Prevention of unfavorable scars using early pulse dye laser treatments: a preliminary report.

Hypertrophic scarring occurs frequently in the trunk and extremities, and sporadically in other areas even under favorable circumstances. Unfortunately, the existing methods of scar manipulation have not been effective in preventing these unfavorable scars. Established hypertrophic scars have been treated by Anderson and Parrish, Alster, and others using the 585-nm pulse dye laser. The current study is the first report of prevention of hypertrophic scarring using the 585-nm pulse dye laser in a large group of elective and traumatic incisions. Treatment within the first few weeks resulted in faster resolution of scar stiffness and erythema, and less frequent development of hypertrophic scarring. An unexpected finding was the substantial improvement in the quality of scarring in all areas of the body, attributed to the excellent color match of the treated scars. These observations suggest that early pulse dye laser treatments can change fundamentally the physiology of wound healing if applied in the early phases. This report provides the first clinical correlation between prophylactic laser reduction of scar microcirculation and prevention of excessive scar formation.

Autogenous latissimus breast reconstruction.

This article discusses the authors' experience with the reliable and easily shaped autogenous latissimus flap. The design and shaping of the flap are discussed as well as its use for both immediate and delayed reconstructions.

Reconstruction of the perineum after tumor surgery.

Major defects of the perineum are often complicated by contracture, radiation injuries, fistulas, and infection. In addition, the perineal surface is unique, and any replacement must meet the requirements of mobility, sensitivity, durability, elasticity, and weight bearing. This combination of complex defects and special surface requirements can be met by adequate extirpative procedures and reconstruction with a number of muscle, musculocutaneous, and fasciocutaneous flap options.

The autogenous latissimus breast reconstruction.

The autogenous latissimus flap is an alternative to tissue expansion and is the standard latissimus flap in reconstruction of the modified mastectomy defect. It is a useful autogenous reconstruction for partial mastectomy defects, and it serves as an alternative to the TRAM flap. The donor site is acceptable to patients, and the overall results are above average.

Repair of the complications of hypospadias surgery.

In 1992 a retrospective review was conducted of 190 patients evaluated and treated for complications of hypospadias surgery during 1979 through 1990 at the Devine Center for Genitourinary Reconstructive Surgery of Sentara Norfolk General Hospital and Children's Hospital of the King's Daughters. We could not contact 13 patients and 8 are awaiting a second stage procedure. Of the 177 patients 167 (94.35%) have had a successful outcome, defined as a controllable urinary stream, functional erection and an acceptable cosmetic appearance, and 2 (1.13%) are considered failures. Details of presenting problems, surgical techniques and recent modifications of these procedures are presented.

Early and late capsular "deformation" as a cause of unsatisfactory results in the latissimus dorsi breast reconstruction.

The latissimus myocutaneous flap breast reconstruction continues to be a popular method, and the mechanics of flap elevation and inset have become routine. Still, it is difficult to obtain a lasting aesthetic result. It may be that we are asking the latissimus reconstruction to do things that are beyond its capabilities. This should challenge us to correct these deficiencies, rather than to discard the procedure in disappointment. The fundamental issue is the implant deformation, both early and late, which is related to the forces of capsular contraction. Early implant firmness and elevation and the late loss of both ptosis and projection are problems that are caused by the capsule itself. These late contour deformities have not previously been reported, but they are disturbing because of the untoward effect on symmetry. If these late findings are confirmed, the standard latissimus reconstruction must be viewed as an operation that can be expected to deteriorate after 5 or more years. The immediate placement of a tissue expander, instead of a permanent implant, is suggested as a means of mechanically manipulating these capsular contraction forces in the latissimus reconstruction. Although this is a logical suggestion, it will require a long-term study to confirm its efficacy.

Use of a latissimus dorsi myocutaneous flap for closure of an orocutaneous fistula of the cheek.

The latissimus dorsi myocutaneous flap can be used successfully for external cover in the cheek region when the nature of the defect precludes the use of other local or regional flaps. It is exceedingly useful when a large amount of well-vascularized tissue is needed. The flap is extremely reliable and versatile as a one-stage reconstruction. Its major drawbacks are its bulkiness and the necessity to reposition the patient intraoperatively.

Useful arterialized flaps for head and neck reconstruction.

During the past 10 years, there have been extensive developments in both "island" muscle and musculocutaneous flaps and in "free" microvascular transfers. Competition still exists between these two schools of surgical methodology, even though both methods are known to be complementary and have comparable success rates. Each individual procedure has its commending features, and the reconstructive surgeon should be conversant with both techniques to plan the best reconstruction for each patient. It is therefore important first to place each local flap into context with other local flaps, so that comparisons can then be made with the several free microvascular flaps that are available.

Soft-tissue repair of myelomeningocele defects using bilateral latissimus dorsi and trapezius musculocutaneous flaps.

An urgent closure of myelomeningocele defects was carried out in 82 newborns using latissimus and/or trapezius musculocutaneous advancement flaps. A three-layer closure of skin, muscle, and fascia was achieved in a single stage without a flank skin graft. All of the wounds healed within a two-week period and no late breakdown of the wound occurred during the eight-year period of study. The urgent closure maximized the neurological salvage and facilitated early cerebrospinal fluid shunting by preventing both infection and neural desiccation. This report represents the largest number of sequentially treated myelomeningocele defects without a major wound healing problem or death. The advancement musculocutaneous flap closure is safe, simple, and effective and is recommended as the preferred method for closure of the myelomeningocele defect.

An early appraisal of the methods of tissue expansion and the transverse rectus abdominis musculocutaneous flap in reconstruction of the breast following mastectomy.

In a 2-year prospective study, the results of two methods of breast reconstruction were compared. The tissue expansion and implant method was found to offer an acceptable reconstruction, but it was associated with a high rate of complications and revisions. The transverse rectus abdominis musculocutaneous flap reconstruction provided a more satisfactory reconstruction, with fewer major complications as well as a higher degree of patient satisfaction and less patient dissatisfaction. The present study does not address the long-term results of either procedure.

Cancer of the floor of the mouth and buccal cavity.

The ability of the surgeon to use the entire armamentarium of reconstructive techniques is essential in head and neck reconstruction. Each modality has its advantages and disadvantages. The decision of which technique to use is, of course, left to the individual surgeon's best judgment. Many new ideas will be explored in the future as the challenge of reconstruction awaits the perfect answer.

Experimental use of intercostal muscle flaps for repair of induced cardiac defects.

Intercostal muscle flaps were successfully used to repair 3 cm defects of the ventricular myocardium in the mongrel dog. Early and late healing of all flaps was uncomplicated and there were no late complications related to aneurysmal formation or electrical abnormalities of the heart. The existing blood supply of the heart was unaffected. The intercostal muscle is suggested as an alternative muscle flap for use in myocardial wall reconstruction.

Experimental reconstruction of the trachea with autogenous materials.

Composite intercostal muscle flaps were experimentally used to repair major intrathoracic tracheal defects in the mongrel dog. These composite flaps provided an adequate tracheal lumen with both sufficient mobility and structural stability. Stenosis of the reconstructed trachea was an uncommon finding, but the incidence of early postoperative mortality was high.

Penile curvatures.

Penile curvatures are common. They are caused by tethering inelastic tissues that can be from the skin externally, from the congenital fibrous tissue of hypospadias and epispadias, and from inelastic tunica albuginea as in fractures, trauma, or Peyronie's disease. At the present time, with sexual organs exposed in photographs, human sexuality talked about with more freedom, and sexual experiences more open, a great deal of mental stress and anxiety can be produced by penile curvatures. Adjunct to this are impotency and other sexual problems. Surgical treatment is generally curative with grafts, flaps, excision of tunica albuginea, or repositioning and coaptation of the corporal bodies. Also, the use of a sex therapist can offer additional aid to the physician and realistic acceptance by the patient. More attention should be given to the patient with this problem. It is not well recognized by most physicians, and therefore, patients may suffer needlessly in silence without adequate help.

Reconstruction for cervical irradiation ulcers with myocutaneous flaps.

Radiation-induced skin changes are commonly seen in patients who have been treated for head and neck malignancies. Some of these skin changes can progress into chronic postradiation ulcers, which despite aggressive medical wound management will not resolve spontaneously. Skin grafts and local cutaneous flaps located within the radiation field are unreliable and rarely provide adequate stable coverage. In this article, the authors report a combined experience of 52 patients whose postradiation cervical ulcers were successfully and reliably treated with myocutaneous flaps.

Hypospadias cripples.

The term "hypospadias cripple" is an apt one. The successful surgery of this condition requires radical correction of all deformities, preferably in a single stage. In doing this one must be conversant with virtually all the existing methods of hypospadias repair and be able to apply them appropriately.

The quantitative study of the use of dextranomer in the management of infected wounds.

Open wounds using quantitative cultures and dextranomer were analyzed. Dextranomer has been shown to be an extremely effective local wound care agent, provided that the wound has an adequate blood supply and complete removal of the used dextranomer is achieved. Under these circumstances, dextranomer provides a rapid and effective means for the treatment of open, exudative wounds.