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PubMed2006

A three-dimensional-weighted cone beam filtered backprojection (CB-FBP) algorithm for image reconstruction in volumetric CT-helical scanning.

Based on the structure of the original helical FDK algorithm, a three-dimensional (3D)-weighted cone beam filtered backprojection (CB-FBP) algorithm is proposed for image reconstruction in volumetric CT under helical source trajectory. In addition to its dependence on view and fan angles, the 3D weighting utilizes the cone angle dependency of a ray to improve reconstruction accuracy. The 3D weighting is ray-dependent and the underlying mechanism is to give a favourable weight to the ray with the smaller cone angle out of a pair of conjugate rays but an unfavourable weight to the ray with the larger cone angle out of the conjugate ray pair. The proposed 3D-weighted helical CB-FBP reconstruction algorithm is implemented in the cone-parallel geometry that can improve noise uniformity and image generation speed significantly. Under the cone-parallel geometry, the filtering is naturally carried out along the tangential direction of the helical source trajectory. By exploring the 3D weighting's dependence on cone angle, the proposed helical 3D-weighted CB-FBP reconstruction algorithm can provide significantly improved reconstruction accuracy at moderate cone angle and high helical pitches. The 3D-weighted CB-FBP algorithm is experimentally evaluated by computer-simulated phantoms and phantoms scanned by a diagnostic volumetric CT system with a detector dimension of 64 x 0.625 mm over various helical pitches. The computer simulation study shows that the 3D weighting enables the proposed algorithm to reach reconstruction accuracy comparable to that of exact CB reconstruction algorithms, such as the Katsevich algorithm, under a moderate cone angle (4 degrees) and various helical pitches. Meanwhile, the experimental evaluation using the phantoms scanned by a volumetric CT system shows that the spatial resolution along the z-direction and noise characteristics of the proposed 3D-weighted helical CB-FBP reconstruction algorithm are maintained very well in comparison to the FDK-type algorithms. Moreover, the experimental evaluation by clinical data verifies that the proposed 3D-weighted CB-FBP algorithm for image reconstruction in volumetric CT under helical source trajectory meets the challenges posed by diagnostic applications of volumetric CT imaging.

Algorithms↗

PubMed2026

Fault-tolerant pedigree reconstruction from pairwise kinship relations.

MOTIVATION: Pedigrees reconstructed from biologically related ancient genomes have revealed many insights into (pre)history. To our knowledge, all reported ancient pedigrees have been primarily manually reconstructed, as existing pedigree reconstruction methods are ill-suited for the quality and nature of ancient DNA data. RESULTS: We introduce repare, an open-source software method to automatically reconstruct pedigrees from inferred pairwise kinship relations, which are readily obtainable from ancient genomes. This method reconstructs pedigrees by iteratively incorporating pairwise kinship relations into a set of candidate pedigrees, with pruning and sampling to reduce its search space. It optionally considers supporting information such as haplogroups and skeletal age-at-death estimates. We evaluate this method on a variety of simulated pedigrees with varying error rates and missingness. We also use this method to reconstruct several published pedigrees that were originally manually reconstructed; for one, we present a potential alternative topology. repare optionally incorporates user-inferred pedigree constraints, enabling "human-in-the-loop" reconstruction workflows. Especially when used with these user-inferred constraints, we find that repare represents a powerful and flexible tool for ancient pedigree reconstruction. AVAILABILITY AND IMPLEMENTATION: repare is freely available at https://github.com/Narasimhan-Lab/repare. In addition, source code, benchmark scripts, and benchmark results used in this work are archived at https://doi.org/10.5281/zenodo.19716772.

Pedigree↗

PubMed1994

Treatment considerations in postmastectomy reconstruction: their relative importance and relationship to patient satisfaction.

Although studies concerning motivation for and satisfaction with breast reconstruction after mastectomy have proliferated, little information is available concerning the relative importance of motivating factors and satisfaction with treatment choice in nonreconstructed and reconstructed mastectomy patients. We studied this by questioning 144 women in four groups: mastectomy patients who had reconstruction; mastectomy patients who did not have reconstruction; and two control groups composed of women who had not had any cancer or who had undergone hysterectomy for uterine cancer. This study was conducted just before the reports of alleged risks of silicone to the patients and reflects the opinions of patients without such bias. This study shows that, although women who opted for reconstruction reported greater concern about appearance than women who did not have reconstruction, both groups described concerns about surgical discomfort and possible complications. Also, women's concerns about appearance did not seem to fall solely into public (others' evaluations) or private (patients' own evaluation) domains. Rather, personal attitudes about appearance may affect interpersonal experiences. Finally, concerns about the possibility of recurrence may reduce patient satisfaction for some women who have reconstruction, so postsurgical education regarding cancer risk may be needed. Reconstructed and nonreconstructed mastectomy patients do not appear to differ in postoperative behaviors promoting personal health. This information, analyzed before the silicone controversy, may serve as a baseline for future research on the impact of the silicone crisis on women's perceptions regarding reconstruction.

Adult↗

PubMed1999

Outcome of renal artery reconstruction: analysis of 687 procedures.

OBJECTIVE: To evaluate the short- and long-term results of surgical reconstruction of the renal arteries, the authors review their experience with more than 600 reconstructions performed over a 12-year period. SUMMARY BACKGROUND DATA: Reconstruction of the renal arteries, whether for primary renal indications or concomitantly with aortic reconstruction, has evolved over the past 40 years. There is concern that renal artery reconstructions carry significant rates of mortality and morbidity and may fare poorly compared with less-invasive procedures. METHODS: From 1986 to 1998, 687 renal artery reconstructions were performed in 568 patients. Of these, 105 patients had simultaneous bilateral renal artery reconstructions. Fifty-six percent of the patients were male; 11% had diabetes; 35% admitted to smoking at the time of surgery. Mean age was 67 (range, 1 to 92). One hundred fifty-six (23%) were primary procedures and the remainder were adjunctive procedures with aortic reconstructions; 406 were abdominal aortic aneurysms and 125 were aortoiliac occlusive disease. Five hundred procedures were bypasses, 108 were endarterectomies, 72 were reimplantation, and 7 were patch angioplasties. There were 31 surgical deaths (elective and emergent) in the entire group for a mortality rate of 5.5%. Predictors of increased risk of death were patients with aortoiliac occlusive disease and patients undergoing bilateral simultaneous renal artery revascularization. Cause of death was primarily cardiac. Other nonfatal complications included bleeding (nine patients) and wound infection (three patients). There were 9 immediate occlusions (1.3%) and 10 late occlusions (1.5%). Thirty-three patients (4.8%) had temporary worsening of their renal function after surgery. CONCLUSION: Renal artery revascularization is a safe and durable procedure. It can be performed in selected patients for primary renovascular pathology. It can also be an adjunct to aortic reconstruction with acceptable mortality and morbidity rates.

Adolescent↗

PubMed2003

Pectoralis muscle flap reconstruction of pediatric sternal wound infections.

Sternal wound infection (SWI) is a life-threatening complication in both the pediatric and adult population. The morbidity and mortality of SWIs have decreased with the use of muscle flap reconstruction of the chest wall. Although the pectoralis muscle flap is the most frequently used flap in adults for reconstruction after SWI, its use in children has not been well described. To review current experience with the use of the pectoralis muscle flap in a pediatric population, a retrospective review of 1,200 consecutive median sternotomies occurring at the Children's Hospital of Pittsburgh between 1992 and 1997 was performed. All cases of postoperative SWI were identified, and the operative management was performed by a single surgeon. Reconstruction was performed with the use of unilateral or bilateral pectoral muscle flap advancements. Sternal wound infections developed in nine patients (0.75% incidence). The mean duration from initial sternotomy to the time of presentation of deep SWI was 39.5 days. Eight patients underwent reconstruction using pectoralis muscle advancement flaps. Two patients (25%) were reconstructed with a unilateral pectoralis advancement flap, whereas six patients (75%) required bilateral advancement flaps. One patient was treated with conservative management. The average length of stay after reconstruction was 9 +/- 4 days. Duration of follow-up ranged from 3 to 42 months (mean: 16 +/- 12 months). All reconstructions ultimately resulted in well-healed wounds with satisfactory cosmesis. No developmental or functional deficits have been documented in follow-up visits. Sternal wound infection is a serious postoperative complication of median sternotomy. Aggressive operative management with the use of muscle flap reconstruction has helped to lower the morbidity and mortality of this infection. The successful use of pectoralis muscle flap advancement for functional and esthetic reconstruction of the chest wall in children is described.

Child↗

PubMedDate not supplied

The quality of 3D reconstructions from 1.0 and 1.5 pitch helical and conventional CT.

PURPOSE: CT data are commonly used to create 3D images. For this purpose, thin and overlapped slices are desirable. Helical (spiral) CT offers the ability to adjust the slice reconstruction interval from 0 to 100%. However, its use in 1.0 and 1.5 pitch helical CT and 3D imaging, especially with respect to surface detail, is relatively untested. METHODS: Ten objects selected for their varying size, shape, and density were scanned (fourth generation Picker PQ2000) by contiguous 2,4 and 8 mm conventional and helical sequences. The latter were obtained with a pitch of both 1.0 and 1.5 and were reconstructed into a 3D image with 0-75% overlapping of the reconstructed slices. Each of the 24 different sequences per scanned object was reconstructed into identical sets (projections) of 3D images displayed on color film. The 24 3D image sets for each object were submitted to six blinded radiologists who separately ranked them from best to worst. RESULTS: 3D reconstructions obtained from CT scans with a thinner slice thickness, half-field (15 cm FOV), and helical technique were rated as statistically superior. The 1.0 and 1.5 helical sequences obtained with a 4 or 8 mm slice thickness scored statistically better than 3D reconstructions from equivalent conventional scans. Overlapping of the reconstructed helical slices by 25-75% generally improved the quality of the 3D reconstruction. CONCLUSION: Helical CT with either a 1.0 or a 1.5 pitch offers the ability to obtain higher quality 3D reconstructions than from comparable conventional CT scans.

Humans↗

PubMed1996

Amputation versus reconstruction in traumatic defects of the leg: outcome and costs.

This retrospective review covers global aspects of reconstructive efforts to salvage severely injured legs. Eighteen patients with traumatic lower leg amputation were compared to 21 patients who underwent complex microvascular reconstruction. The mean number of interventions was 3.5 for amputation and 8 for reconstruction (p < 0.009). Total rehabilitation time was 12 months for amputation and 30 months for reconstruction (p < 0.009). Changes in lifestyle were consistently more important in the amputee group. The mean annual hospital costs for amputated patients were 15,112 Swiss Francs (SD 7,094 SF) for the first 4 years. The mean annual hospital costs for reconstructed patients were 17,365 Swiss Francs (SD 8,702 SF) for the first 4 years. Fifty-six percent of the amputees and 19% of the reconstructed patients were retrained to a different profession (p < 0.025). Fifty-four percent of the amputees and 16% of the reconstructed patients were drawing an extremely costly and life long invalidity pension (p < 0.02). We conclude that for potentially salvageable legs reconstruction is advisable because the functional outcome was better than for amputation and there was no permanent social disintegration due to the long treatment. Total costs (including pensions) for reconstruction were far lower than for amputation.

Adolescent↗

PubMed1999

Lateral thigh free flap for head and neck reconstruction.

OBJECTIVES: To present the technique of lateral thigh free flap reconstruction in the head and neck and review the use of this procedure in 58 head and neck defect reconstructions. STUDY DESIGN: Retrospective review in the setting of a tertiary, referral, and academic center. METHODS: Retrospective review of patient records in cases of lateral thigh free flap reconstruction for head and neck defects. Records were reviewed for patient age, gender, pathologic findings, type of reconstruction (pharyngoesophageal, glossectomy, oropharyngeal, or external soft tissue defects), recipient and donor-site complications, and flap failure. RESULTS: Fifty-eight patients underwent lateral thigh flap reconstruction from 1984 to 1997. Patient age ranged from 10 to 76 years. Thirty-nine patients were men, and 19 were women. Forty-three flaps were used for pharyngoesophageal reconstruction, nine for glossectomy defects, two for oropharyngeal defects, and four for external, soft tissue defects. All resections were for squamous cell carcinoma, except one case of recurrent hemangiopericytoma. One flap failure occurred from venous thrombosis (1.7%). Forty-two of 43 pharyngoesophageal defects were successfully reconstructed (97.6%). Five temporary salivary leaks were noted, but no frank fistulas occurred. One fistula occurred in the oropharyngeal reconstruction group. Four minor donor-site complications were noted (6.9%). CONCLUSION: This series demonstrates the low donor-site morbidity, as well as the reliability and versatility, of the lateral thigh free flap for head and neck reconstruction.

Adolescent↗

PubMed1991

Early definitive bone and soft-tissue reconstruction of major gunshot wounds of the face.

The use of craniofacial surgical techniques, extended open reduction, rigid fixation with plates and screws, and the replacement of severely damaged or missing bone with immediate bone grafting in the treatment of complex facial fractures has been applied to the management of severe gunshot wounds of the face. Early definitive bone and soft-tissue reconstruction has been performed in 37 patients. One-hundred and seventy-seven primary bone grafts were utilized in 33 patients for orbital, nasal, zygomatic, and maxillary reconstruction. Twenty-six patients required mandibular repair with compression or reconstruction plates. Soft-tissue reconstruction was provided by a combination of flaps. Four patients had extensive soft-tissue loss replaced by free vascularized omental flaps. The omentum provided circumferential coverage of the mandibular reconstruction and reconstruction of the floor of the mouth and was then tunneled in a circle through both cheeks into the middle and upper face. The omentum reconstructed deficits in the hard palate and upper buccal sulcus and was then wrapped around all zygomatic, orbital, and midfacial bone grafts and used to fill in dead space in the maxillary, ethmoid, and frontal sinuses. The omentum is not used to provide contour and bulk, but to cover bone grafts and plates and fill in dead space. Carefully shaped bone grafts provide the correct craniofacial scaffold. Early restoration of a midfacial bony scaffold and the prevention of soft-tissue contraction facilitate secondary reconstruction. Four late total nasal reconstructions with tissue-expanded forehead skin wrapped around bone grafts were performed.

Adolescent↗

PubMed1997

The effects of radiation treatment after TRAM flap breast reconstruction.

A subgroup of mastectomy patients receives adjuvant radiation therapy after autogenous breast reconstruction for locoregional control of cancer. The effects of radiation therapy on pedicled transverse rectus abdominis musculocutaneous (TRAM) flaps were determined to evaluate complication rates and aesthetic results. Nineteen patients from 1981 to 1994 receiving radiation therapy after a pedicled TRAM flap reconstruction were compared with 108 patients who received radiation prior to reconstruction and 572 patients who underwent breast reconstruction without radiation. Retrospective reviews of patient charts were completed. Adjuvant radiation therapy was given for chest-wall recurrence in 13 of 19 patients. With a mean follow-up of 47.6 months from the time of reconstruction, 10 patients (52.6 percent) demonstrated postradiation changes in the TRAM flap reconstruction, and 6 required surgical intervention (31.6 percent). Overall complication rates were increased but were not found to be statistically significant between the radiated TRAM flap group and patients with preoperative radiation followed by TRAM flap reconstruction (31 versus 25 percent). Fibrosis was not found in patients with pre-TRAM flap radiation or in patients without radiation but was seen in 31.6 percent of patients who received radiation after the reconstruction. Fat necrosis was not significantly increased between the two groups of radiated patients. The complication rate does not change whether a patient receives radiation before or after her reconstruction; only the nature of the complication changes (fat necrosis to fibrosis).

Breast Neoplasms↗

PubMed1998

Reconstruction of upper cranial and cranial base defects utilizing the scalping flap.

Reconstruction of midfacial defects by means of a scalping flap has been widely practiced and described in the literature. The advantages of the flap are familiar to surgeons who perform extirpations and reconstruction of the head and neck and include contiguous availability, simplicity of application, and a robust and redundant blood supply. Despite these merits, the flap has not been widely used for reconstructions of large anterior cranial defects or defects of the cranial base. A retrospective review of 11 patients who underwent reconstructions between 1990 and 1995 was performed. In each case, a reconstruction of a large anterior cranial or cranial base defect was carried out. The resulting soft-tissue defect was restored via the scalping flap. In six cases, this was carried out in a single procedure. In five cases, flap division and insetting were carried out in a subsequent procedure, following a 1- to 2-week delay. In all cases, the extirpation and reconstruction were well tolerated, and the average time of hospitalization was 5.9 days and ranged from 3 to 11 days. No major surgical complications occurred. One of 11 patients had a minor complication not requiring surgical intervention. There was one recurrence of a cranial base tumor approximately 2 years following the initial resection and reconstruction. In all cases, the final aesthetic and functional results were acceptable to excellent. Follow-up ranged from 11 months to 5 years. In conclusion, the scalping flap can be effectively utilized for soft-tissue coverage in the reconstruction of anterior cranial and cranial base defects. Use of this simple and versatile flap in craniofacial reconstruction is well tolerated and is associated with a low morbidity, a good aesthetic result, and a short hospital stay.

Adult↗

PubMed1998

Free innervated latissimus dorsi muscle flap for reconstruction of full-thickness abdominal wall defects.

Full-thickness abdominal wall defects continue to be a challenge for the reconstructive surgeon. The most frequently used reconstructive techniques are transfer of a pedicled, local abdominal flap or a distant flap from the thigh region. The purpose of this paper is to present a new approach to full-thickness abdominal wall reconstruction using an innervated free latissimus dorsi musculocutaneous flap. Four patients with large full-thickness abdominal wall defects underwent reconstruction with a free innervated latissimus dorsi muscle flap. In two patients, staged abdominal wall reconstruction was performed. Primary closure was first obtained with a skin graft. During the subsequent definitive reconstruction (with an innervated free latissimus dorsi muscle flap), this skin graft was not excised. Instead, deep dermabrasion of the skin graft was performed, leaving a residual dermal layer. This layer was then covered with a free innervated latissimus dorsi muscle flap. In these two cases, there was no need for the use of a prosthetic mesh. A single stage reconstruction was performed in the other two cases. After abdominal wall sarcoma resection, Prolene mesh was placed and subsequently covered with a free innervated latissimus dorsi muscle flap. There were no free flap failures. The average time of surgery was 4 hours, 50 minutes. The average hospital stay was 14 days. No significant complications occurred except for one donor site seroma. No hernias have occurred postoperatively. The mean follow-up was 21 months. Postoperatively, electromyographic testing was performed regularly in all patients to document reinnervation of the latissimus dorsi muscle flap. With reinnervation and intensive muscle training, the transplanted latissimus dorsi muscle offers enough contractile capacity and strength to adequately replace the function of the missing abdominal wall muscles. In complicated staged reconstructions, dermabrasion of the temporary skin graft allows for the use of a residual dermal layer as a fascia-like substitute to aid in the restoration of structural integrity. The combination of the dermal layer with an innervated free latissimus dorsi muscle provides a strong, vascularized fascial repair as well as an overlying vascularized soft-tissue coverage. In conclusion, adequate functional dynamic reconstruction of full-thickness abdominal wall defects is possible using an innervated free latissimus dorsi muscle flap. The reinnervated latissimus dorsi muscle is suitable for reconstitution of the missing functional and anatomic components of complex abdominal wall defects.

Abdominal Muscles↗

PubMed1999

Primary reconstruction of complex midfacial defects with combined lip-switch procedures and free flaps.

Free flaps are generally the preferred method for reconstructing large defects of the midface, orbit, and maxilla that include the lip and oral commissure; commissuroplasty is traditionally performed at a second stage. Functional results of the oral sphincter using this reconstructive approach are, however, limited. This article presents a new approach to the reconstruction of massive defects of the lip and midface using a free flap in combination with a lip-switch flap. This was used in 10 patients. One-third to one-half of the upper lip was excised in seven patients, one-third of the lower lip was excised in one patient, and both the upper and lower lips were excised (one-third each) in two patients. All patients had maxillectomies, with or without mandibulectomies, in addition to full-thickness resections of the cheek. A switch flap from the opposite lip was used for reconstruction of the oral commissure and oral sphincter, and a rectus abdominis myocutaneous flap with two or three skin islands was used for reconstruction of the through-and-through defect in the midface. Free flap survival was 100 percent. All patients had good-to-excellent oral competence, and they were discharged without feeding tubes. A majority (80 percent) of the patients had an adequate oral stoma and could eat a soft diet. All patients have a satisfactory postoperative result. Immediate reconstruction of defects using a lip-switch procedure creates an oral sphincter that has excellent function, with good mobility and competence. This is a simple procedure that adds minimal operative time to the free-flap reconstruction and provides the patient with a functional stoma and acceptable appearance. The free flap can be used to reconstruct the soft tissue of the intraoral lining and external skin deficits, but it should not be used to reconstruct the lip.

Adult↗

PubMed2000

Determinants of patient satisfaction in postmastectomy breast reconstruction.

In today's increasingly competitive health care marketplace, consumer satisfaction has become an important measure of quality. Furthermore, measures of satisfaction with treatment inteerventions are influential factors in determining patients' and payers' choices of health care. This study sought to evaluate satisfaction with postmastectomy breast reconstruction and to assess the effects of procedure type and timing on patient satisfaction. As part of the Michigan Breast Reconstruction Outcome Study, patients undergoing first-time mastectomy reconstruction were prospectively evaluated, including cohorts of women choosing expander/implant, pedicle TRFAM flap, and free TRAM flap procedures. Preoperatively and 1 year postoperatively, participants completed a questionnaire that collected a variety of health status information. The postoperative questionnaire had an additional seven items assessing both general satisfaction with reconstruction (five items) and aesthetic satisfaction (two items) as separate subscales. Patients were asked to respond to each item using a five-point Likert scale. Item responses ranged from 1, indicating high satisfaction, to 5, reflecting low satisfaction. In the data analysis, only patients responding with a 1 or 2 for all of the items within a subscale were classified as "satisfied" for the subscale. To assess the effects of procedure type (implant, pedicle TRAM flap, and free TRAM flap) and timing (immediate versus delayed) on satisfaction and to control for possible confounding effects from other independent variables, multiple logistic regression was employed. In our analysis, odds ratios and associated 95 percent confidence intervals were calculated for each independent variable in the regression. Statistical significance was designated at the p < or = 0.05 level. A total of 212 patients were followed during the period of 1994 to 1997, including 141 immediate and 71 delayed reconstructions. The study population consisted of 49 expander/implant, 102 pedicle TRAM flap, and 61 free TRAM flap reconstruction patients. The analysis showed a significant association between procedure type and patient satisfaction. TRAM flap patients (both free and pedicle) appeared to have significantly greater general and aesthetic satisfaction compared with expander/implant patients (p = 0.03 and 0.001, respectively). Furthermore, pedicle TRAM flap patients were more aesthetically satisfied than those with free TRAM flaps (p = 0.072). The other independent variables of age and procedure timing did not appear to significantly affect either general or aesthetic satisfaction. However, preoperative physical activity was positively correlated with general satisfaction at the p = 0.034 level. The choice of procedure seems to have a significant effect on both aesthetic and general patient satisfaction with breast reconstruction. In this study, autogenous tissue reconstructions produced higher levels of patient aesthetic and general satisfaction compared with implant techniques. Pedicle and free TRAM flap patients do not seem to differ significantly in general satisfaction. However, women receiving pedicle TRAM flaps reported greater aesthetic satisfaction compared with patients undergoing free TRAM flaps. Furthermore, patient age and procedure timing may not have an effect on patient satisfaction with breast reconstruction.

Adult↗

PubMed2002

Functional reconstruction of maxilla with free latissimus dorsi-scapular osteomusculocutaneous flap.

Restoration of oral and nasal function together with facial appearance is still challenging in maxillary reconstruction. Use of a composite flap transfer merely to fill the defect results in unsatisfactory functional and aesthetic outcomes. The authors present a reconstructive procedure for complex maxillary defects using the latissimus dorsi-scapular rib osteomusculocutaneous flap. Some modifications for the reconstruction of the nasal cavity and the hard palate contributed to excellent postoperative functions. Five cases of extended maxillary defect were reconstructed using a novel procedure between February of 1997 and October of 2000. The hard palate was reconstructed with a vascularized scapular angle. The infraorbital rim was reconstructed with a vascularized rib if it was required. A prop bone graft, replacing the zygomatic buttress, was added between the infraorbital rim and the hard palate. The latissimus dorsi muscle flap, which was supported by a skeletal framework and obliterated the remaining cavities around the bone grafts, was left exposed into the nasal cavity, and an 8-French (no. 10) nasal airway tube was placed as a stent in the nasal meatus for 3 weeks after surgery. A skin graft was applied on the scapular angle to reconstruct the oral side of the hard palate. If required, facial skin defect was repaired with a latissimus dorsi musculocutaneous flap or scapular flap. No major complications at the recipient or the donor sites occurred postoperatively in any of the five cases. In cases in which the eyeballs were preserved, almost normal facial appearance was obtained and an orbital extirpation case showed an acceptable postoperative appearance. All five patients returned to an unrestricted diet and their speech was assessed as normal by a speech test. Nasal breathing through the re-epithelialized meatus was possible in all cases. The reconstructed nasal cavity was maintained for more than 6 months in all cases and for more than 2 years in one early case. Rhinometry demonstrated normal function, and histologic findings of the re-epithelialized mucosa over the muscle flap in the nasal cavity revealed a nearly normal architecture. This technique simplifies the reconstructive procedure of massive maxillary defects, including those in the lateral wall of the nasal cavity. It also improves the postoperative oral and nasal functions of the patients.

Adult↗

PubMed2002

Delay in unipedicled TRAM flap reconstruction of the breast: a review of 76 consecutive cases.

Since its introduction in 1982, the transverse rectus abdominis musculocutaneous (TRAM) flap has become the standard therapy in autogenous breast reconstruction. A lower rate of partial flap (fat) necrosis is associated with microvascular free-flap transfer compared with the conventional (unipedicled) TRAM flap because of its potentially improved blood supply. A TRAM flap delay before flap transfer has been advocated, especially in a high-risk patient population (obesity, history of cigarette smoking, radiation therapy, or abdominal scar). The authors reviewed a series of 76 consecutive delayed unipedicled TRAM flap breast reconstructions during a 5-year period. Data were analyzed with respect to type of procedure and time of delay, overall outcome, general surgical complications, flap-related (specific) complications (partial or complete flap loss), and patient satisfaction. Seventy-six unilateral breast reconstructions using the unipedicled TRAM flap were performed between 1995 and 2000 in 76 patients (mean age, 47.4 years). Fifty-four flaps were performed as immediate reconstructions, and 22 as secondary procedures. Seventy-two flaps were based on the contralateral pedicle, and four flaps were based on an ipsilateral pedicle. In all cases, a flap delay consisted of ligature of both deep inferior epigastric arteries and veins, accessed from an inferior flap incision down to the fascia, with a mean of 13.9 days before the flap transfer. No acute flap take-back procedure had to be performed. There was no complete flap loss, and breast reconstruction was achieved in all cases. In five cases (6.6 percent), a partial (fat) flap necrosis occurred. Interestingly, the majority of these cases (four of five) were secondary breast reconstructions. In addition, of the five patients who had partial flap necrosis, four had a history of smoking, two received radiation therapy, three received chemotherapy, and three patients were obese (body mass index greater than or equal to 30) or overweight (body mass index greater than or equal to 25). In three cases, an early surgical complication (two wound infections at the flap interface and one at the donor site) occurred. One patient developed a deep vein thrombosis. Five patients developed secondary ventral hernias necessitating repair (6.6 percent). Forty-one patients underwent secondary nipple-areola reconstruction. In 19 patients of this group, a secondary procedure (e.g., scar revision, limited liposuction, and/or excision of contour deformities) was simultaneously performed. A survey of patient satisfaction was performed using a modified SF-36 questionnaire. Fifty-one patients participated (67 percent). The overall satisfaction was very high and 51 patients reported that they would recommend the procedure to others (100 percent). Multiple factors such as patient selection, surgical expertise, and preoperative and postoperative management contribute to the success of any type of autogenous breast reconstruction. However, rare partial and absent complete flap necrosis in the authors' series may be attributable to the flap delay. A low morbidity rate and short hospital stay may become increasingly relevant, with limited structural and financial resources in the future. Therefore, the delayed unipedicled TRAM flap should be regarded as a valuable option in attempted breast reconstruction using autogenous tissue in both a high-risk and the general patient population.

Body Mass Index↗

PubMed2003

Early reconstruction failures after multilevel cervical corpectomy.

STUDY DESIGN: A retrospective analysis of graft and plate complications after multilevel anterior cervical corpectomy and fusion (ACF) attributed to spondylosis, stenosis, and ossification of posterior longitudinal ligament was conducted. OBJECTIVE: To identify factors contributing to graft and plate complications in this population. SUMMARY OF BACKGROUND DATA: Biomechanical factors contributing to the increased morbidity associated with plated multilevel ACF were evaluated. METHODS: Graft- and/or plate-related complications were retrospectively reviewed in 33 patients undergoing two-level ACF reconstructions and in seven patients having three-level ACF reconstructions performed with iliac crest grafting and instrumentation with a fixed-plated design (cervical spine locking plate). Neurologic status was assessed before surgery and after surgery using both the Nurick Grading Scale and modified JOA (Japanese Orthopaedic Association) Score. The patients were observed an average of 31.4 months after surgery. The follow-up included lateral flexion and extension radiographs and a neurologic examination. RESULTS: Two of the 33 patients undergoing two-level fusions available for long-term follow-up after surgery developed reconstruction failures. All of the remaining fusions were successful, demonstrated by lateral flexion and extension radiographs. Seven patients had plated three-level corpectomy reconstructions. Five of the seven who had anterior-only reconstruction failed. DISCUSSION: A two-level ACF reconstruction is reliable with an anterior strut graft and fixed screw plate construct. A three-level ACF reconstruction is not reliably achieved with an anterior-only construct. The construct failures may be attributed in part to the fixed-plated design being used, as well as the long lever arm of the construct. CONCLUSION: There is a 6% failure rate after fixed-plated (cervical spine locking plate) two-level ACF reconstruction but a 71% failure rate after three-level fixed-plated ACF reconstruction. Future consideration should be given to simultaneous posterior fusion.

Bone Plates↗

PubMed2003

Reconstruction of the hypospadiac hooded prepuce.

PURPOSE: The role of foreskin reconstruction as part of distal hypospadias repair remains uncertain. Thus, we wished to define better the indications with a view to improving the success of this cosmetic alternative. We reviewed the outcome in a group of patients who underwent foreskin reconstruction to highlight the criteria for likely success. MATERIALS AND METHODS: The records of 51 boys who underwent foreskin reconstruction from 1996 to 2001 were reviewed from a total hypospadias repair group of 223. Boys who underwent foreskin reconstruction were 4 months to 9 years old (median age 9.3 months). Surgery included a meatal advancement and glanuloplasty procedure in 22 patients, Mathieu urethroplasty in 2, King-Duplay repair in 2 and a meatotomy in 1, while in 24 with a normal glans meatus foreskin plasty was the only surgery. Cases in which the foreskin was required for chordee release and those in which the gap between the ventral aspects of the foreskin was wide were excluded from foreskin reconstruction. Also, patients were selected by intraoperative assessment of the ability to approximate the foreskin in the midline at the level of the coronal groove. If this maneuver can be performed without placing the foreskin under tension, the foreskin is considered suitable for reconstruction. All patients received regional and general anesthesia plus intraoperative antibiotics. After suitable urethroplasty the technique of foreskin reconstruction was generally similar for all types of the condition. RESULTS: The result was excellent in 36 patients (70.6%) with a normal-appearing foreskin that retracted easily. There was a good result in 8 patients (15.7%) with a satisfactory meatus at the tip of the glans and a retractable foreskin but minor foreskin deformity. Only 3 patients had a minor complication, including a fistula through the prepuce in 2 and wound infection in 1. No boy had a complication due to urethroplasty and there were no urethral fistulas. CONCLUSIONS: Our study shows that foreskin reconstruction is successful, particularly if the proximal, coronal groove portion of the prepuce can be easily approximated manually and the procedure can be combined with a range of distal repairs. We would recommend reconstruction of the prepuce if parents would prefer their son to be uncircumcised, providing that the foreskin is suitable for preservation.

Child↗