Optimum management of hand blast injuries.

A series of 27 blast and gunshot injuries of the hand is presented. These wounds exhibit a spectrum of complexity and may include extensive soft tissue trauma complicated by burns, foreign bodies, fractures and amputations. A systematic management sequence is outlined to evaluate, treat, reconstruct and rehabilitate these hands, with the primary goal of obtaining early maximal function. Since these injuries vary in nature and complexity, this management sequence is specifically adapted to deal with the individual injury. A "reconstructive ladder" of techniques is utilized, ranging from "simple" (e.g., direct closure, skin grafts, local flaps) to "complex" (free flaps, toe-to-thumb transfer). The individual procedure selected is the most straightforward, consistent with expediency and early return of a functional hand. The return of these hands to function has been facilitated by recent advances in tissue assessment, free tissue transfer, and skilled hand therapy.

Surgical treatment of nasal obstruction secondary to craniofacial fibrous dysplasia.

Craniofacial fibrous dysplasia, a skeletal disorder most often affecting the mandible or maxilla, can cause a variety of complications. Nasal obstruction secondary to this unusual disorder presents a diagnostic and therapeutic challenge. The nasal obstruction in this case is due to expansion of fibrous lesions in adjacent bones as well as direct involvement of the turbinates with fibrous dysplasia. We describe the surgical correction of nasal obstruction in this unique setting and present a brief update of this intriguing disorder.

Rectus abdominis flap closure of ischiosacral pressure sore.

An inferiorly based rectus abdominis musculocutaneous flap was used to close a large ischiosacral pressure sore refractory to the usual methods of closure in a paraplegic patient. The functions of the rectus abdominis muscle to initiate vertebral flexion from a supine position and aid in respiration, urination, defecation, and vomiting may play a proportionately greater role in the paraplegic patient. Although our patient did not experience any noticeable clinical deficits, this donor site is theoretically less functionally expendable in the paraplegic patient.

Pressure sore carcinoma.

The development of squamous cell carcinoma in pressure sores is a rare event, considering the high incidence of pressure sores within the elderly and paraplegic populations. The clinical courses of 10 patients with pressure sore carcinoma have been reviewed. The presence of a velvety, cauliflower-like growth on the surface of a long-standing pressure sore should alert the surgeon to the possibility of malignant degeneration. Most of these tumors are well-differentiated squamous cell carcinomas. Of the 10 patients, 8 (80%) died from massive local recurrence or distant metastases an average of 17 months after resection and flap closure despite having apparently localized disease. One patient was disease free when lost to follow-up at 2 years, and 1 patient is without evidence of recurrence or metastases 3 months postoperatively. Altered immunocompetence may play a role in the rapid progression and high mortality associated with this tumor after surgical manipulation.

Shotgun blast injuries to the groin: reconstruction using the rectus abdominis flap.

We discuss our successful management of complex groin wounds caused by shotgun blasts at relatively short range. A straightforward approach to the problem of reconstructing the large soft-tissue defect and providing protection for the femoral artery reconstituted by Gore-Tex graft is described. We emphasize the fundamental principles of management of civilian trauma and illustrate that a Gore-Tex graft need not be covered immediately if there is any possibility that debridement is incomplete. The inferiorly based rectus abdominis flap is recommended as an excellent choice for coverage of the typical shotgun blast groin wound, making it possible to salvage the involved lower extremity in these severe injuries.

Quantitative analysis of blood and fat in suction lipectomy aspirates.

This study of suction lipectomy aspirates from 15 consecutive patients was undertaken to biochemically quantitate the blood-to-fat ratios of the aspirates. A wide variation in the blood-to-fat ratios (8 to 54 percent) was noted, but the authors failed to demonstrate any relationship between the blood-to-fat ratios and the suction lipectomy operative site. Prophylactic measures to allow treatment of patients in a consistently safe manner include carefully screening of patients to exclude those with bleeding disorders or significant illnesses, perioperative oral iron therapy, infiltrating the operation site with a dilute epinephrine solution, hydrating the patients adequately perioperatively, using smaller-diameter cannulas for the aspiration, minimizing aspiration once the aspirate turns grossly bloody, and limiting the aspirate to a volume of less than 1750 ml for any operative procedure.

Pilomatrixoma presenting as a parotid mass.

A rare case of calcifying epithelioma of Malherbe presenting as a large parotid mass is reported in this paper. Preoperative evaluation and considerations are discussed. An exact diagnosis and definitive treatment in this patient consisted of superficial parotidectomy and histologic study.

Meat grinder injuries to the upper extremity.

Three cases of hand injury caused by meat grinders are presented. All 3 injuries involved the dominant hand and resulted in varying degrees of deformity. Two of the 3 patients arrived in the emergency room with the injured hand still firmly wedged in the meat grinder. Although these injuries continue to prove very mutilating, maximum restoration of the injured hand can be accomplished by careful extrication, followed by preservation and reconstruction of all viable tissues. Perioperative antibiotics and wound irrigation with antibiotic solution are recommended. Microsurgical technique can be of value in treating selected patients.

Fasciocutaneous flap coverage for periolecranon defects.

Soft tissue defects in the periolecranon region are difficult to manage by standard techniques such as closure by approximation, split-thickness skin grafting, or healing by secondary intention. We employed cadaver injections and dissections to study the vascular anatomy of the periolecranon region in search of a suitable local flap for coverage of periolecranon defects. This report details our experience in 31 patients with a one-stage technique for elbow coverage employing a proximally based forearm fasciocutaneous flap. Surgical techniques and clinical applications are discussed; a satisfactory long-term outcome is documented in 30 of 31 patients. The advantages of using this model fasciocutaneous flap include enhanced vascularity, sensibility, and ease of elevation.

Functional assessment of ray transfer for central digital loss.

Nineteen patients who had ray transposition for central digital loss were evaluated retrospectively with regard to postoperative function and appearance. Pinch and grip recoveries were better in patients with small-to-ring finger transfers than in those with index-to-long finger transfers. Total average pinch recovery measured 83.3% of the nonoperated side. Total grip recovery was 80.2% of the nonoperated side. Average ranges of motion for all transferred digits were 77.6 degrees (metacarpophalangeal joint), 87.6 degrees (proximal interphalangeal joint), and 80.8 degrees (distal interphalangeal joint). Overall results judged by a five-component assessment scale were excellent.

The posterior calf fasciocutaneous free flap.

Four clinical cases are presented that represent our initial experience with a new fasciocutaneous free-flap unit. The territory of this flap incorporates the skin, fat, and fascia of the posterior calf region. Its design is based on the principle of the fasciocutaneous flap. Anatomic studies confirm that the blood supply to this flap is derived from a descending subfascial branch of the popliteal artery. The flap is well endowed with cutaneous sensory nerves, making it a potential neurosensory free flap. Our technique of flap design and elevation is presented, and potential advantages and disadvantages of this flap are discussed.

Experience with the transverse lower rectus abdominis operation for breast reconstruction.

Our initial experience with the lower rectus abdominis procedure for breast reconstruction in 19 patients is presented. Anatomic considerations, surgical technique, and results are reviewed. Errors in flap design and execution resulted in a disproportionately high complication rate, which improved following certain technical refinements. The lower rectus flap has proved to be an alternative to conventional techniques of breast reconstruction. As more experience is gained with this flap, its particular role in the reconstructive armamentarium will be more clearly defined.

The rectus abdominis free flap for lower extremity reconstruction.

The authors present their successful experience with an attractive alternative to the latissimus dorsi and gracilis muscle flaps for lower extremity reconstruction--the free rectus abdominis muscle flap. The muscle flap has a dual blood supply, but the longer pedicle length and larger vessel diameter of the inferior epigastric vascular pedicle favor its use for free-tissue transfer. Surgical anatomy, technique, indications, and potential complications are outlined.

A free occipital hair-bearing flap for reconstruction of the upper lip.

A free hair-bearing occipital scalp flap was employed for reconstruction of the upper lip in a young man who had sustained a close range shotgun blast to the face. The "moustache" free-flap provides an abundant source of hair-bearing scalp which has certain advantages over conventional techniques of repair. It is a one-stage operation, involves minimal donor site morbidity and uses hair-bearing scalp which is not usually affected by male-pattern baldness.

Aspergillus colonization associated with bilateral silicone mammary implants.

A case of Aspergillus niger fungal colonization associated with bilateral inflatable silicone mammary implants is reported. Painful fibrous capsular contractures without clinical evidence of infection or inflammation characterized the presenting symptoms. Operative findings included a cheesy-white exudate that surrounded the implants and turbid fluid within the implants. All specimens yielded a heavy growth of Aspergillus niger. Special stains of the fibrous capsules were negative for fungal invasion. The etiology and pathogenesis of Aspergillus colonization in this patient are postulated.

Hypertensive leg ulcers.

A case report of hypertensive leg ulcer and its management is described. The diagnosis of hypertensive leg ulcer is primarily based upon clinical findings after other etiologies have been excluded. Microscopic arteriolar changes associated with hypertensive disease do not necessarily preclude the development of hypertensive ulcers. Therapy of these ulcers is based upon a sound understanding of their pathophysiology--control of systemic hypertension, possible enhancement of local tissue perfusion, atraumatic debridement, and skin graft closure.

The evolution of techniques for reconstruction of full-thickness cheek defects.

Our experience with 20 full-thickness cheek reconstruction in 17 patients over the past 27 years is presented. The evolution of techniques for management of full-thickness cheek defects reflects our gradual appreciation of the longitudinal artery concept within axial and musculocutaneous flap units. During the 1950s, defects were managed by random flaps. Popularization of the forehead flap and introduction of the medially based deltopectoral flap during the 1960s heralded the current application of axial flaps. The 1970s saw an explosion of new techniques, including the musculocutaneous flaps and microvascular free tissue transfers, based on the longitudinal vessel concept. A method simultaneously employing the pectoralis major musculocutaneous flap for intraoral lining and the deltopectoral flap for external coverage has been described. A modification of the latissimus dorsi free flap to allow a one-stage watertight closure of large full-thickness cheek defects has been outlined. Our challenge for the 1980s lies in the improvement of techniques to reanimate the reconstructed cheek.