Total reconstruction of aplasia cutis congenita involving scalp, skull, and dura.

A case of total reconstruction of skull and scalp in a patient with a large defect from aplasia cutis congenita is reported. Tissue expansion was successfully employed on two occasions: first to construct a well-vascularized space to sustain multiple rib grafts for cranial reconstruction and then to develop adequate quantities of scalp and forehead for total coverage.

The versatility of pericranial flaps.

The pericranium is the source of multiple, dependable, well-vascularized flaps which are of use to the plastic and reconstructive surgeon for multiple defects of the face and skull. Based anteriorly, the flap can cover the entire central third of the face or be transposed intracranially to correct abnormalities of the cribriform plate and dura. Based laterally on the temporalis muscle, the flap can be turned to multiple arcs for reconstruction of the face, ear, and intracranial defects. Donor-site morbidity and complications have been minimal.

The correction of cleft palate with primary veloplasty and delayed repair of the hard palate.

Optimal repair of the cleft palate requires meticulous balance of the effects of the procedure on craniofacial growth, dentition, and speech. Aggressive, early closure of the entire palate was practiced by the senior author many years ago. Successful closure with reasonable speech was produced at the price of severe facial and dental disturbance. Patients were adversely affected for many years before the "antisurgery war-cry" of dentists and orthodontists tempered our enthusiasm. In the past 5 or 6 years, the din of speech therapists again advocating early closures has arisen. Besieged on both sides, the plastic surgeon must temper the demands of both camps, seeking the overall benefit of the patient. We believe that primary veloplasty and delayed hard-palate closure as demonstrated in this series provide superior speech with minimal deleterious side effects. The results of intravelar veloplasty, when combined with two-step closure, are especially gratifying. It is hoped that the further refinement of this technique in the past several years will improve results even further.

More experience with the "reverse" latissimus dorsi musculocutaneous flap: precise location of blood supply.

Our work demonstrates that the "reverse" latissimus dorsi musculocutaneous flap has a predictable and consistent blood supply. A major portion of the muscle can be nourished by the dorsal perforating branches of the ninth, tenth, and eleventh intercostal vessels. The skin island based on the "reverse" latissimus dorsi muscle can be as large as 8 X 20 cm. This is confirmed by anatomic dissections and clinical cases. Knowledge of the blood supply facilitates elevation of the flap and extends its utility.

Traumatic arteriovenous malformation of the external carotid arterial system.

Traumatic arteriovenous (AV) malformations of the face and scalp are rare lesions characterized by multiple endothelial-lined channels between the arterial and venous systems. If improperly managed they have a high propensity to recur, and may result in severe cosmetic deformity. Lesions should be delineated by arteriography unless small and localized. They are managed by complete excision and ligation of arterial feeding vessels. Five cases of traumatic AV malformation of the face and scalp and their management are reported.

The superficial inferior epigastric artery flap for coverage of hand and forearm defects.

Large wounds of the hand and upper extremity require secure closure for protection of the underlying structures. The skin of the lower abdomen can be raised in a lenticular fashion, supported by the superficial inferior epigastric artery and veins and applied as a flap to wounds of the distal upper extremity. The flap demonstrates versatility in positioning, and the donor site can be closed in a linear fashion. Viability of this superficial inferior epigastric artery flap is demonstrated by the case reports.

The management of hemangiomas of the eyelid and orbit.

The growth of hemangiomas of the orbital region varies greatly; it is unpredictable. Most lesions never reach sufficient size to impair vision; a few, however, may grow sufficiently to cause disastrous complications. Nine children with complete or partial occlusion of the vision by hemangioma of one eye are reported. (Functional vision was preserved only in those patients who had early subtotal excision of the eyelid hemangioma.) Two children with complete occlusion developed amblyopia in the involved eye. One had optic nerve atrophy. One of the four children with partial occlusion of vision had a permanent decrease in visual acuity. Of the remaining three children with normal vision, two had been operatively treated early, and one had unusually rapid involution of the hemangioma. We recommend that when a child has complete or partial visual occlusion due to hemangioma, subtotal or total excision of the hemangioma should be carried out within 1 week of the onset of visual occlusion to prevent amblyopia.

Traumatic upper arm defect treated with latissimus dorsi muscle transposition.

Transfer of the latissimus dorsi muscle was useful in restoring contour and function to a child's acutely injured upper extremity. The procedure provided protection for exposed vital structures. A split-thickness skin graft covered the exposed muscle. Transposition of the latissimus dorsi insertion was not necessary to obtain adequate elbow flexion.

Correction of webbed neck defects.

The posterior approach for correction of the webbed neck defect involves wide anterolateral skin undermining and skin resections from the nape of the neck. The redundant tissue and the underlying defect are corrected and the resultant scar is hidden in the scalp rather than being exposed on the lateral aspect of the neck or shoulder as would be the case with a Z-plasty procedure. In addition, the hairline remains smooth and in a relatively natural position. The surgical dissection is not difficult, and few anatomical structures are involved. The procedure has been employed in 4 patients and has proved to be effective and safe, with long-lasting improvement and acceptable aesthetic results.

A solitary bone cyst of the mandibular condyle.

A review of the literature concerning solitary bone cysts of the jaws is presented. Our patient is typical except for the location of the cyst. No previous case of a solitary bone cyst confirmed to the mandibular condyle has been reported. No precise etiology for solitary bone cyst is known. The use of routine panoramic radiography has made detection of such cysts more common. Surgical exploration is indicated for diagnosis and treatment.

Reconstruction of the chest wall.

Reconstruction of the chest wall can now be accomplished reliably and expeditiously. Past experience with local flaps and split-thickness skin grafts recommends their continued use when appropriate. Recent studies in blood flow have demonstrated that very large muscles with or without the overlying skin can be moved primarily and reliably. The four most reliable myocutaneous flaps for chest wall reconstruction are described. Microsurgery allows movement of large segments of skin and muscle from expendable areas of the body to the chest wall.

Corrective cosmetic otoplasty: a simple and accurate technique.

The authors present a technique for cosmetic correction of protruding ears used in over 100 cases during the last ten years with good cosmetic results and no significant complications.

Skin abuts skin at the alar margins of the nose.

The microscopic anatomy of the alar margins of the nose shows that skin abuts skin without intervening subcutaneous tissues. It is the only place in humans where this occurs.

Forehead and brow lifts and their relationship to blepharoplasty.

The brows and forehead are important considerations in planning a blepharoplasty. Forehead wrinkles, ptotic brows, and frown lines can be corrected effectively and safely with minimal complications at the time of, and prior to, the blepharoplasty. Various approaches that we use are presented here. The surgical procedure selected should reflect the defect present and the surgeon's preference.