BACKGROUND & AIMS: The indications for free flaps have been more or less clarified; however, the course of reconstruction after the failure of a free flap remains undetermined. Is it better to insist on one's initial choice, or should surgeons downgrade their reconstructive goals? To establish a preliminary guideline, this study was designed to retrospectively analyze the outcome of failed free-tissue transfers performed in the authors hospital. Over the past 8 years (1990 through 1997), 3361 head and neck and extremity reconstructions were performed by free-tissue transfers, excluding toe transplantations. Among these reconstructions, 1235 flaps (36.7 percent) were transferred to the head and neck region, and 2126 flaps (63.3 percent) to the extremities. A total of 101 failures (3.0 percent total plus the partial failure rate) were encountered. Forty-two failures occurred in the head and neck region, and 59 in the extremities. Evaluation of the cases revealed that one of three following approaches to handling the failure was taken(1) a second free-tissue transfer; (2) a regional flap transfer; or (3) conservative management with debridement, wound care, and subsequent closure by secondary intention, whether by local flaps or skin grafting. In the head and neck region, 17 second free flaps (40 percent) and 15 regional flaps (36 percent) were transferred to salvage the reconstruction, whereas conservative management was undertaken in the remaining 10 cases (24 percent). In the extremities, 37 failures were treated conservatively (63 percent) in addition to 17 second free flaps (29 percent) and three regional flaps (5 percent) used to salvage the failed reconstruction. Two cases underwent amputation (3 percent). The average time elapsed between the failure and second free-tissue transfer was 12 days (range, 2 to 60 days) in the head and neck region and 18 days (range, 2 to 56 days) in the extremities. In a total of 34 second free-tissue transfers at both localizations, there were only three failures (9 percent). However, in the head and neck region, seven of the regional flaps transferred (47 percent) and four cases that were conservatively treated (40 percent) either failed or developed complications that lengthened the reconstruction period because of additional procedures. Six other free-tissue transfers had to be performed to manage these complicated cases. Conservative management was quite successful in the extremities; most patients' wounds healed, although more than one skin-graft procedure was required in 10 patients (27 percent). In conclusion, a second free-tissue transfer is, in general, a relatively more reliable and more effective procedure for the treatment of flap failure in the head and neck region, as well as failed vascularized bone flaps in the reconstruction of the extremities. Conservative treatment may be a simple and valid alternative to second (free) flaps for soft-tissue coverage in extremities with partial and even total losses.

背景与目标： 游离皮瓣的迹象已或多或少得到澄清; 但是，游离皮瓣失败后的重建过程仍未确定。坚持自己的最初选择是更好的选择，还是外科医生应该降低他们的重建目标？为了建立初步指南，本研究旨在回顾性分析在作者医院进行的游离组织转移失败的结果。在过去的8年中 (1990 1997年)，3361头，颈部和四肢重建是通过自由组织转移进行的，不包括脚趾移植。在这些重建中，1235皮瓣 (36.7%) 转移到头部和颈部区域，2126皮瓣 (63.3%) 转移到四肢。总共遇到101个故障 (3.0% 个故障总数加上部分故障率)。头部和颈部发生42次故障，四肢发生59次。对病例的评估显示，采取以下三种处理失败的方法之一 (1) 第二次游离组织转移; (2) 局部皮瓣转移; 或 (3) 通过清创术，伤口护理和随后通过次要意图关闭的保守治疗，无论是通过局部皮瓣还是植皮。在头颈部区域，转移了17个第二游离皮瓣 (40%) 和15个区域皮瓣 (36%) 以挽救重建，而在其余10例病例中进行了保守治疗 (24%)。在四肢中，除了17个第二游离皮瓣 (29%) 和三个用于挽救失败重建的区域皮瓣 (5%) 之外，还保守地处理了37个失败 (63%)。2例行截肢术 (3%)。从失败到第二次游离组织转移之间的平均时间在头颈部区域为12天 (范围为2至60天)，在四肢为18天 (范围为2至56天)。在两个位置总共34秒的自由组织转移中，只有三个失败 (9%)。然而，在头颈部区域，转移的区域皮瓣中有7例 (47% 例) 和保守治疗的4例 (40% 例) 失败或出现并发症，由于其他手术而延长了重建时间。为了处理这些复杂的情况，必须执行其他六个自由组织转移。保守治疗在四肢非常成功; 尽管10例患者 (27% 例) 需要进行多次皮肤移植手术，但大多数患者的伤口均已愈合。总之，第二次游离组织转移通常是一种相对更可靠，更有效的方法，用于治疗头颈部区域的皮瓣衰竭以及在重建四肢时血管化的骨皮瓣失败。保守治疗可能是第二 (自由) 皮瓣的一种简单有效的替代方法，可用于四肢软组织覆盖，部分甚至全部损失。

BACKGROUND & AIMS: :Current practice patterns for venous thrombembolism (VTE) prophylaxis in autogenous breast reconstruction are unknown. A web-based survey on VTE prophylaxis was distributed to all American Society of Plastic Surgery members in the United States with a clinical interest in autogenous tissue breast reconstruction (N = 3584). A total of 606 completed surveys were returned for a response rate of 16.9%. Overall compliance with established guidelines was low (25%). High volume surgeons (43% vs. 22%) and surgeons in academic practice (42% vs. 22%) were significantly more likely to report prophylaxis regimens consistent with American College of Chest Physicians guidelines (ACCP) recommendations. Subgroup analysis of 72 surgeons who specifically report conformance to ACCP guidelines demonstrated only 38% actually provided prophylaxis consistent with ACCP recommendations. VTE is a potentially fatal complication of autogenous breast reconstruction. Further research is necessary to create VTE prophylaxis guidelines specific to patients undergoing these procedures. The need for surgeon education on appropriate prophylaxis cannot be overemphasized.

背景与目标： : 目前在自体乳房重建中预防静脉血栓 (VTE) 的实践模式尚不清楚。一项基于网络的VTE预防调查已分发给美国所有对自体组织乳房重建有临床兴趣的美国整形外科协会成员 (N = 3584)。总共返回了606份完成的调查，答复率为16.9%。对既定指南的总体依从性较低 (25%)。高容量外科医生 (43% 对22%) 和学术实践中的外科医生 (42% 对22%) 更可能报告符合美国胸科医师学会指南 (ACCP) 建议的预防方案。对72名专门报告符合ACCP指南的外科医生进行的亚组分析表明，只有38% 名医生实际提供了与ACCP建议一致的预防措施。VTE是自体乳房重建的潜在致命并发症。需要进一步的研究来制定针对接受这些手术的患者的VTE预防指南。对外科医生进行适当预防教育的必要性怎么强调都不为过。

BACKGROUND & AIMS: :The purpose of this case is to show the efficacy of buccal mucosa as an alternative to treat a case of severe necrotizing sclero-uveitis (NSU) associated with ocular perforation. We show a severe inflammatory NSU case that did not improve with topical treatment and scleral patch. We performed a buccal mucosa graft taken from the lower lip with excellent functional and anatomical result, with no signs of relapse of the NSU after 2 years of follow-up. Buccal mucosa can be a safe, useful, and effective alternative for the reconstruction of the scleral wall.

背景与目标： : 该病例的目的是显示颊粘膜作为治疗与眼穿孔相关的严重坏死性巩膜炎 (NSU) 的替代方法的功效。我们显示了严重的炎症性NSU病例，通过局部治疗和巩膜贴剂无法改善。我们进行了从下唇取出的颊粘膜移植物，具有出色的功能和解剖学效果，随访2年后没有NSU复发的迹象。颊粘膜可以是重建巩膜壁的安全，有用和有效的替代方法。

BACKGROUND & AIMS: :Various reliable reconstructive options are available for treatment of perineal and perianal skin and soft tissue defects resulting from tumor ablation. Indications for TAR include the following: very low rectal cancers, in which low anterior resection or resection with coloanal anastomosis is not possible: persistent or recurrent anal cancer that has failed to respond to chemoradiation therapy; and previous rectal excision with either recurring colostomy complications or an unacceptable quality of life with a stoma. Of course, adequate surgical oncologic principles must not be compromised to enhance sphincter reconstruction. Either primary reconstruction at the time of cancer excision or secondary reconstruction at a later date is an acceptable alternative. Most investigators believe that primary reconstruction is technically easier and associated with fewer complications. Secondary reconstruction provides the advantage of oncologic certainty. Double dynamic graciloplasty after APR has proved to be anoncologically sound procedure with a good chance of continence and a life without a stoma in most patients. Finally, the preliminary experience with new techniques of electrode implants encourages further application. In most patients who have rectal cancer, a sphincter-saving resection can avoid the need for a permanent stoma. Very low rectal tumors, however, still require an APR as the treatment of choice when a safe coloanal anastomosisis not possible. In recent years, several authors have reported their experience on sphincteric reconstruction after APR. Most of these authors used gracilis muscles transposed from the thigh to the perineum (graciloplasty) to surround a coloperineal anastomosis after pull-through of the distal colon. The best way to achieve fecal continence is to obtain a mechanically sufficient contraction of the sphincter. Electrostimulation of the transposed gracilis muscles creates an essential framework for their postoperative muscular growth and contractility. In particular, adoption of continuous low-frequency stimulation has proved to be effective in increasing fatigue resistance of the transposed muscles, allowing their continuous "pseudotonic" contraction. Despite the general acceptance of the efficacy of this scheme, there are significant variations in various authors' experiences pertaining to graciloplasty configuration, surgical timing of resection and transposition, and electrostimulation device use and implantation.

背景与目标： : 各种可靠的重建选择可用于治疗会阴和肛周皮肤和肿瘤消融引起的软组织缺损。TAR的适应症包括: 非常低的直肠癌，其中无法进行低位前切除或结肠吻合术切除: 对化学放射治疗无效的持续性或复发性肛门癌; 以及先前的直肠切除术，其中有反复的结肠造口并发症或造口的生活质量令人无法接受。当然，不能损害适当的外科肿瘤学原理以增强括约肌重建。癌症切除时的初次重建或以后的二次重建是可接受的选择。大多数研究人员认为，初次重建在技术上更容易，并且并发症更少。二次重建提供了肿瘤确定性的优势。事实证明，在大多数患者中，APR后的双动态股薄肌成形术是一种合理的手术方法，有很好的节制和无造口的生活。最后，电极植入新技术的初步经验鼓励了进一步的应用。在大多数患有直肠癌的患者中，保留括约肌的切除术可以避免永久性造口的需要。但是，如果无法实现安全的结肠吻合术，则非常低的直肠肿瘤仍然需要APR作为首选治疗方法。近年来，一些作者报道了他们在APR后括约肌重建的经验。这些作者中的大多数人使用从大腿转移到会阴的gra肌 (gracillasty) 在远端结肠拉通后包围了一起会阴吻合术。实现大便失禁的最佳方法是获得括约肌的机械充分收缩。转位的gracilis肌肉的电刺激为其术后肌肉生长和收缩力创造了必要的框架。特别是，事实证明，采用连续的低频刺激可有效提高转位肌肉的乏力性，从而使其连续的 “假性” 收缩。尽管该方案的功效已得到普遍接受，但在gra成形术的配置，切除和转位的手术时机以及电刺激装置的使用和植入方面，各种作者的经验仍存在显着差异。

BACKGROUND & AIMS: BACKGROUND:For the past 6 years, we have used double hatchet flaps for reconstruction of lower lid and infraorbital skin defects. METHODS:Twenty-five patients who underwent reconstruction of lower eyelid/infraorbital skin defects using double hatchet flaps were retrospectively analyzed. Defect size ranged from 11 × 11 to 15 × 15 mm. In addition, pearls and pitfalls of the technique are discussed along with the presentation of 3 cases. RESULTS:Flaps were highly viable in all patients. There was no eyelid retraction, scleral show, ectropion, or entropion. Mean follow-up period was 13.7 months. Patient satisfaction with respect to scar appearance was assessed by the standard 5-point scale. Overall patient satisfaction score was 4 (satisfied) in 6 patients, and was 5 (very satisfied) in 19 patients. CONCLUSIONS:On the basis of the critical review of outcomes in 25 patients, use of double hatchet flaps for the repair of lower lid and infraorbital skin defects gives an excellent functional and aesthetic result. Horizontal movement of the hatchet flaps avoids vertical skin tension in the lower eyelid, and hence minimizes potential complications.

背景与目标：

BACKGROUND & AIMS: :This paper examines the psychological and social impact of reconstructive surgery for hemi-facial palsy and considers psychosocial factors which may be associated with patient satisfaction. It reports a retrospective study in which 106 adults were assessed using primarily qualitative methods. All participants had undergone two-stage reconstruction using vascularised free muscle grafts, with all procedures having been carried out by the same surgeon. The participants were all at least 12 months post-surgery. They were assessed using demographic questionnaires, the hospital anxiety and depression scale (HADS) and the facial paralysis evaluation measure (FPEM). In addition, all participants were interviewed using a semi-structured format, the interviews were recorded verbatim and the transcripts were analysed using thematic analysis. Of the total study group, 67% had acquired facial palsy. The mean age of the total group was 44.7 years and 67.9% were female. As a group they were rather less depressed than the normal population with similar levels of anxiety to population norms. The primary motivation for surgery was appearance rather than function. Using interview data in addition to the FPEM, satisfaction with the process and outcome of surgery was assessed. Thirty five percent were very satisfied with both process and outcome, 34% were satisfied with the outcome but found the treatment process stressful, 15.1% were not entirely satisfied with process or outcome but felt surgery had been worthwhile as there had been some improvement. The remainder were very dissatisfied with both process and outcome and regretted having undergone surgery. There was no significant association between dissatisfaction and anxiety, the cause of the acquired palsy, longevity prior to surgery, gender nor whether the condition was acquired or congenital. There was a significant relationship with depression, in that those who were suffering from depression were more likely to be dissatisfied with surgery. Participants were asked in interview about social pressures and comments or remarks made by others about their condition. The majority (89.6%) of the total study group reported intrusive questions by acquaintances and strangers, with more than half of these being distressed by such questions. Following surgery, there was a significant reduction in the incidence of these questions. There was no relationship between distress in response to these questions prior to surgery and dissatisfaction with surgery. However, 27.4% also reported aggressive hurtful comments before surgery with a minimal improvement in incidence following surgery. These participants also reported consistent patterns of social avoidance and social isolation before and after surgery, and were more likely to be depressed than the rest of the study group. They were significantly more likely to be dissatisfied with surgery (p=.016). It is recommended that patients are screened and counseled prior to surgery to identify such problems and referred for psychological treatment in order to ensure they gain maximum benefit from reconstructive surgery.

背景与目标： : 本文研究了重建手术对半面瘫的心理和社会影响，并考虑了可能与患者满意度相关的社会心理因素。它报告了一项回顾性研究，其中主要使用定性方法评估了106名成年人。所有参与者都使用血管化的游离肌肉移植物进行了两阶段的重建，所有手术均由同一位外科医生进行。参与者均在术后至少12个月。使用人口学问卷，医院焦虑和抑郁量表 (HADS) 和面瘫评估量表 (FPEM) 对他们进行评估。此外，使用半结构化格式对所有参与者进行了访谈，逐字记录访谈，并使用主题分析对成绩单进行分析。在整个研究组中，有67% 人患有面部麻痹。该组的平均年龄为44.7岁，67.9% 为女性。作为一个整体，他们比正常人群的抑郁程度要低得多，焦虑程度与人口规范相似。手术的主要动机是外观而不是功能。除FPEM外，还使用访谈数据评估了对手术过程和结果的满意度。30名5% 对过程和结果都非常满意，34% 对结果感到满意，但发现治疗过程压力很大，15.1% 对过程或结果并不完全满意，但认为手术值得，因为有所改善。其余的人对过程和结果都非常不满意，并对接受手术感到遗憾。不满意和焦虑，后天性麻痹的原因，手术前的寿命，性别以及疾病是后天性还是先天性之间没有显着关联。与抑郁症有显着的关系，因为那些患有抑郁症的人更有可能对手术不满意。在采访中，参与者被问及社会压力以及他人对其状况的评论或评论。整个研究小组中的大多数 (89.6%) 报告了熟人和陌生人提出的侵入性问题，其中一半以上的人对此问题感到困扰。手术后，这些问题的发生率显着降低。手术前对这些问题的困扰与对手术的不满之间没有关系。然而，27.4% 还报告了手术前的侵袭性伤害性评论，手术后发病率的改善很小。这些参与者还报告了手术前后一致的社交回避和社交隔离模式，并且比研究组的其他成员更容易抑郁。他们更可能对手术不满意 (p =.016)。建议在手术前对患者进行筛查和咨询，以发现此类问题并转介进行心理治疗，以确保他们从重建手术中获得最大收益。

BACKGROUND & AIMS: :Surgeons who communicate on a regular basis with an anaplastologist will benefit from having a more comprehensive practice and will be able to provide a broader depth of information to their patients contemplating facial reconstruction. When a prosthesis is chosen as the best option, it is important for the surgeon to understand that early communication with the anaplastologist can lead to improved appearance and function of the prosthesis. When the surgeon and anaplastologist work closely, their efforts complement one another in creating a final reconstructive plan that will ultimately improve the patient's quality of life.

背景与目标： : 定期与外科医生进行交流的外科医生将受益于更全面的实践，并能够为考虑面部重建的患者提供更广泛的信息。当选择假体作为最佳选择时，对于外科医生来说，重要的是要了解与外科医师的早期沟通可以改善假体的外观和功能。当外科医生和外科医生密切合作时，他们的努力相互补充，以创建最终的重建计划，最终将改善患者的生活质量。

BACKGROUND & AIMS: :Eleven patients with roller injuries to the upper extremity are described. Nine were treated initially; two were referred for treatment within 3 weeks after injury. Six patients were injured by kneading machines in bakeries, two by hot dry-cleaning mangles, two by industrial rolling machines, and one by a transmission belt which acted as a roller. The tissue damage depends on (1) the space between the rollers, (2) the speed of the rollers, (3) the hardness of the rollers, (4) the temperature of the rollers, and (5) how violently the patient attempts to withdraw the entrapped part. Lesions may be closed, consisting of a compression of the soft tissues, which may result in skin necrosis, or a tearing and separation of the skin and soft tissues away from the deep fascia (more common on the dorsal surface of the hand), or destruction of skin and deep tissue because of burns. Closed injuries usually respond to conservative care, although decompression sometimes is necessary. Experience gained from treating these 11 patients indicates that the inexperienced surgeon often tries to replace distally based flaps. Such flaps usually die and predispose to deep infection. If the condition of the wound permits, primary skin grafts should be applied; but if the bed is of poor quality, skin grafting can be delayed for several days. If it is necessary to protect exposed deep structures, they should be covered with immediate pedicle flaps. It is better to use skin from an uninjured area for a free skin graft than to use the avulsed skin as a graft. Distant flaps should be used if secondary reconstruction is anticipated. In circumferential skin loss, a combination of pedicle skin and free skin grafts is better than encircling the part with a pedicle flap. The thumb and radial fingers should be preserved, but the ulnar fingers are expendible in severe injuries. By amputating parts of fingers, reconstruction often is simplified.

背景与目标： : 描述了11例上肢滚子受伤的患者。最初治疗了9个; 受伤后3周内转诊了2个。六名患者在面包店被捏合机伤害，两名被热干洗杂物伤害，两名被工业轧制机伤害，一名被用作滚筒的传动带伤害。组织损伤取决于 (1) 辊之间的空间，(2) 辊的速度，(3) 辊的硬度，(4) 辊的温度，以及 (5) 患者尝试如何剧烈地抽出夹带的部分。病变可能是闭合的，包括软组织的压迫，这可能导致皮肤坏死，或皮肤和软组织远离深筋膜撕裂和分离 (更常见于手背表面)，或由于烧伤而破坏皮肤和深层组织。闭合性损伤通常对保守护理有反应，尽管有时减压是必要的。从治疗这11名患者中获得的经验表明，经验不足的外科医生经常尝试更换远端皮瓣。这种皮瓣通常会死亡并容易感染。如果伤口条件允许，应进行初次皮肤移植; 但是如果床质量差，则植皮可以延迟几天。如果有必要保护裸露的深层结构，则应立即用椎弓根皮瓣覆盖。使用未受伤区域的皮肤进行游离皮肤移植比使用撕脱的皮肤作为移植更好。如果预计二次重建，应使用远处皮瓣。在周向皮肤丢失中，椎弓根皮肤和游离皮肤移植物的组合比用椎弓根皮瓣包围该部分更好。应保留拇指和radial骨手指，但在严重受伤时尺骨手指可扩展。通过截肢手指的一部分，重建通常被简化。

BACKGROUND & AIMS: OBJECTIVE:to prevent kidney injury in renal artery and juxta-renal aortic surgery. After 30 min of cross-clamping ischaemia, renal arterial inflow is temporary re-established for 3 min. The aim of the study was to retrospectively analyse the results of this original technique. METHODS:between January 1987 and May 1999, 48 patients underwent kidney short-term arterial blood reperfusion, directly or through the Pruitt-Inahara shunt. The reperfusion was repeated every 30 min of ischaemia, whenever necessary. Fifty control patients underwent <30 min of kidney ischaemia. Patients were assessed by serum creatinine, digital angiography and radioisotope renography using technecium(99). RESULTS:in the study group one patient developed an acute renal failure and died (2% (-95% CI: 0-11%)). In both study and control groups patients showed a similar and moderate but temporary decline in renal function, which returned to preoperative levels after 1 week. CONCLUSIONS:the results of this study indicate that kidney short-term reperfusion may protect renal tissue from prolonged cross-clamping ischaemia (up to 100 min), also in patients considered at high risk for acute renal failure.

背景与目标：

BACKGROUND & AIMS: :Using several cases that demonstrate partial or total reconstruction of the nose, the author discusses the necessity of not only a complete functional but an aesthetically acceptable end result of the surgery. Sophisticated surgical refinements of the complex anatomic structures of the nasal tip alae and columella are strongly emphasized, with a first-time description of a newly devised forehead compound island flap for nasal reconstruction.

背景与目标： : 通过几种证明鼻子部分或全部重建的病例，作者讨论了不仅手术具有完整功能而且在美学上可接受的最终结果的必要性。强烈强调对鼻尖alae和小柱的复杂解剖结构进行复杂的外科手术改进，并首次描述了新设计的用于鼻重建的前额复合岛状皮瓣。

BACKGROUND & AIMS: BACKGROUND:Unicuspid anatomy of the aortic valve is infrequent but may require intervention by age 40 for severe regurgitation. We propose a new repair technique for the regurgitant unicuspid valve by converting it into a bicuspid aortic valve. METHODS:Between November 2003 and September 2007, 20 patients underwent regurgitant unicuspid aortic valve repair: 13 had aortic regurgitation (AR) and 7 had combined regurgitation and stenosis. Four patients had previously undergone balloon valvuloplasty for critical aortic stenosis. The aim of the repair was to construct a bicuspid valve with two normal commissures and unrestricted cusp motion. The fused cusp tissue was divided anteriorly and a new commissure of normal height was created. Noncoronary and right coronary cusps were extended with autologous pericardium. Concomitant operations included ascending aortic replacement in 7 and resection of subaortic stenosis in 1. RESULTS:No early or late deaths occurred. Intraoperative echocardiography revealed minimal or no AR in 19 patients. Follow-up was 4 to 47 months. One patient underwent valve re-repair for recurrent and progressive aortic regurgitation 3 years postoperatively. All other valves remained stable throughout the follow-up period. Freedom from relevant aortic insufficiency (> or = II) at 4 years was 77%; freedom from reoperation was 67%; and freedom from valve replacement was 100%. CONCLUSIONS:The regurgitant unicuspid aortic valve can be repaired successfully and reproducibly by converting it into bicuspid anatomy. The functional results are comparable with those obtained in reconstructed bicuspid aortic valves. With this approach, replacement can be avoided in most patients with regurgitant unicuspid aortic valves.

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BACKGROUND & AIMS: :The implementation of laser surface scanning to assess facial symmetry after unilateral face-lift procedures used to reconstruct defects after skin tumor resection is presented. Six patients who had undergone defect reconstruction with a flap raised from the subcutaneous plane were included in the study. Immediate postoperative photographic evaluation confirmed facial asymmetry because of unilateral skin tension. After a minimum follow-up period of 1 year, photographic and laser surface scanning analysis showed restored facial symmetry. In conclusion, laser surface scanning is a promising technology for objectifying results obtained and could be implemented for evaluation of the immediate and long-term effects from rhytidectomy procedures. Subcutaneous flaps without duplication or resection of the superficial musculoaponeurotic system are ideal for unilateral procedures because facial symmetry is restored after 1 year.

背景与目标： : 提出了在皮肤肿瘤切除术后用于重建缺损的单侧面部整容程序后，激光表面扫描的实施来评估面部对称性。该研究包括六名从皮下平面抬起皮瓣进行缺损重建的患者。术后立即进行照相评估，证实由于单侧皮肤张力而导致面部不对称。经过1年的最小随访期后，照相和激光表面扫描分析显示恢复了面部对称性。总之，激光表面扫描是一种有前途的技术，可用于客观化获得的结果，并且可以用于评估除皱术的近期和长期效果。没有重复或切除浅表肌腱膜系统的皮下皮瓣是单侧手术的理想选择，因为面部对称性在1年后恢复。

BACKGROUND & AIMS: BACKGROUND AND PURPOSE:Patients with fusiform basilar trunk aneurysms have a poor prognosis. Reconstructive endovascular therapy is possible with modern devices. We describe the clinical presentation, radiologic features, and clinical outcome of 13 patients with fusiform basilar trunk aneurysms treated with flow diverters, stents, and coils. MATERIALS AND METHODS:Of the 13 patients, 7 were men and 6 were women with a mean age of 59.7 years. Clinical presentation was SAH in 3 patients, mass effect on the brain stem in 4 patients, vertebral artery dissection in 1 patient, and the aneurysm was an incidental finding in 5 patients. Mean aneurysm size was 21 mm. All except 1 were large or giant aneurysms. Nine aneurysms were partially thrombosed. RESULTS:Stents were used in all 13 patients, in 2 patients with additional flow diverters and in 11 patients with additional coils. In 4 patients, 1 vertebral artery was subsequently occluded with coils to decrease flow into the aneurysm. Of 13 patients, 9 had a good outcome with adequate aneurysm occlusion and stable size on follow-up of 6-72 months. One of 3 patients who presented with SAH died of a rebleed 1 month later. One other patient died soon after treatment of in-stent thrombosis, and another patient became mute after treatment. In 2 of 3 patients who presented with symptoms of mass effect, there was improvement at a follow-up of 6-24 months. CONCLUSIONS:Reconstructive endovascular therapy of fusiform and dissecting basilar trunk aneurysms is feasible but carries substantial risks. The safety and effectiveness in relation to natural history has not yet been elucidated.

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BACKGROUND & AIMS: :There is considerable variation in the post-operative management of head and neck free flaps in the UK. We undertook a national postal survey of maxillofacial surgical units in the UK who perform free flap reconstruction following ablative head and neck surgery. Questions were asked about the routine postoperative care of a hypothetical, straightforward patient undergoing free flap reconstruction to determine whether there were any trends in managing these patients. There was considerable variation in the number of free flaps performed by each unit per year. The majority of patients (87%) are managed in either an intensive care or high dependency unit. The routine use of a tracheostomy is common (69%). There was also variation in the management of these cases, particularly with the requirement for ventilation. Few units routinely use dextran or dobutamine infusions, although one-to-one nursing and invasive cardiovascular monitoring are commonplace. Alternative provision of postoperative care is discussed.

背景与目标： : 在英国，头颈部游离皮瓣的术后管理存在很大差异。我们对英国的颌面外科部门进行了全国邮政调查，这些部门在进行了头颈部消融手术后进行了游离皮瓣重建。询问了有关进行游离皮瓣重建的假设，直接的患者的常规术后护理的问题，以确定管理这些患者是否有任何趋势。每年每个单位执行的自由襟翼数量差异很大。大多数患者 (87%) 在重症监护或高依赖性病房中进行管理。气管切开术的常规使用是常见的 (69%)。这些病例的管理也有所不同，特别是在通风要求方面。尽管一对一的护理和侵入性心血管监测很普遍，但很少有单位常规使用右旋糖酐或多巴酚丁胺输注。讨论了术后护理的替代提供。

BACKGROUND & AIMS: AIM:This paper presents a literature review conducted to establish what was already known about critical reflection in the nursing literature and what work had been done on using a critical social theory framework as the basis for critical reflection. BACKGROUND:Critical thinking emerged as a significant aspect of nursing education and practice in the late 1980s. It has been promoted as a means by which issues in clinical practice can be examined through a systematic process of exploration and reasoning. Traditionally, critical thinking has commonly involved an attempt to link practice with theory using a scenario or exemplar from practice to illustrate a practice dilemma. This process is often constructed as a retrospective narrative of events. This paper provides a deconstructive-reconstructive approach that differs from some traditional approaches by taking a critical social theory perspective with an emphasis on improving practice. METHODS:The nursing literature reviewed was accessed through Cumulative Index of Nursing and Allied Health Literature (CINAHL). The search was restricted to English language and published between 1995 and 2005. Based on these findings, we developed a postgraduate advanced mental health nursing programme. FINDINGS:There were 490 articles related to 'nursing' and 'critical thinking'; 34 articles related to 'nursing' and 'critical reflection'; 23 articles related to 'nursing' and 'critical social theory'; 15 articles related to 'mental health nursing' and 'critical thinking'; and two articles related to 'mental health nursing' and 'critical reflection'. In the programme we developed based on these findings, students were facilitated to deconstruct concepts and knowledge integral to their own practice. In the reconstructive phase, students implement a change project in clinical practice, supported by a mentor. CONCLUSION:The deconstructive-reconstructive approach to the development of critical thinking skills provides advanced practitioner with the opportunity to integrate practice, theory and research.

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