The use of selective lymphadenectomy in malignant blue naevus of the scalp.

Malignant blue naevus (MBN) is a rare cutaneous tumour with a close biological resemblance to malignant melanoma. MBN spreads to regional lymph nodes, creating a dilemma in managing patients with clinically negative nodal basins. Sentinel lymph node (SLN) biopsy has evolved as a powerful staging tool by identifying occult metastatic nodal disease in patients with cutaneous malignancies. Here, we report a patient with MBN of the occipital scalp who underwent wide local excision together with preoperative lymphoscintigraphy and intraoperative radiolymphoscintigraphy and vital dye injection to identify all draining SLNs. No occult nodal disease was identified. This report adds to the growing body of literature supporting the role of SLN biopsy in staging individuals with cutaneous malignancies, including MBN.

Dynamic rectus abdominis muscle flap for intestinal stomal continence: a systematic approach.

Several attempts to create a continent stomal sphincter using dynamic myoplasty with limited success have been reported. Denervation atrophy and early muscle fatigue have plagued all reported attempts to make a continent stoma a reality. To address this problem in a series of experiments, we designed a stomal sphincter using the most caudal segment of the rectus abdominis muscle. Then, we performed a study to determine whether a sphincter created with a rectus abdominis muscle island flap could maintain stomal continence in the short term. We found that when stimulated using two different electrical stimulation protocols, in all cases the rectus abdominis muscle sphincter generated peak pressures well above those needed to maintain stomal continence (60 mm Hg). All sphincters were able to maintain stomal continence at all intraluminal bowel pressures tested. We found one of these protocols to be far superior and reached 4 hours of stomal continence after 8 to 10 weeks of electrical stimulation.

Analysis of chronic morphologic changes of small bowel in electrically stimulated canine island-flap rectus abdominis muscle stomal sphincters.

PURPOSE: Dynamic myoplasty to achieve fecal continence has been used in humans with varying results. A potential complication of the use of dynamic skeletal sphincters to attain fecal continence is the development of ischemic strictures within the bowel encircled by the functional sphincter. This study examines the histologic changes present in the bowel wall used to create a functional dynamic island-flap stomal sphincter in a chronic canine model. METHODS: The rectus abdominis muscles of canines were used to create island-flap stomal sphincters. Eight dynamic island-flap stomal sphincters were created from the rectus abdominis muscles in mongrel dogs by wrapping them around a blind loop of distal ileum that was no longer in continuity with the terminal small bowel. Temporary pacing electrodes were secured intramuscularly near the intercostal nerve entry point and connected to a subcutaneously placed pulse stimulator. Two different training protocols resulting in different contractile properties were used: Program A (n = 4) and Program B (n = 4). The island-flap sphincters were trained over 3 months to generate stomal intraluminal pressures of more than 60 mmHg in all animals. The intact sphincters, normal bowel, and contralateral stomal bowel were obtained when the animals were killed. Specimens were processed with paraffin embedding, sectioned, and stained with trichrome and hematoxylin-and-eosin stains. Measurements of the different bowel layers were made with a micrometer. The muscular sphincters were biopsied before and after training. Fiber-type histochemistry was performed with a monoclonal antibody to the fast isoforms of myosin. Pretrained and posttrained skeletal muscle specimens were examined histologically. RESULTS: The bowel wall within the functional dynamic stomal sphincter did not exhibit any significant architectural changes related to ischemic fibrosis or mucosal damage. A significant fiber-type conversion was achieved in both training groups with Programs A and B, with a >50 percent conversion from fatigue-prone (type II) muscle fibers to fatigue-resistant (type I) muscle fibers. Biopsy specimens revealed that fiber-type transformation was uniform throughout the sphincters. Skeletal muscle fibers within both groups demonstrated a reduction in their fiber diameter. There was no evidence of significant fibrosis or deposition of fat within the skeletal muscle of the sphincters. CONCLUSION: Results of our experiment suggest that our anterior abdominal wall dynamic island-flap stomal sphincter, which generates a contractile force over the bowel wall capable of producing enough stomal pressure to achieve fecal continence, is not intrinsically harmful to the bowel that it encircles. The transformation of skeletal muscle to fatigue-resistant (type I) fibers occurred uniformly throughout the skeletal muscle sphincters without evidence of muscle fiber damage or significant fibrosis.

Dynamic rectus abdominis muscle sphincter for stoma continence: an acute functional study in a dog model.

Fecal stomal incontinence is a problem that continues to defy surgical treatment. Previous attempts to create continent stomas using dynamic myoplasty have had limited success due to denervation atrophy of the muscle flap used in the creation of the sphincter and because of muscle fatigue resulting from continuous electrical stimulation. To address the problem of denervation atrophy, a stomal sphincter was designed using the most caudal segment of the rectus abdominis muscle, preserving its intercostal innervation as well as its vascular supply. The purpose of the present study was to determine whether this rectus abdominis muscle island flap sphincter design could maintain stomal continence acutely. In this experiment, six dogs were used to create eight rectus abdominis island flap stoma sphincters around a segment of distal ileum. Initially, the intraluminal stomal pressures generated by the sphincter using different stimulation frequencies were determined. The ability of this stomal sphincter to generate continence at different intraluminal bowel pressures was then assessed. In all cases, the rectus abdominis muscle sphincter generated peak pressures well above those needed to maintain stomal continence (60 mmHg). In addition, each sphincter was able to maintain stomal continence at all intraluminal bowel pressures tested.

Use of the rectus abdominis muscle for abdominal stoma sphincter construction: an anatomical feasibility study.

Permanent fecal abdominal stomas significantly decrease quality of life. Previous attempts to create continent stomas by using dynamic myoplasty procedures have resulted in disappointing outcomes, primarily owing to denervation atrophy of the muscle flap that was used in the creation of the sphincter and because of muscle fatigue resulting from continuous electrical stimulation that is received by the flap to force contraction. On the basis of these problems, we designed two separate studies: an anatomical study addressing flap denervation and a functional study addressing muscle fatigue. The present study addresses the first topic and was designed to develop a rectus abdominis muscle flap into a sphincter that was anatomically situated to create a stoma while preserving as much innervation as possible. In 24 rectus abdominis muscles of human cadavers, the neurovascular anatomy was defined, then the anatomical feasibility of two different muscle flap configurations was considered. The flaps investigated were the peninsula flap and island flap designs, with both using the most caudal segment of the rectus abdominis muscle in construction of the sphincter. Neither flap design required the killing of a nerve for stoma sphincter creation, resulting in minimal muscle denervation. The conclusion of our comparison was that the above, in conjunction with other features of the island flap design, such as muscle overlap after sphincter formation and abdominal wall positioning of the sphincter, made the island flap design better suited to stoma sphincter construction.

Necrotizing infection of the face secondary to intranasal impaction of "crack" cocaine.

"Crack" is a crystalline form of cocaine that is readily available and sold in the form of small granules. The authors report a unique case of forced intranasal impaction of crack cocaine with subsequent extensive necrosis of the nose and upper lip accompanied by a necrotizing infection of the subcutaneous soft tissue of the cheeks, forehead, and temporal regions. The treatment of extensive facial necrosis resulting from infection and ischemia centers around the early diagnosis of the infectious process, prompt and aggressive surgical debridement, and the administration of broad-spectrum antibiotics.

Parotid selective lymphadenectomy in malignant melanoma.

Malignant melanoma of the head and neck can metastasize to lymph nodes within the parotid gland. Selective lymphadenectomy is the modern method of staging regional lymph node basins in clinically localized melanoma. This procedure involves intraoperative lymphatic mapping and directed, selective removal of the first draining nodes or sentinel lymph nodes (SLNs). Historically, the assessment of parotid lymph nodes would involve a superficial parotidectomy with facial nerve dissection. Since 1993, 28 patients with localized melanoma of the head and neck have demonstrated lymphatic drainage to parotid lymph nodes on preoperative lymphoscintigraphy. The overall success rate of parotid selective lymphadenectomy is 86% (24 of 28 patients). Of the 28 patients, there were 6 early patients in whom blue dye alone was utilized intraoperatively, and the success rate is 50% (3 of 6 patients). When blue dye and radiocolloid mapping techniques are combined, the parotid selective lymphadenectomy is successful in 95% of patients (21 of 22 patients). Four of the 24 patients (17%) had metastases to the SLNs and underwent therapeutic superficial parotidectomy and/or modified radical neck dissection. After completion of the therapeutic superficial parotidectomy, 1 of the 4 patients was found to have an additional parotid (nonsentinel) node with melanoma metastases. None of the patients incurred injury to the facial nerve by parotid selective lymphadenectomy. To date, 2 of 28 patients (7%) have had regional recurrence to the parotid gland. Failure of the SLN technique may occur when blue dye alone is used, when human serum albumin (not sulfur colloid) is the radiocolloid, when prior wide excision and skin graft is present before lymphatic mapping, and when all SLNs are not retrieved. We conclude that parotid selective lymphadenectomy is a safe and reliable alternative to superficial parotidectomy for staging clinically localized melanoma of the head and neck.

Aprotinin in ischemia-reperfusion injury: flap survival and neutrophil response in a rat skin flap model.

Multiple drugs have been used in experimental skin flap models to reduce the effects of reperfusion ischemia. The effects of antiproteases, however, have not been studied. A skin flap ischemia reperfusion model was developed in the rat to study the effects that aprotinin, a broad-spectrum antiserine protease, would have on skin flap viability. Thirty-two male rats underwent elevation of a ventral pedicled skin flap based on the superficial inferior epigastric artery. The flaps were subjected to 10 hr of warm ischemia by clamping the neurovascular pedicle followed by reperfusion. Aprotinin or saline (control) was administered systemically via the contralateral femoral vein either before or after the ischemic insult. Full-thickness skin biopsies were obtained at 1, 8, and 24 hr into reperfusion. Biopsies were evaluated for neutrophil concentration (using a myeloperoxidase [MPO] assay) and thromboxane B2 [TxB2] content. Flap survival was calculated at 1 week using standardized photography and computer-assisted digital imaging. Aprotinin given before an ischemic insult significantly improved flap survival compared to saline controls (52.3% alive vs. 29.6%, P = 0.0132, unpaired t-test). Aprotinin given after ischemia did not significantly influence flap survival (28.8% vs. 34.4% in saline controls, P = 0.708). MPO levels in the aprotinin preischemia treatment group were significantly less at 1 and 8 hr into reperfusion, indicating decreased neutrophil numbers. No statistical difference in TxB2 levels was noted in either group at any time after reperfusion. Aprotinin significantly improves skin flap survival when given prior to but not after an ischemic insult. Aprotinin appears to lower the concentration of neutrophils in skin flaps pretreated with the drug. Reperfused skin flap levels of thromboxane B2 are unaffected by the pre- or postischemic administration of aprotinin.

Diagnosis and treatment of retrobulbar hematoma resulting from blunt periorbital trauma.

Retrobulbar hematoma is a rare complication of blunt periorbital trauma with the potential disastrous consequence of visual impairment and blindness. The preoperative assessment, diagnostic symptoms and signs, as well as the treatment of this condition are reviewed. The patients presented as well as a review of the literature confirm that although retrobulbar hematoma is a rare complication of blunt periorbital trauma, irreversible visual sequelae can be prevented by prompt diagnosis and immediate surgical and pharmacological therapy.

Benign symmetric lipomatosis (Madelung's disease).

Benign symmetric lipomatosis, also known as Madelung's disease, is a rare condition characterized by massive fatty deposits arranged symmetrically around the neck, shoulders, and arms. These patients might present for liposuction and body contouring. Although infrequently encountered in the average plastic surgeon's practice, this condition should be considered when evaluating candidates for these procedures. The deformity is associated with chronic alcohol use and also with malignant tumors of the upper airways. The deformity is prone to recurrence and its surgical treatment often results in less than optimal aesthetic outcomes. Despite this fact, surgical removal via either direct excision or suction-assisted lipectomy provides the only real hope of palliation. This report describes a patient with this deformity and a review of the literature.

Prognosis in malignant melanoma.

A uniform and practical classification and staging system for melanoma must exist and be widely adopted if useful comparisons between different treatment centers and databases are to be made. This article reviews the 1992 American Joint Committee on Cancer pTNM staging system. In this classification, localized disease without regional nodal involvement is defined as stage I or II, depending on the tumor thickness of the primary melanoma. Regional lymph node involvement and/or in-transit metastasis is defined as stage III, and systemic metastatic disease is defined as stage IV.

Impediments to wound healing.

Chronic wounds will often heal in a short period of time if factors that inhibit wound healing are identified and managed. Recombinant growth factor therapy may provide an added stimulus to healing in certain types of chronic wounds. However, there remains no substitute for a physiologic environment conducive to tissue repair and regeneration, without which the efficacy of growth factor therapy is questionable. Some of the most commonly encountered and clinically significant impediments to wound healing include wound hypoxia, infection, presence of debris and necrotic tissue, use of anti-inflammatory medications, a diet deficient in vitamins or minerals, or general nutritional deficiencies, tumors, environmental factors, and metabolic disorders, such as diabetes mellitus. Treatment of chronic wounds should be directed against the main etiologic factors responsible for the wound. Moreover, factors that may impede healing must be identified and, if possible, corrected, for healing to occur.

Physiology and healing dynamics of chronic cutaneous wounds.

In the last few decades, a great deal of progress has been made in understanding the cellular and biochemical interplay that comprises the normal wound healing response. This response is a complex process involving intricate interactions among a variety of different cell types, structural proteins, growth factors, and proteinases. The normal wound repair process consists of three phases--inflammation, proliferation, and remodeling--that occur in a predictable sequence and comprise a series of cellular and biochemical events. A review of the biochemical and physiologic processes that regulate wound healing and the cascade of cellular events that gives rise to the healing process is presented here.

Residency training in aesthetic surgery: maximizing the residents' experience.

Plastic surgery residency programs often rely on a residents' aesthetic clinic to help train residents in aesthetic surgery. The television media may be used to help boost interest in such clinics. We report our experience with a local television station in helping to produce a "health segment" broadcast that chronicled the experience of an aesthetic patient in the residents' aesthetic clinic. As a result of this broadcast, approximately 150 people responded by telephone and subsequently attended a series of seminars designed to screen patients and educate the audience about the aesthetic clinic. A total of 121 patients (112 women and 9 men) signed up for personal consultations. The age distribution and requested procedures are presented. From the data, we conclude that there is a healthy demand for reduced-fee plastic surgery procedures performed by residents in plastic surgery. The number and variety of cases generated are sufficiently diverse to provide a well-rounded operative experience. The pursuit of media coverage of a not-for-profit clinic has the potential for generating large patient volume. Such efforts, although very attractive, are not without their own risks, which must be taken into consideration before engaging the media in the public interest arena.

Sentinel node excision for the diagnosis of metastatic neuroendocrine carcinoma of the skin: a case report.

The technology of sentinel node lymphoscintigraphy has made it possible to map and identify the lymph nodes draining the site of a primary cutaneous malignancy. This technique is now being used in the treatment of melanoma, and breast and vulvar carcinoma. With melanoma and breast carcinoma, the histology of the sentinel lymph node (SLN) has been found to be reflective of the histology of the remainder of the nodal basin. The concept of sampling the SLN is to provide an accurate staging for the entire nodal basin, obviating the need for a complete lymphadenectomy if the SLN is negative. It is believed that cutaneous malignancies with a propensity for regional metastasis, such as neuroendocrine carcinoma of the skin, may spread via a similar lymphatic pathway involving an SLN. Using this technique we identified and excised the SLNs in a patient with a neuroendocrine carcinoma of the skin that contained the only focus of metastatic disease. Although this technique is still investigational we believe it holds great promise in being able to detect occult metastatic nodal disease in clinically node-negative patients.

Incidence and natural history of saline-filled breast implant deflations: comparison of blunt-tipped versus cutting and tapered needles.

The silicone shells of breast implants are known to fail. When failure occurs in saline-filled implants, the consequences are always ultimately symptomatic. Failure may be due to shell elastomer fatigue, fold-flaw cracking, faulty valve mechanisms, trauma, and microperforations (defined as perforations that are too small to be seen with the unassisted eye). To determine the incidence and natural history of microperforations, a major manufacturer of saline-filled breast implants was contacted. Over a 30-month period, 289,033 saline implants were sold, and 2844 were subsequently returned due to perioperative deflation. By using a rigorous and reproducible method of evaluating returned deflated saline-filled breast implants, it was found that 197 (0.068 percent of all implants sold) sustained needle damage at the time of insertion and went on to deflate within 6 months. Of the implants returned, overall 6.93 percent were found to have sustained needle trauma as the cause of the deflation, and the incidence appears to be increasing with time. The actual incidence of needle-related deflations may be significantly greater, since these data reflect only those implants which are voluntarily returned to the manufacturer. As a second part of this study, a segment of the silicone shell from a saline-filled breast implant was tested to determine the resistance to puncture using blunt-tipped, tapered, and cutting needles. The blunt-tipped needle required 6.6 times more force to puncture the shell than a cutting needle (p = 0.0011) and 3.2 times more force than a tapered needle (p = 0.0052). The difference in force needed to puncture the shell for a tapered and a cutting needle was not statistically significantly different (p = 0.5045). Microperforations do occur in the operating room and are responsible for a significant percentage of early (less than 6 months) deflations. Blunt needles require significantly more force to puncture the shell of an implant than do cutting and tapered needles, and their use may reduce the incidence of microperforations and subsequent implant deflations.