Showing papers in "Annals of Plastic Surgery in 1996"

The seven deadly sins of statistical analysis.

Abstract: In a pedantic but playful way, we discuss some common errors in the use of 'statistical analysis' that are regularly observed in our professional plastic surgical literature. The seven errors we discuss are (1) the use of parametric analysis of ordinal data; (2) the inappropriate use of parametric analysis in general; (3) the failure to consider the possibility of committing type II statistical error; (4) the use of unmodified t-tests for multiple comparisons; (5) the failure to employ analysis of covariance, multivariate regression, nonlinear regression, and logistical regression when indicated; (6) the habit of reporting standard error instead of standard deviation; and (7) the underuse or overuse of statistical consultation. Confidence and common sense are advocated as a means to balance statistical significance with clinical importance.

Microsurgical reconstruction of the head and neck: interdisciplinary collaboration between head and neck surgeons and plastic surgeons in 305 cases.

Abstract: Three hundred five microsurgical free flaps have been performed for defects of the head and neck by a team of two head and neck surgeons and two plastic surgeons over a 9-year period, with a success rate of 91.2%. The most common flaps used were the jejunum (89), radial forearm (57), rectus abdominis (48), latissimus dorsi (40), scapular (32), fibula (15), and iliac crest (11). Thirty-three flaps required reexploration for anastomotic thrombosis or hematoma (10.8%), of which 18 flaps were salvaged (54.5%). Thirteen flap failures occurred in 113 patients who had received preoperative irradiation (11.5%), but this was not statistically significant. Seven flaps failed in 20 patients who required an interposition vein graft (35%) and this was statistically significant. Ninety patients (31.5%) developed a major complication other than anastomotic thrombosis or death. Despite postoperative intensive care nursing and monitoring, 18 patients died postoperatively in the hospital (6.3%). The average hospital stay was 21.1 days with a range from 5 to 95 days. During this 9-year time period, various free flaps have evolved as the preferred choice for free flap reconstruction of a specific defect of the head and neck. The latissimus dorsal muscle flap surfaced with a nonmeshed split-thickness skin graft is the optimal free flap for reconstruction of the scalp and skull, whereas a multiple-paddle latissimus dorsi musculocutaneous flap is the best flap for reconstruction of complex defects of the middle third of the face and maxilla. The radial forearm flap and free jejunal transfer have become the preferred choices for intraoral reconstruction and pharyngo-esophageal reconstruction, respectively. There still remains no universally accepted flap for mandibular reconstruction, but the fibular osteocutaneous flap and a reconstruction plate protected by a radial forearm flap have largely superseded the iliac crest and scapular osteocutaneous flaps. Radical resection of tumors of the head and neck with immediate reconstruction by microsurgical free tissue transfer followed by adjuvant radiation therapy provides the best possible chance for cure and functional and social rehabilitation of the patient.

Effect of vascular endothelial growth factor (VEGF) on survival of random extension of axial pattern skin flaps in the rat.

Abstract: Current evidence suggests that neovascularization is mediated by a wide range of angiogenic growth factors. Vascular endothelial growth factor (VEGF) appears to be one of the most important angiogenic factors in vivo. The aim of this project was to evaluate the efficacy of VEGF in augmentation of bl

Treatment of earlobe keloids with surgery plus adjuvant intralesional verapamil and pressure earrings.

Abstract: Treatment for keloids remains less than ideal. Previous discouraging results prompted a change in the author's standard treatment for keloids to surgery plus adjuvant intralesional verapamil and pressure earrings. Intralesional verapamil (2.5 mg per milliliter) was administered 7 to 14 days after keloid removal and again approximately 1 month after removal when possible. Between 0.5 ml and 2.0 ml was administered each time, depending on the size of the keloid. Patients were instructed to wear pressure earrings essentially continuously for a minimum of 6 months after excision. Thirty-five African American patients with 45 earlobe keloids were treated with this regimen. Information regarding recurrence was obtained by follow-up, mail, or phone call from 31 patients (89%) with 40 keloids (89%). Minimum follow-up for inclusion was 6 months and average follow-up was 28 months. Twenty-two keloids (55%) in 16 patients (52%) were cured by this treatment modality. There were no significant differences in recurrence rates related to sex, age, keloid size, length of time the keloid was present, how long the ears had been pierced, and how many verapamil injections were received. There was a trend toward an increased recurrence rate for previously treated keloids. Though not optimal, this regimen is superior to some previously evaluated regimens.

Evaluations of aesthetic results in breast reconstruction: an analysis of reliability.

Abstract: This study evaluated the reliability of three commonly used measures of aesthetic outcomes of breast surgery: a four-point ordinal scale of overall aesthetics, five four-point subscales, and a visual analogue scale. Fifty patients were randomly selected from women who underwent breast reconstruction surgery at University of Michigan hospitals between July 1989 and May 1993. Postoperative photographs of these patients were provided to three plastic surgeons, who were asked to rate the photographs using the three methods. The same process was repeated 4 weeks later. Intrarater and interrater reliability ranged from poor to good for the three methods, with the subscales showing the highest reliability. The lowest reliability occurred for those scales with the least-explicit rating criteria. Without explicit criteria, raters must develop and use their own criteria, which are likely to differ for each rater. Separating the various components of the aesthetic results of breast surgery into different subscales helps make the rating criteria more explicit. Scales with demonstrated reliability are critical for ensuring comparability of results across studies.

Anatomical parameters for nipple position and areolar diameter in males.

Abstract: In this paper we present anatomic parameters for nipple position and areolar diameter in males. Larger forms of gynecomastia with significant ptosis pose a challenge to the plastic surgeon with respect to relocation of the nipples on the chest wall. Selection of the appropriate areolar size is also of concern in gynecomastia correction. There is a paucity of information in the current literature pertaining to this problem. In order to establish guidelines for the placement of the nipple in gynecomastia correction and for the selection of the appropriate areolar size, we set out to determine these anatomic parameters. We believe use of these parameters will enhance the aesthetic results of gynecomastia correction. One hundred males between the ages of 17 to 30 years were chosen for this study. The males selected were of ideal body weight and without evidence of gynecomastia. The distances from the sternal notch to the nipple, the midclavicular line to the nipple, and the nipple-to-nipple distance were recorded. The areolar diameter was also measured in each subject. The average distances were determined for each category. The validity of these values was confirmed with statistical analysis. Equations were then derived, using this analysis, to determine nipple position in males. We have determined the nipple position in males to be approximately 20 cm from the sternal notch and 18 cm from the midclavicular line. The ideal nipple-to-nipple distance is 21 cm. The average areolar diameter is 2.8 cm.

Effectiveness of silicone sheets in the prevention of hypertrophic breast scars.

Abstract: A clinical study was designed in which 20 women who were to undergo bilateral McKissock reduction mammaplasties were requested to use a precut silicone elastomer sheet over the scars of one breast, starting at the time of suture removal. The patients were instructed to use the silicone sheet for 12 hours each day for 2 months. Evaluation of the scars at 2 months revealed that 60% of the nontreated scars were hypertrophic and only 25% of the treated scars were hypertrophic. The difference was found to be statistically significant (p < 0.05). The use of the sheets was discontinued after 2 months and the beneficial effect remained at the 6-month evaluation.

Neovaginoplasty in male transsexuals: review of surgical techniques and recommendations regarding eligibility.

Abstract: The surgical aim of genital reassignment surgery in male-to-female transsexuals is to create a perineogenital complex as feminine in appearance and function as possible. In this paper, we present a review of the various methods to line the neovagina in male-to-female transsexuals. These methods may be classified in five categories involving, respectively, application of nongenital skin grafts, penile skin grafts, penile skin flaps, nongenital skin flaps, and pedicled intestinal transplants. Based on this review and our extensive personal experience, we come to certain recommendations regarding the eligibility of these methods.

The latissimus dorsi perforator based fasciocutaneous flap

Abstract: The latissimus dorsi musculocutaneous flap has proven utility in the reconstruction of defects of the breast, chest wall, head and neck, and upper extremity. As a free flap, the latissimus dorsi has become a mainstay for the coverage of severe traumatic tibial/ fibular wounds. We describe a new and useful extension of the latissimus dorsi musculocutaneous unit that consists of a fasciocutaneous segment based on musculocutaneous perforators from the thoracodorsal artery. The vascular anatomy of the flap is described and illustrated with 6 fresh human cadaveric dissections. We also present 3 cases in which in vivo dissections of this flap were performed, 2 at the time of latissimus microvascular transfer and 1 approximately 5 days after microvascular transfer to salvage exposed fractured tibial bone successfully due to distal muscle loss. A pedicled or free latissimus dorsi musculocutaneous flap may be reliably extended and thereby rendered more versatile through the use of the perforator-based fasciocutaneous flap. Benefits and potential applications of the latissimus dorsi perforator-based fasciocutaneous flap are discussed.

Role of growth factors in scar contraction: an in vitro analysis

Abstract: Excessive scar contracture by wound fibroblasts can have devastating consequences, ranging from body disfigurement to joint immobility. The ability of fibroblasts isolated from lesions of hypertrophic scars, keloids, normal skin, or normal scars in contracting the provisional wound matrix (i.e., fibrin clot) was compared and analyzed. Hypertrophic scar fibroblasts showed a consistently higher basal level of fibrin matrix gel (FMG) contraction than other fibroblasts. This heightened basal level of contractility may be attributed partially to the autocrine effect of transforming growth factor-beta 1 (TGF-beta 1). Normal and keloid fibroblasts exhibited similar basal rates of FMG contraction, and both responded to platelet-derived growth factor (PDGF) and TGF-beta by increasing FMG contraction two- to threefold. However, 45% of the TGF-beta-induced increase in FMG contraction by keloid fibroblasts, but not normal fibroblasts, was mediated by the autocrine production of PDGF. Therefore, fibroblasts isolated from different scars exhibit varied degrees of FMG contraction. In addition, the mechanism underlying growth factor-mediated contraction differed vastly among fibroblasts of different scar origin. The significance of these differences in growth factor-mediated FMG contraction is discussed.

Sequelae in the abdominal wall after pedicled or free TRAM flap surgery.

Abstract: Twenty-seven free transverse rectus abdominis musculocutaneous (TRAM) and 16 pedicled TRAM flap breast reconstruction patients were studied for 7 to 41 months (mean, 23 months) postoperatively to compare abdominal sequelae after these two operations. The patient groups were demographically similar; mean age was 47 years in both groups. Subjective grading of the results was similar in both groups. The incidence of minor lower abdominal bulges was higher (44%, 7/16) in the pedicled group than in the free TRAM flap group (4%, 1/27). No hernias were found. Delayed healing of the abdominal scar occurred in 3 free TRAM flap and 1 pedicled TRAM flap patients. Two free TRAM flap (8%) and 7 pedicled TRAM (44%) flap patients had minor edge necrosis of the breast. Trunk strength was tested using an isokinetic device (Lido Multi Joint II), and peak torque for flexion (mean, 111 Nm +/- 25 Nm in the free TRAM flap group and 123 Nm +/- 28 Nm in the pedicled TRAM flap group) and extension (mean, 144 Nm +/- 38 Nm and 167 Nm +/- 45 Nm) were measured. No statistical differences occurred between these groups. Sit-up performance was tested and graded from 1 to 6. Both groups performed equally (4.8 and 4.8) and within normal values for this age group. Ultrasonography of the rectus muscles revealed that in the free TRAM flap group, the rectus muscle of the operated side was significantly thinner (cranial segment 6.8 mm vs. 7.8 mm, p < 0.05), thus the harvesting of a segment of muscle below the umbilicus seems to disturb the quality of the entire muscle. The mean size of the muscular defect in the free TRAM flap group was 4.3 x 6.1 cm. In this study no differences in patient satisfaction or trunk strength could be found between free and pedicled TRAM flap patients.

High-energy Gunshot Wounds to the Face

Abstract: Thirty-three patients with high-energy gunshot wounds to the face were treated at the University of Kentucky Chandler Medical Center between 1976 and 1993. Wounds were classified according to the mass and velocity of the projectile, and the range from weapon to target. More than half the injuries involved multiple facial regions. Twenty patients underwent immediate definitive reconstructive procedures. Intervals between injury and initial nondefinitive reconstruction for the other patients ranged from 1 day to 1 month. Toward the end of the study period, reconstruction was undertaken earlier and more aggressively, and included more attention to primary bone grafting and free tissue transfer. These patients developed fewer problems with infection, long-term scarring, and contracture, and they required fewer operative procedures. There was no operative mortality and none of the patients with self-inflicted injuries reattempted suicide. We conclude that early aggressive treatment of these wounds can produce better structural, functional, and rehabilitative results.

Free tissue transfer in pediatric patients.

Abstract: The majority of reports on free tissue transfer involve adults; few have specifically addressed children. During the past 5 years, 20 free tissue transfers were performed in 19 pediatric patients. Patients ranged in age from 3 to 17 years, with a mean age of 10 years. Eight patients were 6 years and younger; 11 patients were 13 to 17 years old. Soft-tissue defects requiring reconstruction resulted from acute trauma in 12 patients, tumor ablation in 5 patients, infection in 1 patient, and hemifacial atrophy in 1 patient. Soft-tissue defects occurred in the lower extremity in 16 patients, the head and neck in 2 patients, and the upper extremity in 1 patient. The donor tissues included the latissimus dorsi muscle in 7 patients, the radial forearm flap in 7 patients, the rectus abdominis muscle in 4 patients, and the scapular fasciocutaneous flap in 2 patients. All patients received aspirin preoperatively. Mean operative time was 6.5 hours, with a range of 4 to 8 hours. Postoperative heparin infusion was used for 5 days in 7 of the 8 patients age 6 years and younger. All free tissue transfers were successful. One flap to a traumatic foot wound (patient age, 4 years) had a venous thrombosis on the second postoperative day, and was successfully treated with urokinase and heparin infusions and repeat venous anastomosis. There were no other significant morbidities and no mortalities. Hospitalization following free tissue transfer averaged 13 days, with a range of 6 to 37 days. Follow-up has averaged 31 months, with a range of 8 to 59 months. Late complications included a progressive equinus deformity 3 years after a heel reconstruction following a lawn mower injury and a contour deformity following a scapula flap to a gunshot wound of the foot. Sixteen of the 17 lower extremity reconstructions have shown normal growth. No growth disturbances or significant functional losses have occurred at the donor sites. Most patients have maintained normal extremity function including participation in athletics. Special considerations in this group of patients have included subtherapeutic heparin infusion during the postoperative period in young children, minimizing the aesthetic defect at the donor site and providing composite reconstructions whenever possible.

Surgical treatment of hemangiomas of the nose

Abstract: The approach to a rapidly growing vascular tumor is determined by a number of objective and subjective factors. As a rule, treatment of a hemangioma in an infant is usually delayed, in the expectation that involution will be complete. While most hemangiomas are harmless vascular marks, some may grow to become large, infiltrating masses. Local factors that influence treatment decision making include volume, ulceration, secondary infection, and bleeding of the tumor. Hemangiomas situated on the nose are distinguished from other locations by a few but important aspects and may demand a more aggressive position from the surgeon. An important consideration is the potential for aplasia of the delicate nasal cartilages that are undergoing development, due to the mass effect of the tumor. Nasal tip hemangiomas are slow to regress, and contour deformities result from the fibrofatty tissue that invariably remains even after total involution. More importantly, hemangiomas of the nasal region are particularly prone to causing great social distress to the parents, who will request prompt treatment for such a visible, deforming lesion. A definite solution that ensures removal of affected tissue and preservation of anatomy seems to be the best treatment for these tumors. In this article, the experience of the senior author (IP) in treating hemangiomas located on the nose is reviewed. The elliptical midline incision over the nasal dorsum described in the text was developed to address three important aspects: an expedient procedure to treat a highly disfiguring disease; an open access to allow for complete resection and, at the same time, allow for the correction of underlying cartilaginous disruption; and placement of a scar in an anatomic location proven to be very satisfactory aesthetically, permitting access for secondary procedures for better definition of nasal contour. Careful patient selection for this surgical procedure is emphasized.

Upper airway obstruction after pharyngeal flap surgery.

Abstract: Upper airway obstruction after superiorly based pharyngeal flap procedures for the treatment of velopharyngeal insufficiency is described in this series of 32 flaps performed in 29 patients at our institution between 1979 and 1993. A high incidence of upper airway obstruction symptoms (38%) occurred in the early postoperative period but resolved in all but 2 patients within 5 months. None of the patients required flap revision or other procedures for relief of upper airway obstruction. Velopharyngeal insufficiency was improved or completely eliminated in 87% of patients. Significant residual velopharyngeal insufficiency in 13% of patients was treated successfully in all flap revision cases. Race, gender, age at closure, and associated craniofacial anomalies did not correlate with upper airway obstruction or with the efficacy of treatment for velopharyngeal insufficiency. However, patients with transient postoperative upper airway obstruction were only half as likely to suffer residual postoperative velopharyngeal insufficiency. The inverse relationship between velopharyngeal insufficiency and upper airway obstruction (p = .008) suggests that the surgeon may sometimes need to accept some transient upper airway obstruction to achieve correction of velopharyngeal insufficiency.

The ultrapulse carbon dioxide laser with computer pattern generator automatic scanner for facial cosmetic surgery and resurfacing.

Abstract: The ultrapulse carbon dioxide laser has been used in 110 patients for resurfacing and 50 patients for facelift, eyelid, and forehead surgery. Skin resurfacing is able to remove layers of skin of 100 microns without bleeding. Use of the computer pattern generator automatic scanning device allows a very rapid, uniform treatment in a variety of geometric patterns, sizes, and densities. Hemostatic incision is possible for cosmetic surgery. Sequence of the laserbrasion procedure as well as patient preparation, selection for surgery, and postoperative care are detailed. Laser lower blepharoplasty through the transconjunctival approach is commonly done concurrently with skin resurfacing to smooth out fine rhytides and extra skin.

Aggressive use of free flaps in children for burn scar contractures and other soft-tissue deficits.

Abstract: Free flap reconstruction in children is often undertaken with trepidation due to a variety of perceived technical difficulties and variable reports of success. The present report examines the efficacy of free tissue transfer in children, with particular attention given to the use of fasciocutaneous flaps in burn reconstruction. Over a 12-year period, 38 free flaps were done on 30 patients with an average age of 10 years (range, 16 months-17 years). Twenty-five flaps were done for burn deformities ; 6 were done for chronic back wounds ; 2 each were done for chronic lower extremity wounds, lower extremity traumatic defects, and a craniofacial deformity ; and 1 flap was done following the resection of a large thigh vascular malformation. The vast majority of the flaps (84%) were fasciocutaneous : 13 groin, 9 scapula, 5 radial forearm, and 4 others. The mean hospital stay was 10 days and there were 11 major complications (29%). Five of 6 flaps were salvaged by reoperation following vascular thrombosis. Six flaps were unsuccessful (84% total success). Three of these flaps were aborted intraoperatively due to technical difficulties, while 3 others were lost postoperatively due to cellulitis, thrombosis, and patient-inflicted flap removal. During follow-up (range, 1-103 months), 39% of patients underwent a minor secondary revision of the flap reconstruction. This series demonstrates the efficacy of free tissue transfer in children in providing the majority of these patients with a successful, one-stage reconstruction with morbidity similar to that reported for adult patients. Moreover, the use of fasciocutaneous free flaps for pediatric burn reconstruction is shown to provide a durable and aesthetically superior treatment of these difficult problems.

Noma : A review

Abstract: Cancrum oris or noma is a condition not well known in western Europe and North America. It is, however, a relatively common cause of mortality and disability in children of undeveloped areas of Africa, Asia, and South America. This paper describes the experience at Galmi Hospital, in the sub-Saharan region of South Africa in the Niger Republic, with 50 operative patients out of a group of 300 who were referred. An extensive review of the literature is presented describing the epidemiological impact of the disease, the characteristics of the lesions, the pathogenesis, symptoms, sequelae, differential diagnosis, and preoperative preparation. Additionally, we review approaches to anesthesia, methods of reconstruction, and the most common causes of complications and mortality. Numerous photographs illustrating the devastating consequences of this problem are presented.

Free medial thigh perforator-based flaps: new definition of the pedicle vessels and versatile application.

Abstract: The medial thigh flap is a perforator-based flap nourished with septocutaneous or muscle perforators originating from the femoral vessels. To date, 8 patients have been repaired with this flap and extended or connected flaps including this flap : 4 patients with lower leg defects and 4 patients with intraoral and neck defects. The advantages of this flap are (1) several pedicle perforators exist for this flap, which makes possible duplicated vascular anastomoses to establish reliable circulation of the transferred flap ; (2) the flap can be extended or connected to other neighboring flaps in the anterior thigh, so that extensively wide defects can be closed in one stage ; (3) the great saphenous vein can be simultaneously used as a vein graft or for venous drainage for the flap ; (4) the anterior branch of the femoral nerve can be used for sensory potential ; and (5) there is minimum morbidity of the donor defect and a large dominant vessel for the leg can be preserved. The suitable indications for this flap are defects after removal of skin cancer in the foot or lower leg and wide defects after resection of head and neck cancer, which can be reconstructed with the flap connected to neighboring skin flaps. The disadvantages of this flap are that it has a small, short vascular pedicle and the bulkiness of the flap's fatty tissue often requires thinning.

Anatomy, physiology, and functional restoration of the thumb

Abstract: The essential prehensile nature of the human hand rests on the presence of a mobile, sensate thumb with adequate stability and length. The true significance of the thumb-to-hand function is variable and dependent on a person's vocation, expectations, and needs. The frequently stated opinion that the thumb represents 40% of hand function is too exacting and does not allow for flexibility in evaluating a patient's requirements after thumb injury or loss. It is our approach to consider each patient's specific needs for individualized planning of thumb reconstruction. The patient can often offer useful information regarding need for strength vs. precision, width of hand vs. requirements for fine motor function, and concern for the aesthetic nature of an abnormal thumb vs. the variable deformities resultant from thumb reconstruction. We offer a review of the basic anatomy and physiology of the human thumb, with emphasis on hand-and-thumb function. We present the alternatives for thumb reconstruction, the advantages and disadvantages, and the relationships to a specific patient's needs. Clinical examples of various methods of thumb reconstruction, including metacarpal lengthening, phalangization, osteoplastic reconstruction, pollicization, and toe-to-hand transfer are provided.

Angiomatoid fibrous histiocytoma.

Abstract: This article reports a case of angiomatoid fibrous histiocytoma (AFH), a rare fibrous tissue tumor with unique clinical characteristics. Formerly, this tumor was classified as angiomatoid malignant fibrous histiocytoma. First described in 1979, AFH was felt to be a variant of malignant fibrous histiocytoma (MFH). One dominant characteristic that differentiates this tumor from the remainder of MFH subtypes is that it most often presents in individuals younger than 20 years of age. The usual MFH occurs in the seventh decade of life. Because of its rarity, AFH has been difficult to classify and, during this current year, has been designated as a separate entity, rather than a subtype of MFH. Clinically, the tumor presents as a soft-tissue mass in the subcutis or deep dermal layers of the body, often presenting on the extremities or neck. Local recurrence has been reported, but mortality figures are very favorable and wide local removal is sufficient treatment.

Obstetric brachial plexus injury in subsequent deliveries.

Abstract: It is well known that multiparas who had previously been delivered of newborns with obstetric brachial plexus palsy are at risk of having the same complication in subsequent deliveries. However, none of the studies in the literature have actually attempted to estimate how high is that risk. The aims of the current paper were to investigate obstetric brachial plexus injury in subsequent deliveries and to study other factors associated with birth palsy, perinatal morbidity, mortality, and motor recovery of the brachial plexus. We reviewed retrospectively the records of 28 consecutive multiparas who presented with their children to our brachial plexus clinic from 1994 to 1995. Eight of the 28 multiparas gave birth to one or more children after having a newborn with brachial plexus birth palsy. These 8 mothers were delivered of a total of 16 newborns with brachial plexus injury. Injury was associated with vaginal mode of delivery, gestational diabetes, instrumental deliveries, and fetal macrosomia. One neonatal death and significant perinatal morbidity were observed in the affected newborns. Seven newborns (44%) had total birth palsy and the remaining 9 had Erb's palsy. Excellent recovery of the limb occurred in only one-third of the patients. It was concluded that multiparas who had previously been delivered of large infants with brachial plexus injury are at high risk of having the same complication in subsequent deliveries and consideration may be given to delivery of subsequent macrosomic babies by cesarean section.

Reconstruction of a complex midfacial defect with the folded fibular free flap and osseointegrated implants.

Abstract: Refinements in microsurgical techniques, plate fixation, and osseointegration have changed the conceptual approach to midface reconstruction. Free tissue transfer has emerged as the ideal method of reconstructing complex midfacial defects. Single-stage bony restoration of the palate and orbital rim using the folded fibular osteocutaneous free flap is described. The fibular free flap is our first choice for reconstructing complex midfacial defects. The thin, soft, pliable tissue is ideal for intraoral and palatal reconstructions. The bone can be tailored precisely to fit any desired shape, and forms a sturdy support for both orbital and dental prostheses. With a single flap, rapid and reliable restoration of midfacial appearance, orbital support, and palatal function can be achieved.

A new repair technique for penile paraffinoma: bilateral scrotal flaps.

Abstract: Although worldwide incidence is not well known, foreign-body injection is often attempted in order to increase the circumference of the penile shaft. Paraffin, Vaseline, and other materials are injected into the penile skin by the patient himself or by untrained persons who practice medicine fraudulently. Complications usually follow, such as penile deformity, skin necrosis, limited erectile function, and the inability to have intercourse. Definitive treatment of these patients includes the complete removal of skin and subcutaneous tissue infiltrated by the foreign material. Sometimes, complete removal of the foreign material may not be possible and may leave permanent foreign-body granuloma on the corpus cavernosum and/or corpus spongiosum. The remaining foreign material does not permit skin-graft coverage, which is a simple and effective method of resurfacing. In such cases, we tried a new technique comprised of bilateral scrotal flaps to provide for reliable and stable coverage. The scrotal skin, which has high elasticity, seems to be a good material for penile coverage, despite its hairy nature. In our experience, exclusively with Korean males, the scrotal hair has a low density and does not seem to cause serious problems, but patients with hirsute scrotal may be contraindicated. Since 1993, 17 patients with penile paraffinoma have been treated using the bilateral scrotal flap method. All 34 flaps survived completely and the reconstructed penis had immediate postoperative tactile sensibility. The results were successful and without any major complications.

Evidence in support of collateral sprouting after sensory nerve resection.

Abstract: The extent and time course of sensory recovery has been investigated in 13 patients who had resection of a cutaneous nerve. Seven patients were studied within 8 weeks of denervation; 6 others were studied more than 6 months after denervation. Touch sensation was evaluated using a computer-assisted m

The management of pigmented lesions of the nail bed.

Abstract: Pigmented lesions of the nail bed, especially without a history of trauma, represent a diagnostic challenge to the clinician. These lesions are often categorized as melanonychia striata (MS), which refers to any linear tan-brown-black pigmentation of the nail bed. The differential diagnosis of MS includes subungual hematomas, onchomycosis nigricans, junctional nevi, melanoma in situ (MIS), and malignant melanoma (MM). Our algorithm at the New York University (NYU) Medical Center for the treatment of pigmented lesions of the nail bed is presented. A histopathologic diagnosis with any evidence of melanocytic atypia, however subtle, requires absolute confirmation by complete excision. The absence of a clear margin or recurrence requires total nail bed excision and reconstruction using a full-thickness graft. The diagnosis of MIS is similarly treated. The surgical management of subungual MM is discussed. All cases of MM of the hand treated at NYU were reviewed. In all, 30 patients were treated from 1982 to 1995. Follow-up ranged from 6 months to 13 years. In our series, there were 8 cutaneous and 22 subungual melanomas. There was a marked delay in treatment of both groups, with subungual melanomas more often erroneously treated as other pathology prior to correct diagnosis. The 5-year survival rate was 100% for patients with cutaneous lesions, but only 80% for those with the subungual variety. There was a statistical difference in the depths of the lesions (subungual, 3.68 mm ; cutaneous, 1.36 mm) with a pvalue of 0.008. The role of elective lymph node dissection in the absence of clinical metastases as well as intraoperative sentinel lymphatic mapping remains controversial and is discussed.

The surgically delayed unipedicled TRAM flap for breast reconstruction

Abstract: Surgical delay is one method of enhancing the vascularity of the lower abdominal transverse rectus abdominis musculocutaneous (TRAM) flap. The outcome of 7 patients who underwent surgical delay (by ligating both superficial and deep inferior epigastric vessels bilaterally) a week prior to definitive TRAM flap elevation is described. Three patients were smokers, 3 were obese, and 1 was an asthmatic on medication. A satisfactory aesthetic result was achieved in all patients and the complications that occurred were minor. Two patients developed minor skin necrosis due to inadequate trimming of zone 4 on the contralateral side to the pedicle and there were 3 cases of fat necrosis, which occurred below Scarpa's fascia. Surgical delay is a useful technique of breast reconstruction. It allows the flap to be centered safely in the lower abdomen. In the high-risk patient, delay may prevent the need for microsurgery or the sacrifice of both recti.

Gluteus maximus musculocutaneous flap for the treatment of recalcitrant pilonidal disease.

Abstract: Although conservative surgery should be the initial approach to pilonidal disease, there remains a select group of patients with recalcitrant disease who fail repeated interventions and for whom a more aggressive approach is justified. Use of a large gluteus maximus musculocutaneous flap to facilitate wide excision, to allow for primary closure with well-vascularized tissue, and to alter the anatomy of the gluteal cleft has been used in 5 patients with chronic recurrent recalcitrant disease. The use of this large muscle unit in these otherwise healthy adults has achieved control over their pilonidal disease with acceptable morbidity and no demonstrable functional sequelae.

Bell flap nipple reconstruction--a new wrinkle.

Abstract: This single-stage nipple reconstruction technique is designed to produce a properly pigmented nipple-areolar complex that projects well above the breast mound without the need of skin grafts. The basic design of this technique consists of a bell-shaped random pattern flap within a circular subcutaneous island flap. The bell-shaped flap is incised, undermined, elevated, and folded into the shape of an inverted box, forming the new nipple. The remainder of the circular island flap is circumferentially incised, partially undermined, and sutured into a flat cone, forming the new areola. The nipple is inset in the center of this cone, completing the new nipple-areolar complex. This complex is then squeezed and pushed forward by the closure of a purse string suture placed on the raw edge of the outer skin circle. Predetermined pigments are tattooed immediately prior to the skin incisions and Montgomery's tubercles can be added after the pursestring closure by high-temperature cautery or biopsy punch. This technique has been attempted on six nipples in 5 patients for breast mounds reconstructed by musculocutaneous flaps or from breast reductions with satisfactory-to-good results in the past 2 1/2 years. However, at this time, it has not been, nor should it be attempted on breast mounds reconstructed solely by implants, due to unpredictable subcutaneous blood supply.

Sensate Pedicled Neoclitoroplasty for Male Transsexuals: Amsterdam Experience in the First 60 Patients

Abstract: The results of vaginoplasty by inversion of penile and scrotal skin in male-to-female transsexuals, in general, are satisfying. Cosmetic and functional considerations dictate the construction of a neoclitoris ventral to the urethral orifice. Embryologically, the glans penis and clitoris are homologues and mutual substitution seems to be the logical approach. In this paper, the long-term results in the first 60 patients using the pedicled sensate neoclitoroplasty according to Brown are presented and discussed. It has proven to be a safe technique that leads to satisfying cosmetic and functional results in nearly all patients. It should be considered state of the art in primary gender-confirming surgery for male-to-female transsexuals.