Trachea

The Scar Solution Natural Scar Removal

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A tracheostomy is usually present in patients who present for delayed repair of tracheal separation. Unilateral or bilateral vocal cord paralysis is likely to be present. Several of our patients have also had acquired tracheoesophageal fistulae.6 A patient must no longer require ventilation assistance to be a suitable candidate for an operation. An interval of 4 to 6 months should elapse after injury or previous tracheal surgery to allow for subsidence of inflammation and maturation of a scar. If further procedures are anticipated to correct or ameliorate other systems (such as orthopedic operations), these are best completed before the tracheal repair to avoid risk of repeated ventilation after tracheal reconstruction.

Complete evaluation of laryngeal structure and function is essential and is preferably done by an experienced otolaryngologist. This author prefers to see any laryngeal deficits corrected while the preexisting tracheostomy is still in place, to be certain that correction is achieved prior to the tracheal repair. If simultaneous repair of the glottis and trachea is done, a new tracheostomy or splinting T tube is usually necessary. The procedure becomes more complicated if the trachea must be markedly shortened in the repair. As emphasized in Chapter 9, "Tracheal and Bronchial Trauma," a completely paralyzed larynx can be made functional and will subsequently justify reconnection of a chronically separated trachea.

After complete radiologic and endoscopic examination, repair is undertaken as described in Chapter 24, "Tracheal Reconstruction: Anterior Approach and Extended Resection," and Chapter 25, "Laryngotracheal

figure 31-6 A, Intrathoracic lower tracheal laceration with accompanying esophageal tear. Exposure is via a right posterolateral thoracotomy after guided intubation of the left main bronchus with an extra-long endotracheal tube. Only enough dissection is done to expose the injuries fully. The closeness of the left recurrent laryngeal nerve in the left tracheoesophageal groove is kept in mind. Tracheal lacerations may vary in extent, location, and spiral course, and may involve the main bronchi. Little débridement is necessary or permissible.

figure 31-6 A, Intrathoracic lower tracheal laceration with accompanying esophageal tear. Exposure is via a right posterolateral thoracotomy after guided intubation of the left main bronchus with an extra-long endotracheal tube. Only enough dissection is done to expose the injuries fully. The closeness of the left recurrent laryngeal nerve in the left tracheoesophageal groove is kept in mind. Tracheal lacerations may vary in extent, location, and spiral course, and may involve the main bronchi. Little débridement is necessary or permissible.

Bronchoscopy Form

figure 31-6 (continued) B, The tracheal laceration is repaired with interrupted 4-0 Vicryl sutures. The esophagus is closed with two layers of interrupted 4-0 sutures. The mucosa is inverted, and the muscularis is closed with mattress sutures. C, A long intercostal muscle pedicle has been raised, preferably during the thoracotomy, on the basis of identification of the tracheal laceration on preoperative bronchoscopy. The pedicle is sutured over the line of tracheobronchial repair with multiple fine sutures—not merely "tacked" in place. There should be no air leak on a test at this point. The esophageal closure usually falls on the pedicle. Additional sutures may be used to buttress the esophageal suture line against the intercostal flap.

Reconstruction." A dense post-traumatic scar is to be anticipated. Since a severed trachea descends into the mediastinum, the gap between proximal and distal airway segments may not indicate the true length of destroyed trachea. Dissection of the anterior surface of distal trachea may initially be difficult, and care must be taken to protect the brachiocephalic artery. If a tracheoesophageal fistula is present, it is repaired and buttressed with a pedicled strap muscle prior to completing the airway anastomosis. Since laryngeal adequacy is established prior to late tracheal reconstruction, there should be no need for a complementary tracheostomy.

Mid- or lower tracheal fracture may initially go unrecognized and present as a stricture. Such a patient usually has not undergone prior tracheal surgery and is a candidate for early repair. The anterior approach described in Chapter 23, "Surgical Approaches," is used.

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How To Reduce Acne Scarring

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Acne is a name that is famous in its own right, but for all of the wrong reasons. Most teenagers know, and dread, the very word, as it so prevalently wrecks havoc on their faces throughout their adolescent years.

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