Correction of areolar depression in postsurgically treated gynecomastic patients.

Nipple-areolar depression after resection for gynecomastia can be avoided by preserving an ample amount of breast tissue and fat under the areola. If a marked depression of the areola occurs, correction can be difficult. Each patient requires an individual assessment, but the principle of rotation of soft tissue under the areolar complex is usually necessary. An effective way to accomplish this is by deepithelialization of a semilunar area inferior to the original subareolar scar, freeing it at its caudal boarder and advancing this deepithelialized flap under the areola and repairing the wound. The technique is simple in design and may be a useful tool in dealing with this difficult problem.

Negative-pressure dressings as a bolster for skin grafts.

Contoured wounds needing closure with skin grafts are often located in complex anatomic regions or are in unusual positions, which make conventional skin graft stabilization techniques cumbersome and ineffective. Often after 72 hours, a skin graft covered with a bolstered dressing has poor take secondary to shear stresses, as well as hematoma formation or serum collection, negating the effectiveness of the stabilizing dressing. The Food and Drug Administration has recently approved vacuum-assisted closure (V.A.C.), an innovative technique using negative pressure, for closure of chronic wounds. This reportedly leads to enhanced granulation tissue formation and consequently more rapid reepithelialization of wounds compared with conventional packing with saline-moistened gauze. Experimental studies have demonstrated increased oxygen tension, decreased bacterial counts, and increased granulation formation occurring under negative-pressure systems. Extending the use of this concept, we have coupled skin grafting with negative-pressure dressings for closure of large, complex open wounds. Our results indicate greater than 95% graft take in all patients in this study. This technique is extremely efficacious, with increased graft take due to total immobilization of the graft, thereby limiting shear forces, elimination of fluid collections, bridging of the graft, and decreased bacterial contamination. Moreover we have noted decreased edema in rotated muscle flaps, improved contour conformity, and shortened hospitalizations.

Classification and treatment of ulnar styloid nonunion.

Symptomatic nonunion of the ulnar styloid is an uncommon problem that is usually best treated by simple excision of the ulnar styloid fragment. Two types of nonunion of the ulnar styloid are described here on an anatomic basis, and their treatment differs. Type 1 is defined as a nonunion associated with a stable distal radioulnar joint. Type 2 is defined as a nonunion associated with subluxation of the distal radioulnar joint. The postoperative follow-up period for the two types ranged from 4 months to 13 years, with a mean of 5 years 2 months. Eleven type 1 wrists were treated with excision of the fragment, and all patients had satisfactory relief of pain. Nine type 2 wrists required restoration of the anatomy of the traingular fibrocartilage complex. Three of these had large fragments that were treated by open reduction and internal fixation. All three patients were completely relieved of their discomfort. Six other patients underwent excision of the fragment and repair of the triangular fibrocartilage complex to the distal ulna. This group had four excellent, one good, and one fair result. If the distal radioulnar joint is stable on presentation or if its stability is restored, then long-term relief of pain from ulnar styloid nonunion is achieved by treatment of the nonunion.

Sensibility of finger fillet flaps on late follow-up evaluation.

Though the use of fillet flaps salvaged from damaged digits is a well-established technique to obtain soft tissue coverage for the badly injured hand, the sensibility of these flaps has not been evaluated. We examined a series of four patients who underwent digital fillet flaps following hand trauma. Static two-point discrimination measurements of the injured hand and the contralateral hand showed that all four patients retained sensibility in the fillet flap that was equal to or better than the intact skin surrounding the flap. In some cases, the sensibility of the flap was equal to the sensibility in the corresponding contralateral fingertips. No patients had complaints regarding the function of their fillet flaps as sensate coverage of major soft tissue defects.

Lunate morphology: can it be predicted with routine x-ray films?

To assess our ability to predict lunate morphology, x-ray films of 81 cadaver wrists were obtained. The wrists were then dissected to determine true anatomy, specifically the presence or absence of a medial lunate facet. Thirty-five wrists were found to be type 1 lunates, while 46 were type 2. Cartilage erosion at the proximal pole of the hamate was found in association with 28 of the type 2 lunates. The accuracy of determining lunate morphology ranged from 64% to 72%. Therefore, lunate morphology cannot always be reliably predicted by a standard x-ray film. Arthrosis at the lunate-hamate articulation is frequent in association with type 2 lunates.

Familial syndromes with skin tumor markers.

A number of interesting syndromes have been described in which skin tumors are markers of heritable disorders. In Cowden's disease, Muir-Torre's syndrome, and Gardner's syndrome, benign skin tumors accompany and sometimes precede the development of internal visceral malignancy. The association of skin cancers with other abnormalities is found in nevoid basal cell carcinoma syndrome, Bazex syndrome, Rombo syndrome, xeroderma pigmentosum, dysplastic nevus syndrome, and epidermodysplasia verruciformis. Other genetic syndromes in which benign skin tumors herald the existence of systemic diseases include neurofibromatosis, tuberous sclerosis, Haber's syndrome, and Buschke-Ollendorff syndrome. Diagnosis of one of these syndromes may be ascertained by taking a thorough family history. Recognition of the skin tumor may trigger the proper questions regarding family medical history. Diagnosis hinges upon the physician having a high enough index of suspicion to link the appearance of the skin lesions to the diverse manifestations accompanying these disorders. Recognition will also set the stage for appropriate genetic counseling.

Scintigraphic evaluation of brain death: significance of sagittal sinus visualization.

Radiotracer scintigraphy has been commonly used in this country to confirm and document the clinical diagnosis of brain death. Whether the presence of radiotracer activity in the region of sagittal venous sinus (SVS) represents actual blood flow to the brain in the absence of demonstrable cerebral arterial flow remains a controversial issue. Our retrospective study was performed to review the significance of such sagittal tracer activity. Of the 53 patients showing no cerebral arterial flow, 26 showed tracer activity in the region of SVS. The clinical status, EEG findings, and outcome of all 53 patients were the same irrespective of the presence or absence of SVS tracer activity. We conclude that the mere presence of SVS in the absence of demonstrable cerebral arterial flow activity is not clinically significant and does not contradict the diagnosis of brain death.

Budd-Chiari syndrome complicating hepatocellular carcinoma. Demonstration by multiple radiotracer scintigraphy.

A case of hepatocellular carcinoma (HCC) complicated by the Budd-Chiari syndrome is described. The antemortem diagnosis of both conditions was made with the unique findings of multitracer scintigraphy. The difficulty of diagnosing these two conditions by the conventional approach is reviewed. The advantages of using multitracer scintigraphy for evaluation of hepatic lesions are also discussed.