Single-stage, autologous breast restoration.

The skin-sparing mastectomy, when performed with immediate reconstruction, is a major advance in breast reconstruction. Traditionally, reconstruction of the nipple-areola complex is performed as a subsequent procedure. In this study, 17 patients (mean age, 43 years; range, 35 to 53 years) underwent one-stage breast and nipple-areola reconstruction over a 21-month period. In all cases of breast reconstruction, a buried transverse rectus abdominis musculocutaneous (TRAM) flap was used, and all patients had a simultaneous nipple-areola complex reconstruction performed. Nine patients had a Wise keyhole pattern used and contralateral reduction performed. Four patients retained all their breast skin, and a TRAM skin island was used in another four. It has recently been shown that patients with early-stage breast cancer and peripherally sited tumors have a very low risk of nipple-areola involvement. In 10 patients with early disease and peripheral tumors, the areola was retained (as a thin full-thickness graft), but more recently, in three patients with early-stage disease, the entire nipple-areola complex was used as a thin full-thickness graft. The thin full-thickness skin graft is removed from the breast in an apple-coring fashion, so that most of the ducts are retained as part of the mastectomy specimen. (There was histological confirmation of absence of tumor in the nipples of these patients.)One-stage autologous reconstruction should be considered for all patients undergoing immediate breast reconstruction. In patients with early-stage disease and peripheral tumors, the nipple-areola complex may be retained through the use of a thin full-thickness graft that is applied to a deepithelialized CV flap on the TRAM flap. This allows the best method of nipple-areola complex reconstruction: by retaining the original breast envelope, the color match and texture in the reconstruction are ideal. Patient satisfaction in this study was high. Necrosis of the mastectomy flaps impaired the cosmetic results in some patients. A large multicenter study is required to confirm the effectiveness of this procedure.

Superiorly based rectus abdominis wraparound flap for axillofemoral graft sepsis.

Prosthetic vascular graft sepsis, although uncommon, can lead to catastrophic sequelae for life and limb. Axillofemoral grafts are predisposed to sepsis and perigraft seromas because of their length, subcutaneous tunneling, and infrainguinal anastomosis, and are often performed in elderly, debilitated patients. The authors detail the use of a superiorly based rectus abdominis muscle flap, in combination with a sartorius muscle flap to salvage a Szilagy/Samson grade III septic axillounifemoral graft. The superiorly based rectus abdominis wraparound muscle flap should be considered a salvage option for select cases of sepsis involving axillofemoral grafts.

Long-term results of tendon transfers for radial nerve palsy in patients with limited rehabilitation.

The authors reviewed the long-term functional results of 22 patients who underwent tendon transfer for isolated radial nerve palsy. The average number of postoperative visits was eight (range of postoperative visits, 3-16), and the mean follow-up was 6.3 years. All but 1 patient had improved function after the tendon transfers, and could cope with the activities of daily living. Radial deviation of the wrist at rest was present in 10 of the 15 patients with flexor carpi ulnaris transfer and in 2 of 7 patients with flexor carpi radialis transfer, with a mean of 14.5 deg (range of radial deviation, 5-30 deg). Although a global decrease in wrist power and power grip was noted, 13 of 17 previously employed patients were able to work after transfer; however, only 1 of 7 heavy manual laborers was able to return to his previous employment. Despite the poor clinic attendance, the overall functional results compared favorably with other published series. It appears that tendon transfer for radial nerve palsy is a viable option, even in patients with limited rehabilitation.

Aesthetic correction of a contour deformity of the neck with buried expanded flaps.

This case report describes the use of two tissue expanders to correct a contour deformity of the neck, secondary to radical block dissection and radiotherapy for a recurrent parotid tumor. One flap was deepithelialized and then buried under the other to create the necessary bulk. This technique provided tissue similar in texture and color to the adjacent skin, and there is minimal donor site morbidity. It is, however, a staged procedure.

Mirror foot.

Mirror image polydactyly is a rare congenital abnormality that may occur in isolation, or in association with multiple congenital anomalies. A case of unilateral mirror foot with an ipsilateral short, broad tibia is described. The clinical, radiologic, and operative findings are presented, and current theories of embryo-pathogenesis are reviewed.

Combined pedicled flaps for grade IIIB tibial fractures in children: a report of two patients.

Severe open tibial fractures in children are associated with notable morbidity and require early aggressive management to ensure a successful outcome. Free flaps are currently the gold standard in distal extremity reconstruction in which large soft-tissue defects exist, as is often the case with grade IIIB fractures. In severe lower limb trauma, however, free flaps are associated with a relatively high risk of failure, particularly when definitive soft-tissue coverage is delayed. Alternative methods of soft-tissue reconstruction may, therefore, occasionally require consideration. The authors describe the combined use of three pedicled flaps to attain soft-tissue coverage in 2 children with grade IIIB tibial fractures. These three flaps are individually in common use for lower limb soft-tissue coverage, are simple to raise, and in combination can cover extensive soft-tissue defects of the lower extremity. The major vascular axes of the limb are not sacrificed; however, the aesthetic result is modest.

Tissue expansion for frontal hairline restoration in severe alopecia in a child.

Burn alopecia has serious sequelae, both aesthetic and psychological, particularly in children. A case of 70% scalp alopecia due to a flame burn, and the modality of treatment is described. This consisted of an expanded temporo-parietal flap, which was transposed to create a frontal hairline. A relatively simple surgical procedure had both substantial aesthetic, and psychological benefits.

The use of the prepuce for reconstruction of an intraoral burn.

Intraoral and commissural burns present a complex challenge for the reconstructive surgeon, with contractures being the main sequela encountered. Various reconstructive techniques have been described, none of which offers an ideal solution. A case of a severe intraoral contracture due to a caustic burn, and the modality of treatment is described. Once the contractures were released, a full-thickness preputial graft was used to cover the resultant buccal mucosal defect, with a satisfactory result. Due to its unique properties, the prepuce should be included as an additional tool in the reconstructive surgeon's armamentarium.

Tuberculosis of the upper extremity.

Twelve cases of tuberculosis of the upper extremity over a 5-year period are presented. The average time to diagnosis was 5 months. All patients were treated with a regimen of combination antituberculous chemotherapy for a minimum of 6 months, initial splinting, and intensive physiotherapy. The indications for surgery were limited, with biopsy being the most common procedure. Patients with tenosynovitis underwent tenosynovectomy, and nerve decompression was performed when indicated clinically. Large abscesses were drained. No patient had bony debridement or early arthrodesis to control the infection. The pre- and posttreatment range of motion was recorded, with a mean follow up of 25.4 months. Employing this regimen resulted in resolution of infection and an improved range of motion in 11 patients.

Acral dermatofibrosarcoma protuberans with metastases.

Dermatofibrosarcoma protuberans (DFSP) is an uncommon cutaneous tumor that occurs rarely on the extremities. This tumor has a particular propensity for local recurrence following seemingly adequate excision. Metastases are rare, and usually follow repeated local recurrences. On rare occasions, fibrosarcomatous change may arise in a DFSP, and appears to affect adversely the prognosis. The adequacy of the initial resection is the most important prognostic factor; however, suggested margins vary between 1.5 and 5 cm. The ideal margin of resection on the foot is unknown. We report a patient with recurrent, acral DFSP with fibrosarcomatous change and pulmonary parenchymal metastases in a 48-year-old black male.