle bulk, and improved cosmesis of the reconstruction are discussed.
The radial forearm flap, although widely used, has been criticized for the poor quality of its donor site. To investigate the causes of morbidity, 100 radial artery free-flap donor sites have been reviewed. Sixty-seven patients required skin grafting (group 1), and the remaining 33 patients were closed directly (group 2). Seventeen patients in the series had compound osteocutaneous flaps (group 3). Wound healing proved to be a significant problem in groups 1 and 3, and fracture of the radius occurred in 4 of the 17 patients in group 3 and was the most significant cause of morbidity. The radial artery was reconstructed in 12 patients, but only 6 of the arteries (50 percent) were patent at the time of review. Subjective assessment on a scale of 0 to 10 demonstrated a relatively pain-free donor site with low pain scores (2.5 of 10). The cosmetic result was acceptable in men (1.5 of 10) but was less so in women (4 of 10). Angulated fracture of the radius produced an unacceptable cosmetic result (7 of 10). In light of this experience, we no longer reconstruct the radial artery as a matter of routine. The donor defect is closed directly wherever possible using an ulnar artery-based transposition flap when required. A "boat shaped" osteotomy is used in preference to right-angled bone cuts when harvesting a segment of radius to avoid the complications and sequelae of fracture. These changes in surgical technique have improved the acceptability and minimized the problems associated with this donor site.
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A case is described in which a patient with ulcerative colitis developed chronic vaginal ulceration around the incision lines after cone biopsy. The ulcers persisted at the vaginal vault after abdominal hysterectomy and removal of a cuff of vagina. Non-specific histological features compatible with pyoderma gangrenosum were found on biopsy. The auto-immune nature of this chronic ulcer is further supported by its rapid response to steroid therapy and the subsequent development of Behçet's syndrome.
This paper reports a case of cancrum oris in an adult Caucasian female who had no obvious pre-disposing cause. It highlights the difficulties in making this diagnosis in a part of the world unaccustomed to seeing the disease and it illustrates that early surgery and reconstruction can be undertaken. To our knowledge, this is the first published case of cancrum oris reconstructed with the use of micro-vascular free tissue transfer.
A method of direct closure of the donor defect of the radial forearm flap is described. This avoids the complication of delayed wound healing which remains a problem after split skin graft reconstruction.
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The free transfer of two transverse scapular flaps in continuity is described. This provides a donor site capable of yielding a skin flap 50 x 10 cm. Some observations on the vascularity of adjacent axial territories are made.
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A free latissimus dorsi muscle transfer, which required anastomotic revision on two occasions within twenty-four hours of operation, illustrates how the change in response of electrically induced muscle contraction to ischaemia can be used as a rapid and sensitive method of monitoring free muscle transfers. It is a response that has the great merit of being easily recognised by untrained observers because it relies on an absolute rather than a relative change in the measured modality. Furthermore it is not influenced by the clinical condition of the patient or by changes in the flap's environment. Its potential is discussed.
Machine-meshing a split skin graft gives it a three-dimensional flexibility that enables it to conform to irregular and concave surfaces without fixation. The drainage of fluid through the slit-like perforations prevents haematoma formation and permits the graft to be applied to an actively bleeding wound. Rapid firm adhesion occurs, allowing early mobilisation. By ensuring that the skin is applied without expansion, excellent cosmetic results can be achieved. This technique has become the method of choice in our unit when grafting awkward sites and for the cover of tangentially-excised burn wounds and we report on 111 consecutive cases.
43 microvascular procedures were performed in 38 children, (age limit 15 years) over a three year period. The average age was 5.4 years. The majority of the procedures were elective (63%), the remainder urgent or emergency. The overall vascular success rate was 93%, confirming previous reports. Three failures were observed, 2 of these being thumb avulsion injuries, the third a free-flap. Two patients underwent re-exploration of the anastomosis with successful outcomes. Vessel size was not a problem and generally exceeded 0.8 mm external diameter. The total time under anaesthetic averaged 5.5 hours, and post-operative recovery included monitoring and pain control on a High Dependency Unit. The average hospital stay was 10 days. The indications for surgery differ from those in adults, management is more complex, and includes the physical and psychosocial care of the child and parents. Despite raising certain anxieties in the past, microvascular surgery in children is safe, reliable and carries a high success rate.