Koebner phenomenon: what you don't know may hurt you.

Koebner phenomenon is the development of isomorphic pathological lesions in distant wounds of patients with pre-existing cutaneous diseases. More frequent in patients with psoriasis, it can occur in the presence of other cutaneous pathologies. Surgeons should be aware of this entity and warn patients about its possible occurrence.

Motorboat propeller injuries.

It is estimated that approximately 25% of the population of the United States participates in recreational boating activities in a given year. These activities result in 7,000 reported accidents, 60% of which result in injuries. Of these injuries, 19% are fatal (11.3% of accidents). Eighteen percent of these fatalities are caused by propellers (2% of accidents). The death toll from boating accidents ranks second among deaths in all modes of transportation. Open motorboats are involved in half of the fatalities recorded. Propeller injuries have an overall fatality rate of 15% to 17%, and a similar rate of major amputations. Experience with nine propeller injuries treated from 1990 to 1996 is presented. The mechanism of production, some technical aspects of propellers, as well as literature on the subject are reviewed. Three patients are described, demonstrating the severity of these injuries, their sequelae, and the challenges they represent.

Failure of a gastrocnemius muscle flap due to an isolated high-grade stenosis of the sural artery.

The gastrocnemius muscle is highly reliable for flap coverage of defects of the knee or upper third of the leg. Pathology or injury to its dominant arterial pedicle is rare, so preoperative testing is usually not required when distal pulses are present. In this case, an unsuspected high-grade stenosis of the origin of the sural artery was the cause of failure of the flap and made it necessary to use a free flap for salvage. This case raises questions as to the need for preoperative or intraoperative assessment of patency and/or perfusion pressure of the flap vascular supply.

Surgical treatment of solid facial edema: when everything else fails.

A case of persistent solid facial edema is presented to illustrate and discuss this rare, poorly understood condition. It is most frequently a sequela of acne vulgaris, but it can also be caused by other congenital, infectious, and inflammatory processes. This entity is notoriously difficult to treat. Many therapeutic modalities have been tried. Early treatments with isotretinoin, clofazimine, and ketotifen have been occasionally effective while no treatment has been proven successful in the later stages. This is probably the first time that surgical treatment of this problem has been reported. This experience and a review of the literature may prove helpful to other practitioners in our specialty.

The factitious wound: plastic surgeon beware.

Plastic surgeons are frequently consulted for the management of chronic problem wounds, usually after other physicians' efforts have failed. This makes them vulnerable to those patients who feign, produce, or perpetuate their wounds because of underlying psychopathology or attempts at secondary gain. Three cases of factitious wounds, all seen in a plastic surgery practice, are presented. These cases are analyzed in the context of the literature published on this subject. They exemplify this condition and clearly demonstrate the common features of this type of patient. Despite the relevance of this problem and its economic, social, and possible legal implications, very little is published about it in the surgical literature.

Treatment of chronic recurrent synovial fistulae with myofascial flaps.

Chronic recurrent synovial fistulae of the knee are uncommon. They can occur as a surgical complication or as a consequence of traumatic injuries. Conservative treatment is usually adequate for initial management, but no consensus exists about the treatment for chronic or recurrent cases and the literature on the subject is scarce. Two cases are presented in which initial conservative and subsequent conventional surgical management failed and reconstruction with regional myofascial flaps was required.

An easy-to-make, easy-to-use device for preoperative marking for reduction mammoplasty and mastopexy.

A simple, convenient, and inexpensive device for preoperative marking in breast surgery is described. Its design is based on accepted surgical techniques and geometrical principles and obviates the use of multiple instruments commonly used. Its use allows accurate and expeditious planning, measuring, and marking.

The desmoid tumor: "benign" neoplasm, not a benign disease.

The desmoid tumor is a rare neoplasm which, because of its histopathologic appearance, has been traditionally considered to be benign. Despite its benign microscopic features, it has an aggressive local behavior and, if not excised adequately, has a tendency to recur locally and invade neighboring structures with significant potential for morbidity, deformity, or even death. Two cases of recurrent extraabdominal desmoid tumors are presented not only because they are highly representative of this disease, but also because they emphasize the need for aggressive surgical treatment. Also, they are unusual and challenging cases from a reconstructive standpoint. Based on this experience and on the most recent literature, we believe that this tumor, regardless of its microscopic features, should be addressed and treated as a malignancy.

The scrotal myocutaneous flap.

The scrotum is a thermoregulatory, well-vascularized structure formed by skin and nonstriated muscle with unique elastic properties. This makes it an ideal source of tissue coverage for problem wounds in its vicinity. Two patients in which scrotal musculocutaneous flaps were used are reported: one, a paraplegic, with a recurrent ischioperineal decubitus ulcer, and another with an ulcer of the penis with exposed Dacron graft previously placed to treat Peyronie's disease. After reviewing the anatomy of the scrotum and the existent literature, we studied scrotal vascularity in a fresh specimen by transillumination. Based on our experience, we conclude that this flap is easy to perform, reliable, and very useful for wounds around the perineal region.

Reconstruction of the left innominate vein in a patient with invasive thymoma undergoing coronary artery bypass surgery.

This is a report of a case in which a patient undergoing coronary artery bypass surgery was found to have a thymoma invading the left innominate vein without obstructing it. The tumor was removed, the left innominate vein reconstructed with ringed PTFE graft and the coronary revascularization performed successfully. The surgical treatment adopted the considerations involving this particular patient and the literature of similar cases is reviewed and briefly discussed.

The Dacron EXS graft: patency in femoropopliteal and femorotibial surgery.

Choice of the most suitable synthetic graft for use in peripheral vascular surgery in the lower extremity is controversial. The knitted Dacron Velour Externally Supported (EXS) graft is a recently developed vascular prosthesis which promises to be effective and durable for use in femoropopliteal and femorotibial bypass surgery. Between 11/80 and 7/83, 56 grafts were implanted in 49 patients. Eight patients were lost to follow-up, leaving 46 grafts for which patency data was determined. The distribution of sites of distal anastomosis was as follows: 25% were to the popliteal artery above the knee, 50% were to the popliteal artery below the knee, and 25% were to the tibial or peroneal arteries. Graft occlusion was determined by loss of Doppler pulses, return of ischemic symptoms, or failure to visualize flow in angiograms. Overall cumulative patency rates, calculated by the life table method, were as follows: 81% at 6 months; 76% at 1 year; 68% at 2 and 2 and 1/2 years. There was no statistical difference in patency between above-knee and below-knee popliteal artery bypasses. Moreover, patency rates were similar for diabetics vs. non-diabetics, for patients operated on for claudication vs. limb salvage; and for patients who had sympathectomy vs. no sympathectomy. Patency rates for bypass to the tibial and peroneal vessels in this series were better than recently reported in the literature for other synthetic prostheses; i.e. 75% at 4 months and 1 year; 56% at 2 and 2 and 1/2 years.(ABSTRACT TRUNCATED AT 250 WORDS)

Pressure ulcer of the breast after subcutaneous mastectomy and reconstruction with prosthesis.

A 28-year-old woman underwent bilateral subcutaneous mastectomy and immediate reconstruction with silicone gel-filled prostheses. Three months after surgery, she developed an acute pressure sore on one side, owing to prolonged pressure of the insensitive breast against a hard surface. This complication is presented, the literature on the subject is reviewed, and brief considerations and recommendations are made.

Migration of silicone gel to axillary lymph nodes after prosthetic mammoplasty.

Foreign-body reaction to material optically resembling silicone gel was evident in an axillary lymph node of a patient eight years after subcutaneous mastectomy for fibrocystic disease and breast reconstruction with a silicone gel-filled prosthesis. The lymph nodes. was removed as a component of a radical mastectomy for adenocarcinoma and Paget's disease of the nipple that had developed in the residual breast tissue and preserved nipple. Silicone gel may "bleed" through a structurally intact prosthetic envelope and subsequently migrate to regional lymph nodes

Distally based sartorius muscle flap in the treatment of infected femoral arterial prostheses.

Although less frequent, arterial prosthetic infections are still a disaster for patient and surgeon since they can lead to multiple complications. The inguinal area is the site of more than three-quarters of the graft infections because of anatomical and technical factors. Of all the proposed forms of treatment none has proven to be totally effective and applicable to all cases. We have employed a technique in which the infected portion of the graft is removed, replaced by a new graft and covered with a distally based sartorius muscle flap. Two illustrative cases are presented in which the procedure proved to be successful for two and for eleven years, and the question is raised as to the benefits of this maneuver in the prevention of infection in those cases that require re-operation.