Soft tissue injuries to face and neck: early assessment and repair.

The principles of assessment and repair of soft tissue trauma of the face are outlined. The importance of an adequate preoperative evaluation is emphasized. Recognizing lesions in the deep vital structures is extremely important in the initial approach to these patients. The postoperative care and the best management of the sequelae are described.

A randomized prospective study to assess the efficacy of two cold-therapy treatments following carpal tunnel release.

A prospective randomized study was performed comparing the efficacy of controlled cold therapy (CCT) with the efficacy of ice therapy in the postoperative treatment of 72 patients with carpal tunnel syndrome. Immediately after surgery, patients applied either a temperature-controlled cooling blanket (CCT) or a standard ice pack over their surgical dressings. Pain was assessed by visual analog scale and swelling by wrist circumference preoperatively, immediately after surgery, and on postoperative day 3. Patients kept log books of daily treatment times. Narcotic use (of Vicodin ES) was determined by pill count at day 3 and by daily log book recordings. Patients who used CCT showed significantly greater reduction in pain, edema (wrist circumference), and narcotic use at postoperative day 3 than did those using ice therapy. This study indicates that after carpal tunnel surgery, the use of CCT, compared with traditional ice therapy, provides patients with greater comfort and lessens the need for narcotics.

The W-W-Z rhomboid plasty for closure of excisional wounds.

A new method of repairing excisional wounds in the face, trunk, and extremities is demonstrated. The rhomboid W-W-Z-plasty approach is an evolution of the double-Z rhomboid plasty already published. The authors have recognized its value in covering even large defects. The W-W-Z rhomboid plasty adds new gains to the repair of excisional wounds such as skin-sparing resection, fewer scars, less deformity, and a desirable resulting z-shaped scar. The surgical technique and an illustrative case are described.

Triangular mattress suture in abdominal diastasis to prevent epigastric bulging.

In the classic abdominoplasty, the treatment of large diastasis recti with simple or vertical mattress sutures may result in a nonaesthetic bulge. The surgeon may produce a craniocaudal bulge deformity by treating the flaccidity in the horizontal plane only, although it occurs in all directions. The authors describe the triangular mattress suture for the treatment of large diastasis recti, and demonstrate the mechanism involved in producing an epigastric bulge. Also presented is their clinical experience with 56 patients, with a 3-year follow-up, using this new plication method. The triangular mattress suture is a simple, quick, and effective way to correct abdominal diastasis and to avoid the epigastric bulge deformity with no added morbidity.

Utilization of the depressor anguli oris musculocutaneous flap for lip reconstruction.

The authors describe the anatomic aspects and surgical technique of the depressor anguli oris musculocutaneous flap for reconstruction of the upper and lower lips. Twenty patients were submitted to surgical treatment, 19 for carcinoma and for upper lip scar deformity. In all patients the repair was performed with the depressor anguli oris musculocutaneous island flap. At the follow-up, lip function was satisfactory in 19 patients and unsatisfactory in 1 patient. The aesthetic results were considered satisfactory in all patients. The depressor anguli oris musculocutaneous island flap is safe for upper and lower lip reconstruction, with good functional and aesthetic results, and can be added as a new flap for lip reconstruction.

Utilization of muscle flaps in the treatment of bronchopleural fistulas.

This paper reports the results of a series of 5 patients who underwent closure of persistent bronchopleural fistula using extrathoracic muscle flaps over a 6-year period. All patients had failed more conservative treatment. The surgeries were one- or two-stage procedures performed with the collaboration of cardiovascular and reconstructive surgical staffs. There were no associated mortalities. The muscle flaps utilized were the latissimus dorsi, serratus anterior, pectoralis major, pectoralis minor, and trapezius. The results have been encouraging and allowed the complete closure of the bronchopleural fistula in the majority of patients. The authors present the best management of this serious disease, as well as its pathophysiology and clinical aspects.

Endoscopic harvesting of radial artery graft for coronary artery bypass.

The radial artery is used frequently in cardiac revascularization and requires an average 23-cm forearm incision. With proper instrumentation (Tsukuba-West Virginia Endoscopic Radial Artery: TW-ERA series, Takumi Cardio Co., Chiba, Japan), the radial artery can be harvested utilizing two small transverse incisions. The authors report six cases of endoscopic harvest of a radial artery graft. Length of the endoscopic incision is 2 cm proximally and 3 cm distally. Operation time and tourniquet times were approximately 80 to 120 minutes. No complications such as hematomas, nerve damage, or delay in healing were observed at the donor sites. Plastic surgeons, with their expertise in radial forearm flaps, hand surgery, and subcutaneous endoscopic techniques, can contribute greatly to the minimally invasive harvesting of the radial artery, preventing associated morbidity and improving the aesthetic and functional outcome of the donor site.

Muscle and musculocutaneous flap coverage of exposed spinal fusion devices.

Midline wound dehiscence in the back with exposure of spinal stabilization devices remains a challenging problem, mainly in the presence of infection. Usually, the treatment consists of instrumentation removal, wound debridement, and antibiotic therapy. These can result in instability of the spine and significantly prolong the hospitalization. The use of muscle and musculocutaneous flaps provides excellent soft-tissue coverage, obliterates the dead space, controls the infection, and creates conditions to salvage the hardware. Eight cases of spinal rod instrumentation, complicated by wound infection and dehiscence, have been treated successfully with single or multiple muscles and musculocutaneous flaps. Our method of treatment for these complex wounds, in two institutions, is discussed.

Endoscopic harvesting of the radial artery as a coronary artery bypass graft.

With an endoscopic approach we harvested the radial artery as a coronary artery bypass graft, using two transverse 2-cm incisions in the forearm. There were no complications in the forearm and hand. The short-term results of the radial artery graft were good.

Coumadin necrosis of the skin: report of four patients.

Necrosis of skin and soft tissue as a complication of oral anticoagulation therapy is a rare condition with approximately 200 cases documented in the world. Coumadin-induced skin necrosis is a painful skin lesion, sudden, localized, initially erythematous or hemorrhagic, that becomes bullous and eventually culminates in gangrenous necrosis. It develops mainly in women around 50 years of age who are usually obese and have been treated for thrombophlebitis or pulmonary embolism. There seems to be a marked predilection for areas with increased subcutaneous fat content, such as breasts, thighs, and buttocks. The injury is so significant that plastic surgery is frequently required to repair the damaged tissue. The authors present four clinical cases of Coumadin necrosis, observed in two different institutions, and perform a literature review on the mechanisms that trigger the development of the disease. This condition still remains a diagnostic-therapeutic challenge.

Repair of incomplete cleft earlobe.

The repair of incomplete clefts of the earlobe by just freshening the edges and suturing them in apposition may result in an abnormal, pointed earlobe. We present a modification of the technique described by Pardue, preserving the hole for an earring and preventing the pointed earlobe. Two skin suture lines, in opposing directions, maintain the natural curved contour of the earlobe.

Cystic hygroma of the chest wall: a rare condition.

Cystic hygroma of the chest wall is a very rare condition. A review of the literature showed only 15 cases reported worldwide. The authors report a case of cystic hygroma of the chest wall in a male infant 2 months of age that was successfully treated with surgical excision in one stage. The diagnosis was made by physical examination with transillumination and by its typical sonographic pattern. The diagnosis was confirmed by histopathological examination and there is no evidence of recurrence after 24 months of follow-up. A review of the literature, updating the embryology, classification, and treatment of the disease, is also presented.

Diagnosing and treating congenital melanocytic nevus simulating malignant melanoma.

Many cases reported as malignant melanomas arising in benign congenital melanocytic nevi in the neonatal period have not shown evidence of metastases after several years of follow-up. These lesions were probably pathologically misdiagnosed, thus creating a controversy regarding the precise incidence. This article describes the case of an infant with a giant melanocytic nevus simulating malignant melanoma to illustrate the proper criteria for diagnosis of this condition so extensive and unnecessary therapy procedures can be avoided.

Granuloma of the lacrimal sac.

This article describes a rare case of granuloma of the lacrimal sac, which was treated with dacryocistorhinostomy and glabellar flap. In addition, the possible etiologic factors, the differential diagnosis and reconstructive techniques indicated in such cases are described.

Development of an instrument for endoscopic nasal surgery.

The use of endoscopy in nasal surgery gradually is becoming a reality with the development of new instruments and the refinement of techniques. The goals are precision in diagnosis and treatment and improvement of the teaching capabilities in rhinoplasty that always have been a challenge with the blind traditional techniques.

Saving the frontal branch during a low fronto-orbital approach.

This report describes the anatomy of the frontal branch of the seventh nerve and a technique for assuring its preservation when doing a low frontal approach. By dissecting under both layers of the temporal fascia, rapid and safe access to the inferior fronto-orbital region may be achieved. This technique is recommended for exposure of a bony lesion in the fronto-orbital region and when performing an osteoplastic pterional craniotomy.

Repair of thoracoabdominal ectopia cordis with myocutaneous flaps and intraoperative tissue expansion.

Thoracoabdominal ectopia cordis is a congenital malposition of the heart and abdominal viscera, which are externally situated, carrying an extremely poor prognosis. We report a case of a complete thoracoabdominal ectopia cordis that had undergone successful coverage over the exposed heart and abdominal contents. A few hours after birth, the defect was repaired with an expanded polytetrafluoroethylene soft-tissue patch that was gradually reduced by suture plication. Coverage was completed 48 hours later with bilateral pectoralis major and rectus abdominis myocutaneous flaps. Intraoperative tissue expansion minimized the cardiac compression produced by surgical reconstruction of the defect. Our patient, who is now 36 months old, represents the seventeenth case to survive reconstructive attempts.

The versatility of double-Z rhomboid plasty.

The versatility of the double-Z rhomboid plasty is demonstrated in the closure of excisional wounds in the face and extremities following resection of skin tumors. The degree of distortion resulting from the double-Z rhomboid, simple rhomboid, and direct closure are compared in foam rubber models. The original design as described by Cuono is compared with modifications suggested by Katoh. The indications for the double-Z rhomboid repair are reviewed and the technical aspects to maximize the results are described.