Liposuction as an adjunct procedure in reduction mammaplasty.

Liposuction has been recognized as a useful adjunct to breast reduction surgery for fine contouring of adjacent areas to achieve aesthetic balance and preservation of nipple sensation. In particular, the liposuction technique has provided an acceptable way of treating the "fat roll" of the lateral portion of the breast, which extends to the axilla and lateral chest. The purpose of this study was to review the authors' approach to adjunctive lipoplasty with breast reduction surgery and to review their experience. Examination of their own results in 70 consecutive women who underwent reduction mammaplasty in 1998 by the senior surgeon did not reveal any substantial difference in the complication rate of those women who had adjunctive liposuction with their breast reduction surgery vs. those who did not. All complications such as fat necrosis, cellulitis, and seromas were confined to the breast and were not related to the liposuction. Furthermore, there was no additional morbidity associated with ultrasonic liposuction compared with traditional suction-assisted lipectomy. Their experience indicates that patients undergoing reduction mammaplasty may benefit aesthetically from adjunct lateral chest wall liposuction without additional morbidity.

Major leg wound complications after saphenous vein harvest for coronary revascularization.

BACKGROUND: Major leg wound complications after coronary artery bypass graft procedures are infrequent and few are reported in the literature. We present our experience in treating 23 patients with major leg wound complications after coronary revascularization procedures. METHODS: A retrospective review of 3,525 bypass procedures with saphenous vein grafts performed over a 10-year period was conducted. Ten potential risk factors for those who developed major leg wound complications were analyzed and compared with the entire cohort of patients undergoing similar bypass procedures during the same period. RESULTS: Lower extremity wound complications occurred in 145 patients (4.1%), 23 of whom (0.65%) required additional surgical interventions (62 total). There were 32 wound debridements, 8 skin grafts, 11 vascular procedures, 5 amputations, 3 fasciotomies, 2 free tissue transfers, and 1 fasciocutaneous flap. Of ten variables evaluated by multivariate analysis, female gender, peripheral vascular disease, and postoperative intraaortic balloon pump use were identified as significant independent predictors of major leg wound complications (p < 0.0001). CONCLUSIONS: The causes of major leg wound complications after saphenous vein harvest for coronary artery bypass graft procedures are multifactorial. To minimize these complications, we recommend vascular evaluations before saphenous vein harvest, attention to proper surgical technique, and careful harvest site selection.

Granular cell tumor in a child's finger.

Granular cell tumor is an uncommon tumor found in the hand. It is probably of Schwann cell origin and may be associated with a peripheral nerve. Although it is often described as a painless tumor of the oral cavity and skin, its presentation in the fingers or hand is often painful--a characteristic not well recognized.

An unusual presentation of constriction band syndrome.

Congenital constriction band syndrome is a rare entity with a wide spectrum of associated congenital anomalies. Review of the pathogenesis and an unusual case of constriction band syndrome in a newborn are presented. Surgical excision of the deformity and the band was performed within the first week of life. There were no vascular or neural structures within the excised tissue, and there were no other associated anomalies other than dextrocardia and an equinovarus deformity of the foot. The wound was closed primarily without the need for Z-plasties. This alternative method of treatment can be considered in such unusual locations of constriction band syndromes.

Intrathoracic application of the reverse latissimus dorsi muscle flap.

The use of the reverse latissimus dorsi muscle flap based on its paraspinous perforators for posterior trunk wound coverage has been described previously. However, few studies have reported its intrathoracic application. In this study the authors present their experience in treating 3 patients with various intrathoracic defects using the reverse latissimus dorsi muscle flap. There were 1 male and 2 female patients who ranged in age from 4 to 74 years (mean, 49 years). The etiology included an infected aortic graft, a bronchopleural fistula, and a recurrent congenital diaphragmatic hernia. Follow-up ranged from 2 to 24 months. Successful outcomes were achieved in all 3 patients, and there was no recurrence or wound complication identified. Their results demonstrate the versatility and reliability of the reverse latissimus dorsi muscle flap in treating low posterior intrathoracic defects.

Reconstructive surgery in children after meningococcal purpura fulminans.

BACKGROUND/PURPOSE: Purpura fulminans (PF) is a serious, often life-threatening disease. As more children are surviving their disease, surgeons are presented with increasing numbers of multiple and complicated wounds as sequelae of PF. The purpose of this paper is to review the management of nine cases of PF, and present the reconstruction method in treating bilateral exposed elbow and knee joints. METHODS: All cases of pediatric patients with PF and treated by the division of plastic and reconstructive surgery between 1986 and 1998 were reviewed. RESULTS: Seven children (78%) had meningococcal PF, and one (11%) had PF after Haemophilus influenza septicemia. PF developed in one (11%) but with no growth in either blood or cerebrospinal fluid cultures. Five children (56%) required amputation procedures. Two children (22%) required knee disarticulation. Two patients (22%) had free myocutaneous flap transfers for bone coverage. One (11%) had PF involving the face. CONCLUSIONS: Meningococcal PF is a rare, often life-threatening disease generally of childhood. More children are surviving their diseases but with devastating sequelae. Successful reconstructive treatment outcome of these children requires a multidisciplinary team approach involving multiple specialties. The goal is to preserve function, maintain maximal length, and salvage limbs when possible. Flexibility and innovation are necessary in treating these multiple and complicated wounds.

The use of tissue expanders in staged abdominal wall reconstruction.

Reconstruction of large abdominal wall defects not amenable to primary closure remains a challenging problem. Various reconstructive techniques have been described in the surgical literature each with its advantages and disadvantages. In this report the authors describe their experience in treating 11 patients with large abdominal wall defects utilizing prosthetic mesh in conjunction with tissue expanders. Between 1986 and 1997 there were 6 pediatric and 5 adult patients treated with this method. The etiology included three congenital omphaloceles, five cases of necrotizing fasciitis, and three gunshot wounds. All patients initially required insertion of prosthetic mesh to bridge their large abdominal wall defects. This was followed by staged abdominal wall reconstruction with tissue expanders and prosthetic mesh. None of the patients had mesh infection or extrusion, and none developed enteric fistula or recurrent hernia. The tissue expansion process was well tolerated by all patients. One patient had partial exposure of the tissue expander due to thinning of the expanded skin. Our results suggest that the use of tissue expanders provides reliable, well-vascularized soft-tissue coverage and minimizes potential mesh-related complications in abdominal wall reconstruction.

Surgical management of large breast tumors in the adolescent.

The management of adolescent females with giant cystosarcoma phylloides remains controversial. Since in this age group the overwhelming majority of these neoplasms are benign, aesthetic outcome is as important as adequate tumor resection. Traditional, treatment has been wide local excision, which may lead to substantial breast deformity. In addition, inadequate planning with improper incision placement may result in visible scarring and impair immediate or subsequent breast reconstruction. The treatment of four adolescent females with large breast masses using breast-sparing techniques is discussed.

Epithelialization of the lining of a breast implant capsule. Possible origins of squamous cell carcinoma associated with a breast implant capsule.

The authors described a case in which the capsule surrounding a breast implant was lined by benign squamous epithelium. A second case, in which a woman was found to have a squamous cell carcinoma in the capsule surrounding a breast implant, was also reported.

Compartment syndrome in children.

The development of compartment syndrome is a well-recognized clinical entity. The diagnosis and management of compartment syndrome in the adult population is well established. Because of the difficulty with cooperation in physical examination of children with pain, the early recognition of compartment syndrome in this group of patients can be more challenging. Furthermore, the potential inability to make a prompt and accurate diagnosis can lead to significant extremity morbidity and possibly mortality.

Viability of the rectus abdominis muscle following internal mammary artery ligation.

The purpose of this study was to determine if the rectus abdominis muscle in the dog model could be used as a transposition flap based on its proximal blood supply following ligation of the internal mammary artery. In 11 dogs, the left internal mammary artery and vein were ligated at the fifth intercostal space. Both the left and right rectus abdominis muscles were elevated from their respective beds, dividing the inferior epigastric and intercostal vascular pedicles. Each muscle was then wrapped in a thin silicone sheet and replaced. One week later the dogs were returned to surgery and the muscles inspected. The right rectus abdominis muscle was completely viable in all the dogs. In 10 of the 11 dogs, the left rectus abdominis muscle was completely viable. We conclude that a superiorly based rectus abdominis muscle in the dog can maintain its viability following ligation of its proximal blood supply at the fifth intercostal space.

Rhabdomyolysis and lower extremity compartment syndrome due to influenza B virus.

Rhabdomyolysis is an unusual complication following infection with influenza B virus. We recently managed a young boy who presented with severe rhabdomyolysis and bilateral lower extremity compartment syndrome due to infection with influenza B virus.

Squamous carcinoma metastatic to the sternum.

A 63-year-old man had a 10 x 16-cm sternal mass 18 months after a second aortocoronary bypass operation. The resected lesion was a metastatic tumor of squamous histology. No primary tumor was found. The diagnostic work-up and treatment options are presented.

The inferior gluteal free flap in breast reconstruction.

The inferior gluteal musculocutaneous free flap usually provides a sufficient amount of autogenous tissue for breast reconstruction when adequate tissue is not present in the lower abdomen or back. Its arteriovenous pedicle is longer than the superior gluteal musculocutaneous free-flap pedicle and permits microvascular anastomosis in the axilla, avoiding medial rib and cartilage resection. In the thin patient, there is more available donor tissue than with the superior gluteal musculocutaneous free flap. Cadaver dissections confirm the greater pedicle length and the local area of the lower gluteus maximus muscle needed to carry the skin island and have helped define a safe approach to flap elevation. We have used four flaps for breast reconstruction without vascular compromise or the need for reexploration. The low donor-site scar in the inferior buttock fold has been acceptable, especially for a bilateral reconstruction. The anatomy of the gluteal region, the surgical technique for the inferior gluteal free-flap transfer, and a 3-year patient follow-up are presented.

Outer table skull erosion causing rupture of scalp expander.

Many various complications have been reported with tissue expansion since it was popularized by Radovan. As expected with any foreign body implantation, the most frequent complication is infection. Rupture of the expander is relatively rare even in the face of overexpansion or blunt external trauma. Complications from tissue expansion of the scalp are similar to those encountered with the placement of expanders elsewhere in the body. We had a case recently involving rupture of an expander placed in the scalp of an 18-month-old child as a result of erosion of the outer table with bone spur formation. This was a local reaction to the pressure exerted by the expander. We present the following case report to document another potential complication with tissue expansion of the scalp.

The VY tensor fasciae latae musculocutaneous flap.

When first introduced in 1978, the tensor fasciae latae flap was used both as a free-tissue transfer and as a local rotational flap. Its use as a free flap has diminished as other more appropriate flaps for free-tissue transfer have been described. The tensor fasciae latae flap has remained, however, an instrumental flap in the coverage of anterior and posterior soft-tissue defects around the hip region. The purpose of this paper is to present a new design of the tensor fasciae latae flap in the coverage of trochanteric pressure sores. By essentially creating a VY advancement flap into the trochanteric defect with the tensor fasciae latae, one can cover the trochanteric defect with the best-vascularized portion of the flap and avoid the dog-ear deformity.

Pathogenesis of myocarditis in Rocky Mountain spotted fever.

Because myocarditis has been noted frequently as present at necropsy in fatal Rocky Mountain spotted fever (RMSF) and ECG alterations may also accompany the disease, we studied the pathogenesis of myocarditis in RMSF. Increased heart weight in eight of nine cases and increased interstitial volume in six of nine cases suggest that myocardial edema is present. Specific immunofluorescent demonstration of Rickettsia rickettsii in myocardial capillaries, venules, and arterioles in eight of nine cases correlates well with the patchy distribution of interstitial mononuclear myocarditis and provides the pathogenic mechanism for vascular injury-induced myocardial edema. Absence of left ventricular dilation suggests that severe myocardial failure was not the apparent cause of hypotension, shock, and death in RMSF.