Two giant basal cell carcinomas presenting simultaneously in the same patient, one resulting in lower extremity limb loss.

Giant basal cell carcinomas are a rare form of the most common malignant neoplasm of the skin. They are commonly found on the trunk and display a more aggressive behavior, resulting in local invasion and metastasis. Giant basal cell carcinomas that reach a critical size of 10 cm in diameter almost always present with metastases. We present an 82-year-old woman who presented with two giant basal cell carcinomas of critical size-one that occurred on the lower extremity and resulted in limb loss without any sign of metastasis.

Flap closure of postpneumonectomy empyema.

Empyema continues to be an uncommon, frustrating, and potentially lethal complication of pneumonectomy. Between 1990 and 1994 we treated 16 cases of recalcitrant postpneumonectomy (partial or total) empyema with combinations of pulse lavage, sharp debridement, muscle flaps, myodermal flaps, and thoracoplasty. We performed 11 pectoralis muscle flaps, 6 serratus anterior muscle flaps, 9 latissimus dorsi muscle flaps, 6 rectus abdominis muscle flaps, and 1 trapezius muscle flap for an average of 2.1 muscle flaps per patient. There was 1 omental flap. Of these flaps, 2 were free and the rest pedicled. Ten of the muscle flaps carried deepithelialized cutaneous paddles, and 6 were larger than 150 cm3. Thoracoplasty was done in 11 patients to decrease the volume of the postpneumonectomy empyema cavity. Of 16 patients, 4 failed initially because of persistent bronchopleural fistula or infection but resolved after one additional procedure. There was 1 perioperative death, 3 reoperations for bleeding, 1 patient with upper extremity deep vein thromboses, 1 seroma, and 1 patient with significant postoperative pain syndrome. In order to determine the efficacy of different operative approaches, patients were retrospectively divided into two groups according to the number of operations using flaps needed to resolve their postpneumonectomy empyema. Group A required only one operation using flaps to eliminate the postpneumonectomy empyema. Group B required two operations using flaps to remedy the postpneumonectomy empyema. Group B operations were further classified into B1, for the first operation, and B2, for the second operation. No patient needed more than two operations using flaps. Three significant variables were identified, the number of muscle flaps, the number of ribs in any thoracoplasty, and the preoperative serum albumin level. The A and B2 groups had significantly more muscle flaps transposed (p = 0.006) and ribs resected (p = 0.0002) than the B1 group. These findings suggest that filling the postpneumonectomy empyema space with muscle and collapsing any remaining space by thoracoplasty were the most successful strategy. The B2 group's average albumin level was significantly higher (p = 0.03) than that in either the A or the B1 group, suggesting that improved nutrition may have played a role in the lack of recurrence. Our goals of single-stage closure and decontamination of empyema cavities were best achieved by following these principles: removal of infected and necrotic tissue using sharp debridement and pulsed lavage, repair of bronchopleural fistulas with muscle flaps, and minimization of the dead space with combinations of muscle flaps and thoracoplasty.

Tropical pyomyositis presenting in the upper extremity.

Tropical pyomyositis is a staphylococcal infection, usually of a single large muscle, most commonly seen in young men in tropical regions. The following presents a case of tropical pyomyositis in a 62-year-old man that affected all four extremities, including the muscles of the forearms. Computed tomography was a useful guide for directing surgical explorations. To decrease the degree of disability from the multiple operative sites, we successfully used limited longitudinal incisions and conservative débridements.

Fetal fibroblast contraction of collagen matrices in vitro: the effects of epidermal growth factor and transforming growth factor-beta.

Wound contraction is an important component of healing but, in the extreme, may lead to excessive scar formation and pathological wound contracture. Fetal rabbit wounds heal without contraction or scarring, whereas excisional fetal sheep wounds have been shown to contract, but no scarring or pathological wound contracture is noted. We used an in vitro model, the fibroblast-populated collagen lattice, to study the ability of fetal fibroblasts to coordinate contraction of a collagen matrix and the modulating effects of epidermal growth factor and transforming growth factor-beta 1 on this contraction. With increasing gestational age, fibroblasts increased the degree of collagen lattice contraction. Epidermal growth factor inhibited contraction by fetal fibroblasts, whereas transforming growth factor-beta 1 stimulated it. These findings suggest that while intrinsic differences between fetal and adult fibroblasts exist, polypeptide growth factors may operate at the site of tissue repair to alter cell phenotype. Further work is underway to delineate the role of soluble protein factors responsible for the absence of scarring and contracture seen in the fetal wound.

Lobular carcinoma of the male breast.

BACKGROUND: A case of lobular carcinoma in a male breast is described. Lobular carcinoma is a very uncommon histopathologic form of male breast cancer because of the absence of lobules in the normal male breast. The cytoarchitecture of the normal male breast can be deranged in conditions such as Klinefelter's syndrome or as a result of estrogen exposure. Lobular carcinoma of the male breast has been described in such instances where cytoarchitectural changes are likely to have occurred. METHODS AND RESULTS: After the pathologic diagnosis was made, a fibroblast karyotype was performed to confirm a male genotype. The patient had received no hormonal therapy. The English language literature was reviewed. CONCLUSIONS: This case represents the first report of lobular carcinoma in a proven genotypic male patient receiving no exogenous estrogens.

Prefabricated flap size limitations utilizing an omental carrier.

Several researchers and clinicians have taken advantage of the omentum's rich vascular arcades to support skin grafts. We have previously described an experimental model using the omentum as a vascular carrier for prefabricated free flaps in the rat. In this study, we used this model to compare three different sizes of free flaps using the same size omental carrier. Twenty-four male Sprague-Dawley rats were used for this study. A 2.5 x 4 cm patch of omentum with gastroepiploic vessels and its rich vascular arcades was transferred under a bipedicled 2.5 x 6 cm (group I), a 2.5 x 8 cm (group II), and a 4 x 10 cm (group III) right abdominal panniculocutaneous flap. On the seventh postoperative day, the skin pedicles were divided and the skin flap raised as a composite island flap vascularized only by the underlying omental patch. The composite flap was then sutured back in place. Prefabricated flaps examined 7 days postoperatively demonstrated a dye florescence index percent (DFI) of 38.19 +/- 7.52 and 98.13 +/- 3.72% flap survival (FS) in the 6 x 2.5 cm skin flap group; a DFI of 39.96 +/- 6.81% and FS 94.88 +/- 7.08% in the 8 x 2.5 skin flap group (P > 0.05) and a DFI 29.71 +/- 2.85% and FS 57.06 +/- 9.52% in the 10 x 4 cm skin flap group (P < 0.05). India ink injection study and histologic examination confirmed revascularization of the overlying skin at 7 days. This study confirms that omentum can be used as a vascular carrier for prefabricated flaps. However, there is a limit to the size of the flap. A 10 cm2 carrier can support 57% of a 40 cm2 (10 x 4 cm) flap for a total area of 22.8 cm2, more than twice the area of the carrier.