Management of the chest-wall deformity in male patients with Poland's syndrome

The chest-wall deformity associated with Poland's syndrome was reconstructed in eight male patients 16 to 38 years old (average age 20 years). Follow-up ranged from 1 to 10 years. Two patients had custom silicone implants placed subcutaneously. In one of these patients, the edge of the implant could be seen. Three patients had transfer of an ipsilateral pedicled latissimus dorsi muscle flap with intact thoracodorsal nerve. All these patients had noticeable atrophy of the flap, and one underwent subsequent implantation of a custom silicone implant beneath the flap. Three other patients had a custom silicone implant covered immediately by a latissimus dorsi muscle flap. All four patients who had a combination of silicone implant and latissimus dorsi muscle flap had satisfactory correction of their deformity.

Fibroblast-mediated contraction in actinically exposed and actinically protected aging skin

The changes in skin morphology over time are a consequence of both chronologic aging and the accumulation of environmental exposure. Through observation, we know that actinic radiation intensifies the apparent aging of skin. We have investigated the effects of aging and actinic radiation on the ability of fibroblasts to contract collagen-fibroblast lattices. Preauricular and postauricular skin samples were obtained from eight patients aged 49 to 74 undergoing rhytidectomy. The samples were kept separate, and the fibroblasts were grown in culture. Lattices constructed with preauricular fibroblasts consistently contracted more than lattices containing postauricular fibroblasts. The difference in amount of contraction in 7 days between sites was greatest for the younger patients and decreased linearly as donor age increased (r = -0.96). This difference may be due to preauricular fibroblasts losing their ability to contract a lattice as aging skin is exposed to more actinic radiation.

Early experience with high thoracic epidural anesthesia in outpatient submuscular breast augmentation

High thoracic epidural anesthesia was administered by anesthetists in 20 patients undergoing submuscular breast augmentation. An average of 12 ml of 2% lidocaine was instilled after sedation with midazolam, 2-6 mg. The augmentation procedure averaged 90 minutes. In 3 patients, the block developed more rapidly on one side than the other, but soon became symmetrical in all; additional subcutaneous infiltration of lidocaine was necessary in 1 patient because of infraclavicular pain; ephedrine, 10 mg was needed in 2 patients to treat hypotension (greater than 20% decrease in blood pressure). Three patients felt infraclavicular pressure; 1 had a brief sensation of breathlessness; 3 had nasal stuffiness from Horner's syndrome associated with the block; none developed headache, back pain, or paresthesias; and 3 had postoperative nausea. The average time from the end of the procedure to patient discharge was 96 minutes. In this limited series, high thoracic epidural anesthesia for submuscular breast augmentation was extremely satisfactory.

Conchal cartilage and composite grafts for correction of lower lid retraction

Lower eyelid retraction may be due to vertical deficiency of the anterior lamella, supporting cartilage, or posterior lamella. We have used autologous cartilage grafts from the conchal bowl for reconstruction of the central lamella, reestablishing and augmenting support of the lower lid. The positioning of the graft is dependent on the specific anatomic deficiency, and the etiology of the lid retraction must be carefully evaluated. In patients with posterior lamella deficiency, the contracted lower lid retractors and conjunctiva are released and the graft is placed facing the bulbar conjunctiva and is allowed to reepithelialize. In patients in whom there is an associated skin deficiency, composite auricular grafts are used. We present our experience in 33 patients with lower lid retraction. Twenty-three patients required placement of a cartilage graft only, while 10 patients had an associated skin deficiency requiring placement of composite cartilage. In nine patients the cartilage graft was seated against the bulbar conjunctiva and allowed to reepithelialize. Reepithelialization was complete within 3 1/2 weeks in all but two of these patients. This technique has provided stable lid support in all 33 patients.

Removing broken needles and other foreign objects

A needle or other foreign body that has penetrated the skin superficially can be located and removed fairly easily. If it is too deeply embedded to be palpated, it should be located by use of an image intensifier and two venipuncture needles. If this is unsuccessful, exploration and removal must be done in the operating room.

The temporal island scalp flap for management of facial burn scars

Facial burn scars are difficult to conceal and often preclude an aesthetic rehabilitation of the patient. Multistaged scalp and neck flaps have been described to provide hair-bearing skin to resurface burn scars in men. We have been resurfacing the upper lip and cheek in a one-stage procedure using a temporal artery island scalp flap. The temporoparietal fascia has been well described in recent years, and the understanding of this anatomy has facilitated the use of the island scalp flap for more distal transfers.

Fasciocutaneous flap closure of a grade III lower third tibial fracture: an alternative to free flap coverage

We present a patient who sustained a close-range shotgun wound resulting in a grade III fracture of the lower tibia. The wound was debrided on several occasions and, on day 4, was closed with a flexor digitorum muscle and pedicled fasciocutaneous flap. Grades III and IV lower one-third tibial fractures generally require a free flap to accomplish stable soft-tissue coverage. Free-tissue transfer, however, remains a tedious and lengthy procedure. Occasionally a fasciocutaneous flap may be available to facilitate wound closure and spare the patient a lengthy procedure and distant donor site. The established principles of compound tibial coverage must be adhered to when choosing a local fasciocutaneous flap.

Heterotopic brain presenting as a lip lesion

Heterotopic brain tissue in the upper lip of a newborn child is presented and discussed. This rare developmental anomaly is usually present at birth and may simulate hemangioma. Before any surgical procedure can be performed, thorough radiographic and neurosurgical examination is essential to rule out eventual communication of the tumor with intracranial space.

Studies on the endogenous flora of the human breast

Identification of the endogenous microbiological flora of the human breast and its role in breast infections following subglandular augmentation or reduction mammaplasty was undertaken. A total of 231 cultures were performed on 59 breasts in 30 patients. Patients were followed for 12 months. No fungus was cultured from any specimen. Of the breasts cultured 53% were positive for coagulase-negative staphylococcus. Other aerobes found included diphtheroids, lactobacillus, D-enterococcus, micrococcus, and alpha-hemolytic streptococcus. Propionibacterium acne was the most frequent anaerobic bacteria cultured. Other anaerobes included peptococcus and clostridium sporogenes. There was no correlation with respect to the type of bacterium and the depth within the breast where the culture specimens were taken. Postoperative wound infections developed in 2 of 19 patients undergoing reduction mammaplasty. Bacteria identical to those cultured at the time of surgery were again cultured from the wound. Twenty subglandular augmentation mammaplasties were performed with a 25% capsular rate at one year. Two capsules were associated with no bacterial growth at the time of mammaplasty surgery, whereas three were associated with coagulase-negative staphylococcus, Propionibacterium acne, and diphtheroids, respectively. Of the 15 breasts with no capsular contracture after one year, operative culture revealed coagulase-negative staphylococcus in 8 and no bacterial growth in 7. Even breast tissue located deep within the gland away from the nipple contains a flora that is similar to that of normal skin. Cases of infection in which the endogenous bacteria were correlated with later infection was documented.

Topical 5-fluorouracil in treatment of carcinoma of nasal floor and nasal alae

Squamous cell carcinomas of the nasal floor present problems for surgical therapy. Similarly, basal cell carcinoma of the nasal floor and alae requires extensive reconstruction when cures are obtained. To improve the results, we have treated the squamous cell carcinomas with topical 5-fluorouracil to obtain sensitization and shrinkage of the tumor before resection. The same has been done with basal cell carcinomas, but in selected patients the topical 5-fluorouracil has been continued until biopsies are negative. Thus, the costs of resection and reconstruction have been avoided and excellent cosmetic results are possible. This treatment is lengthy and requires weekly supervision. It offers a different approach that gives surgeons further options in treating these difficult carcinomas in carefully selected and cooperative patients.

Burn management: the role of tissue expansion

Tissue expansion has facilitated reconstruction in selected burn patients. For the past 5 years the authors have used this modality in 45 patients, reconstructing the head and neck, trunk, and extremities.

Expanded myocutaneous flaps: their clinical use

In particularly large defects the best available flap may not provide sufficient tissue for satisfactory correction. Pre-expansion of an overlying musculocutaneous flap allows transposition of a larger flap to reconstruct such defects. The authors present their experience in four patients to illustrate the efficacy of this modality in select patients.

Rapid expansion: experimental and clinical experience

One of the drawbacks of clinical expansion is delay of the final reconstruction and patient inconvenience. The authors have explored the physiologic response to rapid expansion in an animal model and present initial clinical experiences with three patients.

Squamous cell carcinoma of the parotid gland

Squamous cell carcinoma involving the parotid gland is an aggressive and rapidly advancing lesion which if not recognized and treated early will result in a high morbidity and mortality. We reviewed 30 patients with squamous cell carcinoma involving the parotid gland. Twenty-four patients had had previous epidermoid skin lesions in an area known to drain to the parotid gland and three resulted from direct extension into the gland from an overlying skin carcinoma, whereas only three were primary lesions of the gland. Patients who presented with involvement of the gland more than 4 months after excision of the skin lesion had a poor prognosis. Patients with epidermoid skin cancer in areas with a propensity to secondarily involve the parotid gland must be closely followed after treatment of the primary skin lesion.

Enhanced capillary blood flow in rapidly expanded random pattern flaps

We have quantitatively examined the effect of rapid sequential skin expansion on capillary blood flow in the porcine random flap model in order to determine the relation between the increased survivability of expanded random flaps and capillary blood flow. Three 6 X 20 cm random flaps were tattooed on the backs of six small (20-kg) pigs. One flap was not manipulated (control). A 450-ml expander was inserted at the base of the second flap and left in place (sham). At the base of the third flap a 450-ml expander was inserted and each day for 5 days sequentially filled to the limits of skin viability as determined by vital dye staining (expanded). Capillary blood flow was measured on day 8 by measurement of radioactivity after injection of 15-microns radiolabeled microspheres. Samples were taken at 4-cm intervals from the base of each flap. Rapid expansion led to significant increases in capillary blood flow in expanded skin and to enhanced preservation of capillary flow after elevation of random pattern flaps based on expanded skin compared to sham and to control tissues. This correlates with and explains at least in part our previous observation of improved length of survival of flaps raised on expanded skin.

Response of random skin flaps to rapid expansion

We studied the physiologic accommodation of tissues to 5-day expansion in a porcine random flap model to assess the time taken to expand skin to provide early coverage of traumatic defects. Three 6 X 20 cm random flaps were outlined but not elevated on the backs of 12 small (20-kg) pigs. One flap was not manipulated (control). A 450-ml expander was inserted at the base of the second flap and left in place (sham). At the base of the third flap a 450-ml expander was inserted and sequentially filled to the limits of skin viability each day for 5 days (expanded). Skin tension produced by the pressure of expansion and tissue oxygen (TpO2) in each flap were measured before and after each manipulation. Flaps were raised on day 8, and survival determined on day 15. Creation of the pocket reduced TpO2 to 55% of control values, expansion to 17.5% of control. Within 24 hours both sham and expanded had recovered to 80% of control values. After the second expansion, recovery from hypoxia was again almost complete after 24 hours. Recovery after subsequent expansions was less complete, but 3 days after the final expansion there was no statistical difference between TpO2 values in expanded, sham, and control groups. High pressures generated in the flap by expansion also returned to near normal within 24 hours. Flaps utilizing expanded skin survived to greater length (14.2 cm) than did sham (11.6 cm) or control (7.2 cm) flaps (p less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Advances in tissue expansion

Tissue expansion offers a versatile new technique in the reconstruction of many areas of the body. The authors discuss laboratory studies that provide insight into the mechanism of the technique and present examples from clinical experience acquired over the past seven years, including applications in breast reconstruction and reconstruction of the scalp, head and neck, and extremities.

Traumatic arteriovenous malformation of the external carotid arterial system

Traumatic arteriovenous (AV) malformations of the face and scalp are rare lesions characterized by multiple endothelial-lined channels between the arterial and venous systems. If improperly managed they have a high propensity to recur, and may result in severe cosmetic deformity. Lesions should be delineated by arteriography unless small and localized. They are managed by complete excision and ligation of arterial feeding vessels. Five cases of traumatic AV malformation of the face and scalp and their management are reported.

Silicone implant correction of pectus excavatum: indications and refinement in technique

Pectus excavatum is the most common deformity of the chest wall. The overwhelming majority of patients with pectus excavatum have no physiologic compromise. Adolescents beyond their growth spurt and adults who are asymptomatic are best served by placement of a silicone implant to correct the chest-wall defect. We have treated 12 patients in this manner. The initial 7 were treated with placement of a subcutaneous implant. Despite patient satisfaction, we noted several problems that compromised the aesthetic result. In the last 5 patients, the implant has been placed subpectorally, and room temperature vulcanizing silicone has been used to augment the preformed silicone implant if necessary. Subpectoral placement of a preformed silicone implant is a relatively minor procedure with a short hospital stay and minimum morbidity. It avoids a major reconstruction of the chest wall with its inherent risks and complications and provides a pleasing aesthetic result. All 5 patients, 4 of whom had severe deformity, have had good results with postoperative follow-ups of between 8 months and 2 years.

Transcoronal removal of an atypical orbitoethmoid osteoma

Craniofacial osteomas are lesions of bone that most commonly occur in the paranasal sinuses. Characteristically they remain dormant or slowly enlarge but remain asymptomatic. The more rapidly expanding tumor types may extend to adjacent structures, but signs and symptoms of such involvement are rare before the third decade. Presented is a patient with an ethmoid osteoma associated with a 2-year history of progressive proptosis first noticed at age 14. The operative approach afforded through a transcoronal incision combines excellent surgical exposure with hidden scar.