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Program Director, Creighton University School of Medicine

Rectus abdominis muscle and overlying skin paddle (dark arrow) supplied by the inferior epigastric vascular pedicle (open arrow) symptoms toxic shock syndrome retrovir 100 mg without prescription. Motor innervation to the gracilis is supplied by the obturator nerve symptoms 9 dpo buy retrovir 100mg lowest price, which divides into fascicles to different portions of the muscle medicine song discount retrovir. The gracilis muscle is a medial rotator and superficial adductor of the medial thigh whose primary role in head and neck reconstruction is for facial reanimation treatment 21 hydroxylase deficiency buy retrovir on line amex. The main advantages of the gracilis flap for facial reanimation are the fascicular neuroanatomy of the obturator nerve, the long vascular pedicle (up to 6 cm), and the ability to allow a simultaneous two-team harvest. Benefits of routine maxillectomy and orbital reconstruction with the rectus abdominis free flap. Jejunal Enteric Free-Tissue Flaps the jejunal enteric free-tissue flap is based on arborizing vessels from the superior mesenteric artery and vein. The antimesenteric border of this flap may be filleted, exposing a mucosal surface and providing a pliable and secretory flap for pharyngeal and oral cavity reconstruction. This tubular flap has been used extensively for pharyngoesophageal defects and the diameter of the jejunum makes it appropriate for this purpose. Omental & Gastroomental Free-Tissue Flaps the omental flap derives its vascular supply from the right and left gastroepiploic vessels. This flap includes the double layer of peritoneum that hangs off the greater curvature of the stomach. Because of its excellent blood supply, the omentum has a wide variety of uses in the head and neck, including reconstruction of the skull base and large scalp defects, carotid coverage, the management of wounds with osteomyelitis and osteoradionecrosis, and facial contouring. The gastroomental tissue includes gastric mucosa, which provides potential secretions useful for oropharyngeal defects. Donor site morbidity includes potential intraabdominal complications such as a gastric leak and gastric outlet syndrome. Latissimus dorsi flap based on the thoracodorsal artery (arrow); it is shown here as a single large skin paddle (horizontal lines) or as two separate paddles (vertical lines). The unique aspect of jejunal and omentalgastroomental tissue in head and neck reconstruction is the availability of a mucosal surface that may be used to reconstruct the aerodigestive tract. Both jejunum and gastroomentum flaps may be used as a tubed flap or mucosal patch. Jejunal flap showing a segment of bowel (dark arrow) based on the mesenteric branches of the superior mesenteric artery and vein (open arrow). Gracilis Jejunum Maxillary and mandibular defects Maxillary and mandibular defects Maxillary and mandibular defects Near-total mandibular defects Mandible, orbit Myogenous-Myocutaneous Large maxillary and skull base defects Skull base, glossectomy, and large cervical cutaneous defects Facial reanimation Enteric Pharyngeal, esophageal defects Can be filleted for oral cavity; pharyngeal defects Skull base, large scalp defects Coverage for wounds with osteomyelitis and osteoradionecrosis Carotid coverage Facial contouring Oropharyngeal defects Cervical, esophageal defects Lateral arm Lateral thigh Scapula Temporoparietal fascia tion. Free jejunal interposition reconstruction after pharyngolaryngectomy: 201 consecutive cases. Postoperative Monitoring the dreaded complication of microvascular reconstruction is flap loss from vascular compromise. The most commonly used monitoring techniques are clinical assessment and Doppler ultrasound flowmeter. Clinical evidence of venous congestion includes a purplish, turgid flap with rapid capillary refill (less than 1 second). Pinprick of the cutaneous portion of the flap with an 18-gauge needle is also an excellent means of assessing the quality of blood flow to and from the flap. A congested flap rapidly bleeds dark blood, whereas a flap with arterial insufficiency may not bleed at all or may bleed bright blood after a significant delay (> 4 seconds). The Doppler ultrasound flowmeter is also a convenient tool to assess vascular flow.

Superinfection should be treated with warm compresses medicine quetiapine cheap retrovir 300 mg mastercard, topical antibiotics medications 122 buy 300mg retrovir mastercard, and selective use of oral antibiotics symptoms parkinsons disease 300 mg retrovir for sale. Pathogenesis First branchial cleft anomalies occur as a result of anomalous fusion of the first and second branchial arches symptoms esophageal cancer retrovir 100 mg low price, with incomplete obliteration of the first branchial cleft. Clinical Findings Patients may present with a cyst or tract along the anterior border of the sternocleidomastoid muscle. One may also see a corresponding tract at the junction of the bony and cartilaginous ear canal. The patient may have a history of recurrent infection and drainage from the ear or neck. Eruption may occur secondary to instrumentation, foreign objects-including jewelry, ear plugs, and hearing aids-and other objects used to scratch pruritic lesions. The tract may be intimately involved with the facial nerve, which is at risk during excision. This is in contrast to irritant-mediated contact dermatitis, which usually manifests earlier. Clinical Findings Allergic contact dermatitis is characterized by an indurated, erythematous, pruritic, and poorly demarcated process. This is in contrast to irritant dermatitis, which often presents with well-defined areas of exposure. Treatment the avoidance of exposure to irritants and allergens and high-dose topical glucocorticoids are the mainstays of therapy. Pathogenesis Freezing temperatures lead to both direct cellular injury as well as vascular compromise. Prolonged exposure to cold temperatures can lead to vasoconstriction, cold-mediated dehydration, endothelial injury, thrombosis, and ischemia of auricular tissue. In the early stage, this process may be reversible, but over time, it leads to tissue necrosis. Ultimately, as the ear thaws, pain, erythema, and subcutaneous bullae secondary to extravasated extracellular fluid or blood may develop. Full-thickness, subdermal, and deep partial-thickness burns of the auricle heal with scarring and contracture and may be complicated by suppurative chondritis. These burns should be treated with both topical (usually silver based) and systemic cartilage penetrating antibiotics. Secondary reconstruction is usually performed at approximately 1 year after injury. Aloe vera has antithromboxane properties and, together with ibuprofen, may aid in reestablishing circulation. Surgical management and strategies in the treatment of hypothermia and cold injury. Clinical Findings Patients may present with pain, pruritus, conductive hearing loss, and bleeding. A persistent foreign body may lead to infection and the formation of granulation tissue. General Considerations Thermal injury can be classified by the degree of the burn. Subdermal burns extend into the subcutaneous tissue, including fat, muscle, tendon, cartilage, and bone. Two percent lidocaine may be used for the removal of insects both to achieve topical anesthesia and also to kill the insect. Clinical Findings Superficial auricular burns present with erythema secondary to dermal capillary dilation and vessel congestion. Patients with partial-thickness burns usually present with blisters that blanch on direct pressure and are very painful. Deep partial-thickness burns are associated with less pain, and there may be an eschar.

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Those leaks that go unrecognized or are not adequately repaired may result in delayed intracranial infections medications kidney damage buy line retrovir. The creation of an osteoplastic flap and the cranialization procedure are the two primary procedures used today to repair complex frontal sinus fractures treatment 7th feb cardiff purchase cheap retrovir line. The choice of when to operate and which procedure to perform depends on the extent of the fracture treatment lyme disease cheap retrovir 100 mg. More recent advances in instrumentation and technique have also allowed endoscopic methods to be used to repair and/or camouflage fractures medicine 027 buy retrovir cheap. These techniques are performed through small incisions behind the hairline similar to the approach used for an endoscopic brow lift. The osteoplastic flap-The concept of removing the frontal sinus as a functioning unit was introduced in 1958 by Goodale and Montgomery with the osteoplastic flap. This flap or hinged opening of the frontal sinus is created through either a midforehead or coronal incision and sinus obliteration; this approach may also be used through an existing forehead laceration. The procedure, which remains one of the principal means for treating frontal sinus fractures today, involves rais- C. The anterior table of the frontal sinus is then opened at its superior and lateral margins, creating an inferiorly based bone flap. All mucosa is then stripped from the sinus and all the bony walls of the sinus are burred down with a drill to ensure complete mucosal removal. The frontonasal recess mucosa is stripped or turned down into the ostium, and the ostium is obliterated using a muscle or fascia plug. Finally, the anterior wall of the frontal sinus and the coronal or midforehead flap is replaced. The cranialization procedure-In the cranialization procedure, the posterior wall of the frontal sinus is removed and the frontal dura is allowed to rest against the anterior table of the frontal sinus. This procedure also involves complete stripping of the mucosa, burring any mucosal remnants from the remaining anterior sinus wall, and plugging the frontonasal recess. Endoscopic repair-Using endoscopic techniques, incisions can be made smaller and morbidity from extensive dissection minimized. At this point, endoscopic techniques are used to repair and/or camouflage frontal sinus fractures involving the anterior table only, although technique development is ongoing. Small incisions behind the hairline are used to reduce and fixate fractures and camouflage contour defects through onlay grafts and other techniques for improved cosmesis. Surgical grafts-There has been significant debate over which material is best for obliterating the frontal sinus. One option is to remove all mucosa, plug the frontonasal recess, and allow ingrowth of fibrous tissue without obliteration. Autologous fat grafts-Free-fat grafts have been both studied and used most extensively. Overall autologous fat provides a safe obliterative material with few infectious complications. Other autologous tissue grafts-Other autologous tissues for obliteration include cancellous bone, muscle, and pericranial flaps. Autologous grafts typically involve some donor site morbidity, such as pain, infection, or the formation of sarcomas, hematomas, or both. Pericranial flaps with an inferior or lateral base offer a living tissue option for both obliteration and recreation of the anterior table with minimal donor site morbidity. Grafts of synthetic materials-One difficult situation in which synthetic materials may play a role is in 285 fractures with a loss or a severe comminution of the anterior table. In these scenarios, bone grafts (iliac, rib, or split calvarial) or methyl methacrylate have been used to recreate the anterior table. Titanium mesh offers a synthetic alternative for severely comminuted fractures, but its use is limited in cases with significant loss of anterior table bone.

Newer techniques have now been described for endoscopic placement of cartilage grafts to address the posterior component of circumferential subglottic stenosis symptoms 0f colon cancer buy retrovir 100 mg online. Many types of stents have been used medications memory loss order retrovir 300mg fast delivery, leading surgeons to conclude that no one stent necessarily guarantees a complication-free recovery and healing period medicine to treat uti generic 300 mg retrovir overnight delivery. The most commonly used stents include rolled silicone sheeting (the "Swiss roll") treatment uterine cancer purchase retrovir 100 mg fast delivery, polytef tubes (eg, Aboulker or Cotton-Lorenz), and preformed hollow silicone tubes (eg, Montgomery T-tube. For multistage procedures, stents have been kept in place from several weeks to over a year. Because of the many possible complications of indwelling stents, the most rational approach involves limiting stent duration; ideally, technically adequate expansion surgery should not require long-term stenting. Other medical conditions that may impact healing, such as diabetes and chronic steroid dependence, should also be considered during surgical planning. Newer techniques are being developed to prevent restenosis, which is the most common reason for decannulation failure. Other, more extensive procedures designed to remove rather than expand the stenotic segment have also been developed, including cricotracheal resection, slide tracheoplasty, and even tracheal homograft transplantation. Cricotracheal resection-Cricotracheal resection was originally reserved for patients who failed initial laryngotracheal reconstruction with grafting, but it is now being implemented as a first-line treatment for some patients with severe and even moderate stenoses. The procedure involves resection of the entire anterior cricoid arch with preservation of a posterior mucosal flap along the posterior cricoid plate. The normal trachea is then transected and telescoped into the posterior cricoid plate and secured with sutures to the mucosal flap and thyroid cartilage. Involvement of the vocal folds is a contraindication, and generally, a superior margin of 3 mm is recommended for success. Inferior resection margins have extended as low as the second tracheal ring, with the longest reported resection length being 3. A tension-free anastomosis is critical for success and a suprahyoid release has been used to achieve this. Slide tracheoplasty-Slide tracheoplasty has been used for congenital long-segment tracheal stenosis, which is often associated with a pulmonary artery sling. The principles of slide tracheoplasty involve tracheal transection at the midpoint of the stenosis with an anterior midline incision of the distal tracheal segment and a posterior midline incision of the proximal tracheal segment. The segments are then telescoped and sutured, ideally doubling the tracheal circumference and quadrupling the cross section of tracheal lumen. Rarely, a child with significant cardiac or pulmonary compromise or failure to thrive may need surgical treatment. The technique is tailored to the type of laryngomalacia that exists in the particular patient. A wide-mouthed laryngoscope (eg, a Lindholm laryngoscope) may be helpful in providing the best view of the supraglottis. The procedure is usually performed under general anesthesia with spontaneous ventilation. The three most common techniques include (1) trimming the lateral edges of the epiglottis, (2) releasing foreshortened aryepiglottic folds, or (3) excising redundant arytenoid mucosa. Care must be taken to avoid lasing adjacent surfaces to prevent scar formation; overly aggressive surgery can also lead to an increased risk of postoperative aspiration. Most patients can be extubated at the end of the procedure, and often a short course of postoperative steroids is given. Tracheotomy is an option for both diagnoses, but is generally not considered an optimal long-term solution. The other functions of the larynx, including airway protection, may worsen with any of these procedures, thereby increasing the risk of aspiration. Open or endoscopic procedures with posterior cartilage graft placement may also be used.