Human immunodeficiency virus infection and subsequent melanoma.

Immunosuppression has been known for many years to be associated with the development of skin cancer, particularly squamous cell carcinoma. The association with melanoma is less clear. This report describes 4 patients with known human immunodeficiency virus (HIV) positivity who subsequently developed malignant melanoma. The subtypes and precursors of the tumors vary. Three of 4 patients treated using accepted surgical standards remained disease free an average of 33 months postoperatively. Treatment of the melanoma as in the non-HIV infected melanoma patient is advised. Epidemiological studies remain to be done to determine the significance of this association. In the meantime, melanoma remains a surgical disease and early, aggressive, standard surgical treatment is encouraged for these patients. Despite the immunocompromised state that their HIV status implies, surgical treatment offers local and regional control of disease and possibly cure.

Anti-HBc assays: evaluation of end-point sensitivity and performance.

The performance characteristics of eight commercially available anti-HBc assays-seven ELISAs and a modified haemagglutination assay-were assessed using an eight-sample panel of sera collected from blood donors representing a cross-section of anti-HBc-positive donors that might be expected to be encountered in the course of routine screening of blood donations. End-point sensitivity was investigated with a view to choosing one anti-HBc ELISA for use in a second phase routine donor screening study in parallel with the modified haemagglutination test. The chosen anti-HBc ELISA had to be of an acceptable sensitivity level in comparison with all the other ELISAs investigated, and the ease of use and overall test time had to be taken into account. With a view to this, although the Murex assay was by far the most sensitive, the test time with the protocol available at the time was too long and therefore the Biokit ELISA was chosen for the second phase.

A muscle-sparing technique for reconstruction of the defect left after excisional hip arthroplasty.

Muscle flap closure is the treatment of choice for coverage of the failed hip arthroplasty defect. Several described muscle flaps work well, but they sacrifice functioning parts of the abdominal wall or quadriceps femoris mechanisms. The authors describe the use of the tensor fascia lata musculocutaneous flap for this purpose. The technique described has been previously used successfully to reconstruct over 100 trochanteric pressure sores. This flap spares more important muscles, requires no skin graft, and exposes the deep wound well for debridement.

The role of orbital ultrasound in the diagnosis of orbital fractures.

The role of CT scanning in the diagnosis and management of craniomaxillofacial injuries is well documented. However, coexistent injuries, limitations on patient positioning, CT availability, or financial constraints may prevent or delay the diagnosis of significant orbital wall defects. Real-time ultrasound represents a safe, inexpensive, noninvasive, portable, and readily available diagnostic modality which has had a limited application in the diagnosis of orbital pathology. The objectives of this study were to define the role of orbital ultrasound in the assessment of the traumatized orbit and to provide correlation of pathology with CT imaging. Eighteen patients (16 males, 2 females) having sustained trauma to the orbitozygomatic region were assessed at a regional trauma center over a 6-month period. Each patient underwent an ultrasound examination of both orbits. Confirmatory CT scans (5-mm axial and 1.5-mm coronal orbital cuts) were then obtained for comparative assessment. Patients with open globe injuries, alteration of visual acuity, or life-threatening conditions were excluded from the study. The results of the study revealed a positive correlation between the ultrasound and CT findings in 17 (94 percent) of the patients. Ultrasound demonstrated satisfactory sensitivity (92 percent) and specificity (100 percent) and positive predictive value (100 percent) when compared with CT scanning. Soft-tissue herniation, orbital emphysema, and muscle entrapment were well visualized by means of real-time ultrasound. It is concluded that orbital ultrasound is an accurate diagnostic modality in the investigation of orbital trauma and correlates well with CT findings. A cost analysis will be presented, and details of the limitations and efficacy of orbital ultrasound will be discussed.

Human immunodeficiency virus status in facial fracture patients.

A prospective study was performed to obtain an indication of the incidence of human immunodeficiency virus (HIV) among the population of facial fracture patients treated at a city hospital in Toronto, Ontario, Canada. This study was stimulated by the observation that a significant number of the patients treated at this unit were drug and alcohol abusers, inmates of a local penitentiary (where homosexual activity is believed not to be uncommon) or had no fixed address. In addition, the surgical treatment of these patients involved the use of sharp, high-powered motorized instruments e.g., saws, drills, wires, etc., and resulted in the spillage and aerosolization of considerable amounts of blood and other tissues. Operating room staff are exposed to these patients for 12 to 18 hours on many occasions. Accidental exposure to body fluids can occur easily. It was thus decided to obtain consented HIV testing of all facial fracture patients managed by the Plastic Surgery Team between July and December 1990. Fifty-two patients were seen, and 47 (90.4%) of them were tested for HIV. Results were obtained for 46 (97.8%) of those tested. One patient (2.2%) was found to be positive for HIV. This figure was smaller than anticipated considering the patient population demographics, but is not an insignificant number and thus it is advised that if any suspicion arises, consented HIV testing should be obtained and the necessary precautions taken.

Results and prognosis following surgery for malignant tumors of the skull base.

A series of 155 malignant craniofacial tumors referred to a specialized craniofacial center for surgical treatment are presented. One quarter of these were primary and three quarters recurrent. The statistics of long-term follow-up are presented, and it is concluded that this type of surgery for these difficult problems is worthwhile. The increasing experience gained from operating on and following up these patients is presented.

Infection following cranial bone grafting--a need for caution?

A case of delayed infection following the use of split-cranial bone graft is presented. Trauma and bacterial contamination of the donor area six months before harvest were the likely causes. We advise caution and the use of alternate donor sites in cases where a history of previous contaminating trauma exists, even if the cranial bone is clinically completely healthy.

The fasciocutaneous flap: a conservative approach to the exposed knee joint.

The exposed knee joint poses a challenge to the reconstructive surgeon. The currently popular approach to the repair of exposed knee joints is use of muscle flaps. However, this leaves the patient with a deficit. We have therefore begun using the fasciocutaneous flap as an initial approach to this problem. In seven patients, aged 28 to 74 years, fasciocutaneous flaps have been the reconstructive procedure of choice for repair of exposed knee joints. One patient with a very large open wound required a concomitant medial gastrocnemius muscle flap. One minor wound separation occurred in a paraplegic patient with severe spasm. No other complications occurred. Follow-up ranged from 3 to 12 months, with good success in wound closure. An approach to small and intermediate wounds is presented in which the V-Y technique is used to obviate the need for skin grafting of the donor site.

Immediate breast reconstruction: reducing the risks.

One-hundred and sixty-five consecutive immediate breast reconstructions in 157 patients were reviewed. Reconstructions were performed with tissue expanders (53 percent) or immediate gel prostheses (47 percent). Immediate reconstruction was associated with an 18 percent rate of implant loss. Certain risk factors were identified at the p less than 0.05 level using immediate gel implants: failure to achieve complete muscle coverage of the implant, smoking at the time of surgery, initial gel implants of 400 ml or more volume, and age. Expander loss was increased by detaching the pectoralis major (p less than 0.05) and probably by lack of complete muscle coverage in general. Chemotherapy, history of previous smoking, and clinical stage of the carcinoma did not seem to affect reconstructive success. Smoking and patient age should be considered during patient selection for immediate reconstruction. Muscle coverage of the prosthesis should always be attempted. Muscle coverage is mandatory in the smoker. Gel implants of 400 ml or more volume are to be avoided at the initial operation. This approach should enable all surgeons to achieve lower rates of implant loss.

Calibrated alar base excision: a 20-year experience.

Conflicting guidelines for excisions about the alar base led us to develop calibrated alar base excision, a modification of Weir's approach. In approximately 20% of 1500 rhinoplasties this technique was utilized as a final step. Of these patients, 95% had lateral wall excess ("tall nostrils"), 2% had nostril floor excess ("wide nostrils"), 2% had a combination of these ("tall-wide nostrils"), and 1% had thick nostril rims. Lateral wall excess length is corrected by a truncated crescent excision of the lateral wall above the alar crease. Nasal floor excess is improved by an excision of the nasal sill. Combination noses (e.g., tall-wide) are approached with a combination alar base excision. Finally, noses with thick rims are improved with diamond excision. Closure of the excision is accomplished with fine simple external sutures. Electrocautery is unnecessary and deep sutures are utilized only in wide noses. Few complications were noted. Benefits of this approach include straightforward surgical guidelines, a natural-appearing correction, avoidance of notching or obvious scarring, and it is quick and simple.

The diagnosis of osteomyelitis in patients with pressure sores.

A prospective blind trial was undertaken to assess the usefulness of commonly used tests to diagnose osteomyelitis underlying pressure sores. Sixty-one pressure sores were studied, with a histopathologic diagnosis from the ostectomy specimen being available in 52. White cell count, erythrocyte sedimentation rate, plain pelvic x-ray, technetium-99m bone scan, computerized tomography, and Jamshidi needle bone biopsy were studied. The most useful individual test was a needle bone biopsy, with a sensitivity of 73 percent and a specificity of 96 percent. Technetium-99m bone scans and computerized tomography are not indicated in the diagnosis of osteomyelitis associated with pressure sores. Plain pelvic x-ray, white cell count, and erythrocyte sedimentation rate, with a diagnosis of osteomyelitis if any test is positive, is the most sensitive (89 percent), specific (88 percent), noninvasive workup. Jamshidi needle biopsy may be useful where these tests are negative and a clinical suspicion of osteomyelitis remains. Extent of surgical debridement and antibiotic therapy can then be rationally decided on the basis of this information.

Herpes zoster as a complication of a face lift.

A case of herpes zoster neuritis (shingles) is reported, closely following a face lift with adjunctive dermabrasion and chemical peel. The etiologic relationships are unclear. However, the mental nerve distribution suggests mechanical irritation of the nerve as a possible factor. Management of this complication is conservative. It is suggested that herpes zoster be included in the differential diagnosis of unusual alterations of sensation or persistent pain following procedures for facial aging.