Biomedical subjects
Publications and source records attributed to H Holmström.
Five patients with congenital blepharoptosis have undergone a simple adaptation of Müller's muscle to the tarsal plate. In two patients this led to a good postoperative result, in one to an over-correction, while two were not corrected enough. These results should stimulate further studies on the importance of Müller's muscle in congenital blepharoptosis.
Deep wound infection after open-heart surgery remains a major problem. In this paper potential indications and techniques for use of muscle flaps in the treatment of chronic sternal infections are discussed and the authors' early experience with such treatment is presented. A well vascularized muscle flap fills out the defect, may help to control infection, and accelerates healing. After adequate excision of infected tissue, bone and cartilage, the resulting defect is covered with a muscle flap immediately or after a period of open treatment. Coverage with a flap of pectoralis major muscle was used in five patients 3 weeks to 6 months after cardiac surgery. Primary healing occurred in two patients, secondary healing in one and healing with residual fistula in one patient. In the fifth case there was uneventful recovery with primary healing until death occurred from cerebral haemorrhage after 3 weeks. Use of muscle flaps seems to be a valuable complement in the management of severe sternotomy infections.
In some cases of extensive palatal defects surgical closure may be regarded as unfeasible, and the condition treated with an obturator prosthesis. In such a case the cleft can be closed in one operation by means of a pharyngeal flap elongated through a pharyngotomy according to Bengt Johanson (1966). Eleven patients who had used obturators were operated on between 1957 and 1978. The mean age of the patients was 39 years. All patients were cleft lip and palate or cleft palate cases; two unilateral, five bilateral, and four with an isolated cleft palate. In most of these patients a temporary tracheostomy was performed after which the pharynx was opened through a neck incision. A flap was created which reached the alveolar ridge. For oral closure, mucoperiosteal flaps were used. Anterior palatal fistulas developed in two cases; one closed spontaneously and the other remained as a 3-mm fistula behind the alveolar ridge. Three patients had postoperative transient dysphagia. Phoniatric evaluation showed that two patients had better speech after operation than before with an obturator. Gross speech improvement at this late age should not be expected and is not the primary goal of the procedure. The aim of surgical closure with an elongated pharyngeal flap is to replace the obturator.
In 48 patients with maxillonasal dysplasia the retruded nasal base was corrected with onlay cancellous bone grafts after subperiosteal dissection using an oral vestibular approach. Support for the nasal dorsum was achieved in 39 patients with an L-shaped bone graft from the iliac crest introduced through the same approach. The advancement of the nose was found stable on lateral cephalograms; i.e., resorption did not occur. However, the grafts showed considerable remodeling. Half the patients found the stiffness of the nose to be disturbing. In nine patients, the cartilaginous septum was used instead as a support for the nasal dorsum and tip. At operation, the entire cartilaginous septum was mobilized after subperichondrial dissection and rotated forward either pedicled at the nasal dorsum or completely released. Cartilage regenerated in the periochondrial pocket left behind the advanced septum. The anterior transfer of the nose was 6 to 10 mm. The use of septal advancement is preferred over bone implants in the correction of maxillonasal dysplasia in patients in whom the bony nasal dorsum is of adequate height because it results in a soft and flexible nose and the risk of traumatic fracture and resorption is eliminated. The technique has been used in adolescents with promising results.
A new technique for lining the superiorly based pharyngeal flap is described. After the soft palate in the oral mucosa is incised, the muscular velum is dissected laterally. A flap is then prepared on the nasal side of the palate with its pedicle on one side of the posterior edge of the palate. The pharyngeal flap is sutured into the donor defect of the palatal flap, which is reflected and used to line the pharyngeal flap. Both surface and bulk are added to the pharyngeal flap and the obturating effect is increased. This method is therefore especially indicated in patients with primary velopharyngeal insufficiency and decreased lateral pharyngeal mobility. In 8 patients studied over a two-year period we achieved reduced nasality and no rhinolalia clausa.
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In the treatment of cicatricial entropion it may be necessary to bring new tissue to the lid margin after this has been split and the eyelashes have been everted. A bipedicled tarsoconjunctival flap from the proximal part of the tarsus forms a stable and non-irritant new lid rim for both the upper and the lower eyelid. The donor site is closed by advancement of the conjunctiva of the fornix. Three case histories are presented.
A case is presented where a myocutaneous latissimus dorsi flap was used to cover a defect resulting from irradiation injury to the neck region in a young woman. The advantage of this flap is the donor scar which is less disfiguring than flaps from the anterior chest usually chosen in such cases. The flap is taken the shortest way to the head- and neck region, through the axilla, under the insertion of the major pectoral muscle, and through the trigonum deltoideopectorale.
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In search for a free microvascular flap which would give abundant reconstructive material as well as a satisfactory donor site the free abdominoplasty flap was developed. The flap is designed on the area between the umbilicus, the pubic region and the anterior superior iliac spines and is based on the inferior epigastric vessels on one side only. In eight regular abdominoplasty procedures elevation of this flap and keeping the blood flow intact through the isolated vessels did not jeoparding the viability of the flap. Angiography of the specimens showed a good perfusion. The free abdominoplasty flap has been used for breast reconstruction in 2 cases of radical mastectomy. The first was failure because of venous thrombosis. In the second case 3 veins were anastomosed, 2 venae comitantes to the inferior epigastric vein and the contralateral superficial epigastric vein and the result was favourable.
During a ten-year period 17 patients with total congenital absence of the vagina were treated by a split-skin inlay grafting technique. The average age at the time of operation was 21 years. Associated malformations, mostly afflicting the urinary tract, were found in 9 patients. The skin graft was applied on a perforated hollow acrylic mould, 12 cm long and 4 cm in diameter. The acrylic mould was removed on the tenth day and a soft silicon mould was then utilized for at least 6 months. The mean hospitalization time was 28 days. The grafts took completely in 11/17 patients and in the remaining cases the take averaged 80%. There was no major complication, such as fistulas, in the series. With the exception of two patients with male hermaphroditism all patients were contented with the operation and stated that they had a satisfactory sex-life. In 9/17 patients, a closer follow-up including a biopsy was made. The average depth of the vaginas was 8 cm (range, 6 to 10 cm), and the average diameter 3 cm (range 2.5 to 4 cm). The histological studies consistently showed that the original skin morphology was maintained in the recipient site.
Histological studies were performed on granulation tissue from cylinders implanted 2 to 8 weeks and 4 months in bipedicle tube flaps on rabbits. Tissue from cylinders implanted in skin folds were used as controls. Flap and control tissue showed similar changes over the weeks. At weeks 2 and 3 the tissue was rich in cells, blood vessels and collagenous fibres. At week 4 the tissue showed transitional changes to week 5, when there were zones of loosely textured tissue with fine, fragmented collagen fibres. At week 5 some of the loose tissue was replaced by fat. Macrophages and inflammatory cells had appeared. By week 7 the fatty and collagenous tissue was mature and macrophages and inflammatory cells had disappeared.
203 cancers of the eyelid were operated on in 193 patients. 65% of the tumours occurred in males and the peak incidence was at 75 years. 60% afflicted the lower eyelids and 21% the medial canthi. Basal cell carcinoma were found in 182 specimens and spinocellular carcinoma in only 8. Malignant melanoma, Meibomian gland carcinoma and rhabdomyosarcoma appeared each in one patient, the latter representing the only fatal case in eyelid cancer. All cancers were excised with a free margin around 5 mm. The standard procedures of reconstruction of the eyelid defect were a fullthickness skin graft in cases where conjunctiva and tarsus could be preserved (97 cases), and a tarsoconjunctival flap in full-thickness defects of the lower eyelid (58 cases). Other methods used were wedge excision and direct approximation in very small lesions involving the lid margin, an infratarsal island flap from the lower eyelid for medium-sized to large defects in the upper lid and a forehead or scalp flap after exenteration of the orbit. 18/203 cancers recurred and 12 of these were primarily regarded as radically treated. Seven of the latter were reoperated after more than 3 years and may in fact be new tumours. No metastases were found. The various reconstructive procedures are discussed in detail
The oxygen consumption rate (QO2) of granulation tissue from cylinders implanted in bipedicle tube flaps of rabbits was measured weeks 2 to 7 in vitro in a Biological Oxygen Monitor. Granulation tissue from cylinders implanted in skin folds was used as control. The QO2 of granulation tissue decreased slowly as the oxygen tension in the medium fell. All measurements were made at an oxygen tension of 75 mmHg. At week 2 the QO2 of granulation tissue in flaps was high and a decrease occurred between week 2 and week 4. A further decrease took place between weeks 6 and 7 and a very low QO2 was found at week 7. Control granulation tissue showed a higher QO2 than skin flap granulation tissue at weeks 3, 4, 5 and 7.
The protein synthesis and the collagen synthesis by 2- to 7-week-old granulation tissue from implanted cylinders in bipedicle tube flaps on rabbits were measured in vitro by the incorporation of 14C-proline in proteins and in collagen hydroxyproline. Granulation tissue from cylinders implanted in skin folds were used as controls. In the skin flap group the protein synthesis was high at week 2, after which it decreased to week 5. In the controls the protein synthesis was the same as in the skin flap group at week 2. A decrease occurred between weeks 2 and 4 and a further decrease between weeks 6 and 7. At weeks 5 and 6 the protein synthesis was higher in the controls than in the skin flap group, but at week 7 it was the reverse. The collagen synthesis was high and equal in both groups at weeks 2 and 3 and then decreased to weeks 4 and 5. Between weeks 6 and 7 a further decrease was found in the controls, but not in the skin flap group.
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Explore the source record for details and available documents.
Explore the source record for details and available documents.