Reconstruction of the perineum.

The pelvic and perineal regions are affected by a heterogeneous spectrum of pathologies, many with a tendency to recur. Extensive mutilation carries physical, sexual, and psychological sequelae. Primary reconstruction reduces morbidity and shortens recovery. Modern management calls for a multidisciplinary approach. Not uncommonly, patients come with previous surgery and/or chemoirradiation. They may also be elderly and debilitated. The literature on reconstruction of the perineum can be confusing because knowledge has evolved by an accumulation of isolated short reports of individual methods. This led to the lack of a unifying basis for nomenclature and a failure to relate specific techniques to their roles in repairing particular types of defects. This article gives an overall summary of the approaches in a structured and rational manner. Defects of the external pelvis and perineal lining are usually amenable to coverage with local or regional fasciocutaneous flaps, if primary closure or skin graft is not appropriate. These flaps depend on the integrity of the vascular territories of the internal pudendal, the upper medial thigh plexus, or the descending branches of the inferior gluteal. The location and extent of the resection usually determine the requirements of the reconstruction and may dictate the choice of options. When defects are pelviperineal, particularly when the vagina needs to be reconstructed, myocutaneous flaps are of proven advantage in dealing with both the resurfacing as well as providing the bulk needed to fill the pelvic cavity after extensive resections. The rectus, gluteus, and gracilis are the best known options. Owing to the intrinsic limitations with the gracilis flap, the rectus and gluteus flaps have largely superseded its role in most situations. The rectus flap, in particular, provides good bulk as well as reliable skin. The use of muscle sparing flaps based on the perforator principle in suitable instances has increasingly been reported. The role of free tissue transfer, however, remains limited to isolated situations not amenable to current standard techniques. New and innovative reconstructive modifications keep appearing and larger scale series are needed for more evidence-based information on the outcomes achieved.

"Cystic" parotid swelling on FNA: significance on clinical management.

The clinical significance of a cystic aspirate, defined as an aspirate yielding fluid of any nature, on fine needle aspiration cytology (FNA) of parotid masses was studied. A total of 464 FNA from 236 patients over a 4-year period in a university head and neck department was analyzed. The incidence of cystic aspirates was 17.4%. The gross appearance of the aspirated fluid was consistent between sessions. Aspirated fluids could be blood-related, serous, or purulent, and these were associated with the pathological nature of lesions. Volume and viscosity were not useful features in predicting pathology. Cysts that could be completely emptied may not recur, but the pathology should still be noted. There was no difference in pathology between cystic and noncystic swellings. The incidental finding of fluid on FNA carries very limited clinical implication and parotid masses should be fully worked up and treated as in the noncystic swelling.

Frozen section during parotid surgery revisited: efficacy of its applications and changing trend of indications.

BACKGROUND: Efficacy of frozen sections was assessed in terms of its various applications. The changing role of frozen sections in parotid surgery was examined. METHOD: Records of parotid operations over a 15-year period in a University Department of Head & Neck Surgery were reviewed. RESULTS: Of 241 operations, frozen sections were performed on 32. Applications of frozen sections included diagnosis, margin clearance, and checking suspicious lymph nodes and nerve invasion. The false-positive rate for malignancy was 12.5%. Margins may still be involved despite correct tissue diagnosis from sampling error. No inappropriate surgery resulted from the information obtained. With the advent of fine-needle aspiration, frozen sections were less often called for and a shift from a diagnostic role to margin checking was seen. Frozen sections picked up all unsuspected malignant tumors. CONCLUSION: Frozen sections are helpful when interpreted cautiously, but clinical assessment and fine-needle aspiration are also important components in the workup.