Artificial skin in the treatment of a large congenital nevus.

An 8 year-old girl had a large congenital nevus involving the posterior thigh, leg, and foot. The nevus on non-weight-bearing areas was resected, and the areas were resurfaced with artificial skin and ultra-thin split-thickness grafts. A good result was ultimately achieved. Our management of this case and the relative merits of this new technology are detailed.

Laser resurfacing complication.

A 43 year-old woman had full facial laser resurfacing for treatment of multiple actinic keratoses and aging skin. Healing was uneventful on most of the areas treated except the forehead, where a progressive nonhealing wound developed. After seeking numerous consultations around the Southeast, the patient came to our facility, 6 months after the initial laser treatment, with exuberant granulation tissue of the forehead and temples and a painful wound. Many topical treatments had been previously tried. Debridement and split-thickness skin grafting were done using general anesthesia. Pathologic analysis revealed hyperplastic granulation tissue and epidermal appendages. The wound healed with an improved aesthetic result. This case illustrates that seemingly impossible laser complications can be handled by a basic approach to wound healing.

Design-enhanced breast reduction: an approach for very large, very ptotic breasts without a vertical incision.

Breast reduction and mastopexy have been performed with a number of techniques. Due to problems encountered with prior procedures (such as fat necrosis, skin and nipple necrosis, decreased nipple sensitivity, shaping difficulties, and bleeding), we have changed our approach to breast reduction and mastopexy. Eleven initial patients have been operated with a design-enhanced procedure that emphasizes (1) a wide-based, glandular deepithelialized pedicle; (2) an attempt to preserve the fourth intercostal nerve; (3) adequate vertical-dimension skin excision leaving no vertical scar; (4) mesial advancement of thick, superior skin flaps; and (5) administration of dilute lidocaine/epinephrine solution. We have been pleased with our results and recommended this technique as our procedure of choice for patients with very large, very ptotic breasts.

Surgical management of giant nonmelanoma skin neoplasia.

BACKGROUND: Management of advanced integumentary malignancy has been controversial. We have evaluated and treated 10 patients with giant nonmelanoma skin neoplasias more than 8 cm in diameter. METHODS: Aggressive surgical ablation was prospectively recommended to treat giant basal cell or mixed basosquamous tumors and two purely squamous cell tumors. Radiation therapy was given in three surgical patients. Our data are analyzed retrospectively. RESULTS: Survival of the two patients who refused surgery was measured in weeks. One patient who refused adequate surgery survived 9 months before dying. All of the adequately treated surgical patients are alive as of this writing, including one who had subsequent resection of pulmonary metastases. Three patients required free tissue transfer. The average survival of surgically treated patients was 2.7 years. CONCLUSION: An aggressive surgical approach to the management of advanced/giant skin neoplasia is justifiable and the only treatment that may produce long-term survivability.

Versatility of the microvascular serratus anterior muscle vascularized rib flap (SARIB) for multifaceted requirement reconstructions.

We have employed the serratus anterior muscle vascularized rib (SARIB) composite flap for a variety of multifaceted reconstructive applications in which bone and soft tissues were needed. Seventeen patients have undergone this procedure for reconstructions of the upper extremity (5), lower extremity reconstructions (4), and reconstruction of head and neck defects (8). Sixteen of the reconstructions (89%) have been successful, with an average follow-up over 2 years. One patient had partial loss of a rib transferred to the head and neck for palatal reconstruction. One patient had complete flap loss of a maxillectomy reconstruction owing to a necrotizing infection. We have found this procedure to be applicable to a number of clinical reconstructive situations and recommend the SARIB procedure as a versatile operation that is successful in a high percentage of cases.

Explantation of silicone breast implants.

Silicone gel-filled breast implants have been employed clinically for decades for aesthetic augmentation or postmastectomy reconstruction. Most patients and surgeons attest to the efficacy and safety of these devices. However, more recently in the medical literature and popular media, silicone gel-filled breast implants have been claimed to incite an array of clinical sequelae such as capsular formation, granulomatous disease, arthritis, arthralgia, fibromyalgia, autoimmune collagen vascular disease, human adjuvant disease, siliconosis, silicone-related disease, and silicone implant-associated syndrome. During a recent 24-month period, 25 referred patients underwent explantation of bilateral silicone gel-filled prostheses at the University of South Alabama. Patient-reported symptoms and signs included mastodynia, arthralgia, fibromyalgia, xerophthalmia, xerostomia, hypesthesia, and amblyopia. Clinical examination and mammography were reliable in diagnosing implant rupture, but only re-exploration reliably detected implant leakage. Most patients underwent concurrent replacement with saline-filled devices. Histopathologic analyses of all tissue samples revealed chronic inflammation. Subjective improvement of patient-reported symptoms and signs occurred over the course of months postoperatively. There was no mortality associated with explantation, with or without replacement, but an overall morbidity incidence of 20 per cent (5 of 25) was observed. Predicated upon review of the available scientific literature and analysis of this modest number of patients, the following perspectives are germane. 1) A small cohort of patients of status postimplantation of silicone gel-filled devices will manifest chronic morbidity. Identifying such patients prospectively remains problematic. 2) Whether or not silicone gel incites adverse systemic phenomena is unproven, although it has been implicated. 3) Symptomatic patients with silicone gel-filled implants in place should be considered for removal, with full knowledge of the morbidity associated with revisional procedures. 4) Patients currently undergoing breast augmentation or reconstruction employing prosthetics are perhaps best served by insertion of saline-filled devices. 5) Patient-physician dialogue regarding the risk-benefit analysis of prosthetic implantation is imperative. Patients consenting to such procedures must be willing to assume risks.

Subtotal midfacial/total nasal reconstruction following shotgun blast to the face employing composite microvascular serratus anterior rib, muscle, and scapular tip.

A 40-year-old man presented with near-complete mid and lower facial destruction from a shotgun blast to the face. His midface was reconstructed with a serratus anterior muscle composite flap employing rib for nasal reconstruction and scapular tip for palate. Surfacing was done with split-thickness skin grafts. A temporoparietal scalp flap completed the upper lip reconstruction, and tubed, thick, split-thickness grafts supplemented with full-thickness grafts allowed airway reconstruction. Successful restoration of form and modest function were achieved with several surgeries. Our paper discusses the controversies and difficulties encountered in achieving autogenous tissue reconstruction of this devastating injury.

Periorbital varicella gangrenosa necessitating orbital exenteration in a previously healthy adult.

A previously healthy 31-year-old man had profound neurologic compromise and necrotizing periorbital infection due to a complication of varicella infection. Despite aggressive treatment, he required orbital exenteration and radical debridement of the involved tissues. He survived in a vegetative state for almost 1 year before succumbing to progressive neurologic deterioration. We present and discuss this complicated case of varicella gangrenosa to show the devastating nature of complications that can occur from varicella infection in the unsensitized adult.

Hemicorporectomy.

Intractable decubitus ulcers and femoropelvic osteomyelitis are rare sequelae of paraplegia. Therapy for these conditions ranges from the simple to the complex, including wound debridement and care, alimentary and urinary tract diversion, hip disarticulation, and myofasciocutaneous rotational flaps. Should the condition be recalcitrant to these modalities the only curative therapy is hemicorporectomy. A 28-year-old rendered paraplegic 3 years ago presented manifesting sepsis; marasmus; hip and knee flexion contractures; suppurative sacral and femoropelvic decubitus ulcers, exposed bone, and osteomyelitis; and fecal and urinary incontinence. Pre-operative nutritional supplementation, wound debridement and care, and psychological counselling were provided. Hemicorporectomy was performed, including colostomy, ureteroileal conduit, gastrostomy, and translumbar amputation. Several anatomical, physiological, and operative-technical perspectives are emphasized: a two-staged approach may be preferable--at the first setting an intra-peritoneal exploratory celiotomy with alimentary and urinary tract diversion; and at the second setting an extra-peritoneal hemicorporectomy; preservation of abdominal wall musculature and fasciae to facilitate wound closure; sequential and bilateral ligation of the arteriae et venae iliaca communis; translumbar amputation between the fourth and fifth lumbar vertebrae; extirpation of the fourth lumbar processus spinosus vertebrarum; closure of the dura mater and translation of musculi sacrospinalis into the vertebral canal; avoidance of hypervolemia and hyperthermia; avoidance of wound pressure; testosterone replacement therapy for eunuchism; and physical and occupational rehabilitation including adaptation to a customized bucket prosthesis.

Hand injuries secondary to subcutaneous illicit drug injections.

We present a retrospective analysis of 32 patients admitted over a 5-year period to a metropolitan regional trauma center with recently induced subcutaneous ("skin pop") illicit drug injectional injuries involving the hand. Cocaine derivatives were the most frequently reported illicit drug used (75%). All patients had local disease manifested by subcutaneous abscess formation, and several had regional disease (cellulitis, lymphangitis, or lymphadenopathy), but only one patient had systemic illness. Microbiological analysis revealed endogenous integumentary and oral flora sensitive to oral preparations of several antibiotic medications including cephalosporins. Primary therapy included intravenous administration of antibiotic medications in all instances and simple incision and drainage under local anesthesia in 26 patients (81%). Six patients (19%) required more radical operative therapy. All patients were hospitalized and recovered without sequelae, with preservation of hand function after follow-up evaluation, which ranged from weeks to months, except for 1 patient who required digital amputation because of necrosis. Although the issue of compliance in terms of wound and general medical care for this patient population is problematic, analysis of the data suggested that patients with illicit drug injectional injuries of the hand confined to subcutaneous regions could be effectively and safely managed in outpatient settings by simple wound care and orally administered cephalosporin medications.

Facial arteriovenous malformation managed with ablative surgery and dual rotational flap reconstruction.

A 34-year-old man had previously had partial resection of a left facial hemangioma or arteriovenous malformation which included partial mandibulectomy and external carotid arterial ligation for treatment of recurrent bleeding. Because of recurrent intraoral bleeding with aspiration and profound anemia and angiographic analysis showing large tortuous abnormal vessels feeding the lesion from the cranial base, the patient had tracheostomy for airway control, radical left facial resection, completion hemimandibulectomy, and subtotal maxillectomy. He required 20 units of blood components intraoperatively. Oral reconstruction was done with a pedicled pectoralis major myocutaneous flap, and left facial reconstruction was done with a rotational transaxillary latissimus dorsi myocutaneous flap supplemented with skin grafts as appropriate for coverage of the rotated muscles. Postoperatively, the patient has had no further oral bleeding. This case illustrates the multiple difficulties involved in the surgical management of a high-flow arteriovenous malformation.

Management of exposed inguinofemoral arterial conduits by skeletal muscular rotational flaps.

Peripheral vascular reconstructions are common operations for the treatment of occlusive atherosclerosis, and the vast majority are uncomplicated. However, despite all precautionary measures, a small percentage of patients will manifest wound infection and graft exposure that may evolve to loss of limb and/or life. Treatment has traditionally consisted of systemic administration of antibiotic medication(s), graft extirpation, and extra-anatomic arterial bypass; yet despite use of these more radical modalities, morbidity and mortality have remained high. An additional meritorious adjunct for the treatment of exposed prosthetic or autogenous saphenous vein arterial bypass grafts is the use of local/regional autogenous skeletal muscular rotational flaps. Reported herein are the results of this technique applied to the inguinofemoral regions of eight patients. Rectus abdominis (1 patient), rectus femoris (4), and sartorius (4) skeletal muscular rotational flaps were employed. Seven of eight (88%) patients convalesced well at mean duration of follow-up measuring 24 months, although one patient subsequently required major amputation due to progression of occlusive atherosclerosis. One of eight (12%) patients succumbed secondary to irreversible sepsis, despite radical amputation. The data suggest that use of local/regional skeletal muscular rotational flaps is a useful adjunct for the treatment of patients with exposed arterial conduits.

Bilateral forearm and hand compartment syndrome following thrombolysis for acute myocardial infarction: a case report.

A patient suffering from a cocaine-induced myocardial infarction was treated with thrombolytic therapy and developed acute bilateral compartment syndromes of the upper extremities and hands from bleeding due to attempted bilateral radial artery cannulation. He was treated with emergent decompression of the forearm compartments and intrinsic muscles of the hands and recovered excellent hand function without significant neurologic or muscular damage. The problems encountered in the management of this case are detailed, and recommendations for prevention and therapy are discussed.

Penetrating thermal vascular injury in a child: a case report.

Penetrating vascular trauma in children is most commonly seen in wartime settings or more recently as a result of attempts at invasive imaging. Treatment of these patients can be more complicated than treatment of trauma in adults and must include maintenance of symmetric limb growth, compensatory growth of the vascular graft and its anastomoses, and the need for very long-term graft patency. This report describes the care of a 5-year-old child who was impaled by a hot metal pipe and sustained a penetrating thermal injury to the distal external iliac artery and vein. Issues such as conduit choice, extraanatomic reconstruction, anastomotic suture technique, and soft tissue coverage are reviewed in the report.

Irrigation of the abdominal cavity in the treatment of experimentally induced microbial peritonitis: efficacy of ozonated saline.

Ozone is an oxidizing agent possessing potent in vitro microbicidal capacity. This study was designed to address the extent to which irrigation of the contaminated abdominal cavity using a saline solution primed with ozone is effective in reducing morbidity and mortality. Gelatin capsules containing different quantities of a premixed slurry of filtered human fecal material were implanted in the peritoneal cavities of a preliminary series of rats. Three inocula concentrations were selected for later experiments, based upon their ability to produce morbid consequences: (1) high (100% 1-day mortality), (2) medium (70% 3-day mortality, 100% abscess rate in survivors), and (3) low (100% 10-day survival, 100% abscess rate). Fecal and abscess bacteriology were similar in all rats. The peritoneal cavities of 240 rats then underwent fecal-capsule implantation (three groups of 80 rats/inoculum concentration). At celiotomy 4 hours later, equal numbers of rats from each group were randomly assigned to one of four protocols: (1) no irrigation, (2) normal saline irrigation, (3) saline-cephalothin irrigation, and (4) ozonated saline irrigation. Each treatment lasted 5 minutes, using 100 ml of irrigation fluid. Mortality was significantly reduced when, in lieu of no irrigation, any of the irrigation solutions were used. Additionally, ozonated saline statistically proved the most effective irrigating solution for reducing abscess formation in survivors.

Ventral/incisional abdominal herniorrhaphy by fascial partition/release.

Ventral/incisional abdominal hernias following celiotomies continue to be a vexing problem for both patients and general and plastic and reconstructive surgeons, since no universally applicable preventive or reconstructive techniques have evolved. With reference to reconstruction, for example, primary repair is associated with a high incidence of recurrence; utilization of synthetic mesh is susceptible to extrusion, infection, and intestinal fistulization; and employment of truncal or extremity, free or rotational, myofascial flaps is associated with the morbidity of the procedure per se. By contrast, the use of fascial partition/release of the components of the abdominal wall employing bilateral parasagittal relaxing incisions in the obliquus externus abdominis and/or transversus abdominis fascia facilitates coaptation of the linea alba and obviates the aforementioned morbidity. This technique was utilized electively in seven adult patients with large defects of the anterior abdominal wall. In addition, for two patients, synthetic nonabsorbable mesh was applied superficial to the midline fascial closure. During a mean follow-up interval of 18 months (range 6 to 36 months), each patient healed per primum without evidence of eventration or herniation. The theoretic and pragmatic advantages of this technique are discussed. The use of fascial partition/release for reconstruction of abdominal wall defects should be part of the armamentarium of all herniotomists.

Breast cancer after mammary augmentation.

Augmentation mammoplasty has been said to reduce the risk for subsequent development of mammary gland carcinoma, but it may confer a worse prognosis should breast cancer develop. Nine patients who had breast cancer after augmentation mammoplasty were treated at the Ochsner Foundation Hospital and Clinic. The mean interval between augmentation and the development of a palpable mass was 6.8 years (range, 2 to 20 years). Four patients were treated with modified radical mastectomy, one was treated with radical mastectomy, and four were treated with tylectomy, axillary dissection, and radiotherapy. One of the four treated with tylectomy required salvage mastectomy. Reconstructions were done in all except one mastectomy patient. Five patients had stage I disease and four had stage II disease at the time of diagnosis. Over a mean follow-up of 4.75 years from the time of diagnosis of carcinoma of the breast, three of the four patients with stage II disease have either had recurrent disease or died of breast cancer, and one of the patients with stage I disease died with hepatic metastases. Mammography was not found to be useful for the detection of masses after augmentation mammoplasty. Needle aspirations were useful for diagnosis of nodal disease outside the breast, but not helpful in diagnosis of the breast lesion proper. Our analysis suggests that breast augmentation and the patient's psychologic considerations may delay the diagnosis of breast cancer. Additionally, patients may fare worse when breast cancer develops after mammary augmentation. We recommend preoperative mammography in most patients before mammary augmentation, particularly in those over the age of 30 years and those with a family history of breast cancer.

Congenital cutis laxa: a case report and review of loose skin syndromes.

Congenital cutis laxa is a deforming disease that may present for plastic surgical consultation during childhood. Failure to differentiate cutis laxa, with near normal wound healing, from the other forms of hyperelasticity syndromes with poor wound healing, has historically led to conflicting recommendations regarding the surgical management of patients presenting with loose skin. A face-lift and direct nasolabial fold excision was performed in a 10-year old patient with congenital cutis laxa with a good result. The other major syndromes presenting with loose skin as a clinical feature are reviewed and distinguished from cutis laxa. Plastic surgical procedures can be aesthetically and psychologically beneficial in children with congenital cutis laxa, and can be recommended without overt fear of wound disruption, poor scarring, and medical catastrophies that can occur with other hyperelasticity syndromes.