Basal cell carcinoma in the groin of a black patient with femoral vessel invasion and a second primary malignancy.

We have presented an unusual case of basal cell carcinoma that presented in a 76-year-old black woman. This is an atypical case in that it occurred in a black patient, and the incidence of basal cell carcinoma is low in black people. The lesion was located in the groin, which is an uncommon location for basal cell carcinoma. The femoral vessels in this patient also were invaded by the tumor, which is also a very rare occurrence. The patient in this report had a coexisting squamous cell carcinoma of the lung, which may be a common finding in black patients with basal cell carcinoma. It is extremely important for the physician to include skin cancer in the differential diagnosis of any suspicious skin lesion. This will avoid delays in treatment and decrease the overall morbidity. The physician who encounters a black patient with a basal cell carcinoma also should screen the patient for a coexisting noncutaneous malignancy.

The inferiorly based rectus abdominis island flap for the treatment of complex hip wounds.

Complex wounds in the hip region often result from complications of orthopedic procedures performed in this region such as total hip arthroplasty, ORIF procedures, tumor ablation, and/or radiation therapy. Exposure of bone, joint capsule, prostheses, and other hardware often results with these wounds. Salvage of these exposed and/or infected essential elements and providing soft-tissue coverage are difficult and challenging problems for the orthopedic and plastic surgeon. To provide coverage for such situations, we have developed an aggressive strategy of thorough debridement, systemic antibiotics, and well-vascularized soft-tissue coverage utilizing an inferiorly based rectus abdominis island flap. This technique was utilized in five patients with all wounds and joints remaining stable at follow-up periods ranging from 2 to 7 years.

A new suction device for microsurgery.

A new suction device for microsurgical procedures is presented. This device is made of soft, compliant PVC, which enables all fluids to be evacuated from the surgical field without damaging the surrounding soft tissue. The device is designed with front and radial ports that allow placement onto the blood vessel or nerve while the anastomosis is being performed. There is a tapered end providing the surgeon with fine control of the suction. Unlike other bulky suction devices, this one readily fits into the operative field without inhibiting operative procedures. It also readily fits varying sizes of conventional Frazier-type tips. The device has been used in over 100 microsurgical procedures and it has served well.

A new vessel occluder for microvascular anastomoses.

A vessel occluder has been developed that is easy to use and provides effective, safe, vascular occlusion. The occluder is small and is easily rotatable in the operative field. It consists of a plastic backing and a compliant foam strap that wraps around the blood vessel. The foam absorbs blood and irrigation which keeps the vessels moist during the anastomosis. This vessel occluder possesses the ability to vary the amount of blood flow through the vessel, enabling the surgeon to identify and readily repair anastomotic leaks. This occluder has been used successfully by the authors in 100 anastomoses.

Anatomical parameters for nipple position and areolar diameter in males.

In this paper we present anatomic parameters for nipple position and areolar diameter in males. Larger forms of gynecomastia with significant ptosis pose a challenge to the plastic surgeon with respect to relocation of the nipples on the chest wall. Selection of the appropriate areolar size is also of concern in gynecomastia correction. There is a paucity of information in the current literature pertaining to this problem. In order to establish guidelines for the placement of the nipple in gynecomastia correction and for the selection of the appropriate areolar size, we set out to determine these anatomic parameters. We believe use of these parameters will enhance the aesthetic results of gynecomastia correction. One hundred males between the ages of 17 to 30 years were chosen for this study. The males selected were of ideal body weight and without evidence of gynecomastia. The distances from the sternal notch to the nipple, the midclavicular line to the nipple, and the nipple-to-nipple distance were recorded. The areolar diameter was also measured in each subject. The average distances were determined for each category. The validity of these values was confirmed with statistical analysis. Equations were then derived, using this analysis, to determine nipple position in males. We have determined the nipple position in males to be approximately 20 cm from the sternal notch and 18 cm from the midclavicular line. The ideal nipple-to-nipple distance is 21 cm. The average areolar diameter is 2.8 cm.

Basal cell carcinoma in black patients: the need to include it in the differential diagnosis.

We present a retrospective study of 276 basal cell carcinomas which we have identified 5 (1.8%) black patients. This finding agrees with the current literature, which states that basal cell carcinoma in the black population is relatively infrequent. Although basal cell carcinoma in black patients is uncommon, it should be included in the differential diagnosis of any suspicious lesion in this population to avoid the morbidity that is associated with a delay in diagnosis. In this study we also present the possible association of basal cell carcinoma occurring concomitantly with a second primary malignancy in this population. In black patients basal cell carcinoma is found more frequently in regions of the body that are protected from ultraviolet radiation when compared to white patients. This leads to the speculation that a different pathogenesis of basal cell carcinoma exists for black patients.

Supplemental oxygen: ensuring its safe delivery during facial surgery.

Electrosurgical coagulation in the presence of blow-by oxygen is a potential source of fire in facial surgery. A case report of a patient sustaining partial-thickness facial burns secondary to such a flash fire is presented. A fiberglass facial model is then used to study the variables involved in providing supplemental oxygen when an electrosurgical unit is employed. Oxygen flow, oxygen delivery systems, distance from the oxygen source, and coagulation current levels were varied. A nasal cannula and an adapted suction tubing provided the oxygen delivery systems on the model. Both the "displaced" nasal cannula and the adapted suction tubing ignited at a minimum coagulation level of 30 W, an oxygen flow of 2 liters/minute, and a linear distance of 5 cm from the oxygen source. The properly placed nasal cannula did not ignite at any combination of oxygen flow, coagulation current level, or distance from the oxygen source. Facial cutaneous surgery in patients provided supplemental oxygen should be practiced with caution when an electrosurgical unit is used for coagulation. The oxygen delivery systems adapted for use are hazardous and should not be used until their safety has been demonstrated.

Staple versus suture closure of skin incisions in a pig model.

The purpose of this study was to find out whether skin staple closure was a reasonable alternative to conventional nylon suture closure. Mechanical strength, histologic characteristics and time of closure were compared in skin incisions made on the backs of Yorkshire swine. The results showed that stapled and sutured wounds have similar mechanical strength up to 21 days. Stapled wounds are substantially narrower and are associated with less inflammation than sutured wounds. Staple closure is much less time-consuming than suture closure.

An anatomic study of the venous drainage of the transverse rectus abdominis musculocutaneous flap.

The authors studied the venous drainage of the abdominal wall and its application to the transverse rectus abdominis musculocutaneous flap on 12 cadavers by injecting methylene blue and methyl methacrylate to follow the venous pathways. The nonvascular tissues of the specimens injected with methyl methacrylate were corroded away to show the three-dimensional arrangement of the vessels. We describe the veins of the anterior abdominal wall in relation to the transverse rectus abdominis musculocutaneous flap. The venous drainage of the transverse rectus abdominis musculocutaneous flap when used for breast reconstruction occurs from the cutaneous part of the flap to the inferior deep epigastric veins through vertical perforators that are mainly periumbilical. From there the flow is through the deep superior epigastric veins into the internal mammary vein. The deep inferior epigastric veins were found to have valves that prevent retrograde flow. In designing the flap, its safety is increased if it includes the periumbilical perforators. Thinning the flap should be done at the deep surface to preserve Scarpa's fascia and the superficial epigastric system.