Paraspinous muscle flaps.

Coverage of midline posterior wounds presents a challenge to the reconstructive surgeon, especially when spinal stabilization hardware has been present and exposed in the wound. Most commonly those wounds that involve the mid to upper thoracic spine have been covered by latissimus dorsi muscle or musculocutaneous flaps. Lower midline wounds, especially in the thoracolumbar region, have needed more complex means of coverage. These have included reversed latissimus dorsi flaps, free flaps, extended intercostal flaps, or fasciocutaneous rotation flaps. We have utilized a far simpler and effective muscle flap: the paraspinous muscle flap. We have raised paraspinous muscle flaps bilaterally and have been able to cover a number of difficult wounds. The wounds were presented by 8 patients with exposed Harrington rods, 3 patients with cerebrospinal fluid leaks, and 1 patient with exposed spinous processes. The wounds in 5 of these 12 patients were in the upper thoracic region, where a latissimus flap was utilized as an additional layer of muscle coverage. The other seven patients had wounds in the lower midline region below the potential reach of the latissimus dorsi. In the latter patients the only flaps employed were paraspinous muscle flaps. We had only one failure in all patients, which involved a recurrent cerebrospinal fluid leak in which there was no decompression of the cerebrospinal fluid pressure utilized in the immediate postoperative period to protect the dural repair. In that instance, a leak recurred. This paper presents the method of flap elevation and the results of our series.

Keratoacanthoma: is it a real entity?

Keratoacanthoma of the skin and well-differentiated squamous cell carcinoma are two cutaneous neoplasms that most often occur in sun-exposed sites of light-skinned persons. It is often difficult to distinguish these two from each other either clinically or histologically. The view that these two cutaneous neoplasms are part of the same disease entity is not new. We reviewed 150 patients with these two diseases in an effort to see whether any specific criteria for diagnosis and treatment could be achieved. It is our hypothesis that they are not separate diseases but within the spectrum of the same disease. Keratoacanthoma may be some sort of aborted malignancy or hyperplastic premalignant lesion within the squamous cell carcinoma spectrum. The incidence of metastases from squamous cell carcinoma of the skin may be as high as 3%. We do not have the courage to wait 3 months to see if a potentially invasive and metastatic neoplasm is indeed involutional. Incision biopsy may be wrought with significant histopathological inconsistencies. We believe that early, complete excision is the treatment of choice for all skin neoplasms thought to be keratoacanthoma.

Obtaining projection in the amputation free nipple/areolar graft breast reduction without a vertical scar: using breast parenchyma to create a new mound.

Multiple techniques for breast reduction in the giant breast have been used. The amputation technique with the free nipple/areolar graft has been the mainstay for severe macromastia since 1921. Traditional methods for amputation of the inferior pole of the breast have created fairly flat breast mounds. Projection of the mound was enhanced by an inferior pleat with a resulting vertical scar. A new technique employing a superiorly based dermal fat flap folded back behind the residual breast to improve projection and roundness has been developed. It has not only eliminated the vertical scar but improved the shape of the mound. It has also given patients who were not previously good candidates for reduction with other techniques an option for surgery despite the presence of old scars or the need for lumpectomy in the lower third of the breast. A clinical series is presented.

Creating a curvilinear scar.

A technique is presented by which predictable curvilinear scars can be produced by using asymmetrical lenticular excisions. This is particularly useful for the excision of skin tumors of the cheeks and lateral to the commissures of the lips. It must be remembered not to compromise the surgical resection margins in order to achieve the optimal aesthetic result.

The effect of tension on muscle flaps.

An experiment with an animal model was designed to investigate whether an arterialized and innervated muscle flap has an optimal tension when being inset. Arterialized pedicle muscle flap operations using various tensions at the time of insetting were performed on beagles. At three months no acute, recent, or chronic changes were noted in the muscle fiber or in the surrounding connective tissue when biopsy samples were examined microscopically. We conclude that the tension of a pedicle muscle flap makes no difference in its long-term compliance or morphology.

Varix of the facial vein.

The differential diagnosis for a mass overlying the angle of the mandible but not attached to it includes lymphatic masses, benign and malignant parotid lesions, cysts, and vascular malformations. Thrombosis of the facial vein is a rare entity that now must be added to the list. This article details the first English-language description of such a thrombosis presenting as a mass. The possible causes are antecedent trauma, infection, or thrombosis of contiguous venous structures. While the diagnosis could be made preoperatively by selective venography or ultrasonography, it most likely will be made by surgical excisions. The preoperative diagnosis may be suggested by the "turkey wattle sign" (i.e., fluctuation in the size of the mass with bending the head downward). In this article the entity and differential diagnosis are reviewed and discussed.