Sarcoidosis presenting as a solitary parotid mass.

We describe an unusual case of sarcoidosis in which the patient presented with a discrete solitary parotid mass and no other manifestation of the disease. The diagnosis was based on the unexpected pathologic findings during examination of a superficial parotidectomy specimen. To the best of our knowledge, no such presentation has been previously reported in the English-language literature.

Modified separation of parts as an intervention for intraabdominal hypertension and the abdominal compartment syndrome in a swine model.

Standard therapy for abdominal compartment syndrome is laparotomy. In many patients, laparotomy involves a recent incision; for others, volume of resuscitation may be the cause. The components separation technique allows difficult abdominal closure. The authors studied the effect of a modified separation of parts on abdominal compartment syndrome in an animal model. Eight pigs were instrumented for measurement of central venous pressure, mean arterial pressure, peak airway pressure, and intraabdominal pressure. Intraabdominal hypertension to 25 mmHg was established with intraperitoneal fluid infusion. Modified separation of parts was performed by sequential release of the abdominal wall layers. With increased intraabdominal pressure, mean arterial pressure (55.3 +/- 12.0 to 65.3 +/- 11.0), central venous pressure (7.7 +/- 2.4 to 13.3 +/- 6.9), and peak airway pressure (20.2 +/- 2.4 to 25.3 +/- 4.1; p < 0.05) also increased. Maximum intraabdominal pressure was 26.0 +/- 1.2 mmHg. Skin incision resulted in a decrease in intraabdominal pressure to 21.7 +/- 4.5, external oblique release to 18.3 +/- 3.9, internal oblique release to 13.2 +/- 4.0, and transversus muscle incision to 7.0 +/- 2.5 mmHg (p < 0.05). With completion of components separation, mean arterial pressure remained increased (63.2 +/- 16.9), central venous pressure decreased (6.8 +/- 3.6; p < 0.05), and peak airway pressure decreased (22.7 +/- 3.9; p < 0.05). Modified separation of parts technique effectively releases intraabdominal hypertension and reverses the physiologic derangements associated with abdominal compartment syndrome in the animal model.

Reconstruction of difficult wounds with tissue-expanded free flaps.

Tissue expansion of free flaps before transfer have been used to increase the size of the transferred tissue and to allow primary closure of the donor site. This is especially important in burns when there is a lack of healthy tissue, and in children when there is a relative lack of tissue. In this study the authors present their 17-year experience with tissue-expanded free flaps. Between 1985 and 2002, 14 cases of tissue expansion of free flaps before transfer were performed at the authors' institution. The indications for vascularized tissue were 9 facial defects (8 severe burns and 1 neurofibromatosis), 3 large lumbosacral ulcers resulting from spina bifida, 1 large vulvoperineal defect resulting from resection for Chron disease, and 1 large circumferential tissue defect at the lower extremity resulting from tumor extirpation. The flaps were 6 radial forearm, 4 parascapular, and 4 lateral arm free flaps. Tissue expanders were placed under the subcutaneous plane between the deep fascia and the muscle layer, preserving the pedicle architecture and integrity. The size of the tissue expander ranged from 250 to 700 mL and expansions were done either weekly or biweekly for a 10- to 20-week period. The patients were followed for 1 to 17 years. The outcome of the study was based on donor and recipient site morbidity, rate of complications, patient satisfaction, and long-term outcome of the donor and recipient sites. There was no failure in any of the transferred tissue at the recipient site and no tissue loss. Three patients had transient congestion of the free flaps, which resolved without any intervention. In all patients the donor area was closed primarily. One black patient had hypertrophic scar formation at the radial forearm donor site requiring reexpansion and primary closure. In other patients the scar was acceptable. One patient had an infection at the tissue expander site that was treated with removal of the implant and transfer of the free flap to the recipient defect the following day. In 4 patients with facial burns, posttransfer tissue expansion of the free flap at the recipient site was performed for minor revisions at later dates. All patients had good outcomes and were satisfied with the procedure. Preexpansion of free flaps is an effective but underused method. It is safe in terms of complications, results in a better appearing donor site scar, and allows transfer of larger amounts of tissue in patients with tissue deficiency.

Aberrant branch of the radial artery encountered during elevation of the radial forearm free flap.

Although the radial arterial system is fairly consistent in structure, rare anomalies have been encountered. During the elevation of a radial forearm free flap for floor of mouth reconstruction, the authors have encountered an accessory branch of the radial artery arising from the main radial artery at the level of the mid forearm, extending laterally over the brachioradialis muscle, and descending into the dorsal wrist in the subcutaneous plane. This artery, named as the superficial radial artery, is a very rare vascular anomaly of the radial arterial system in the forearm. The reconstructive surgery literature is relatively silent about this particular variant. Knowledge of possible anatomic anomalies and careful identification of vessels are important to prevent damage to the arterial system and enable optimal flap harvest.