Outcome of scalp donor sites in 450 consecutive pediatric burn patients

The scalp is a useful and reliable donor site in pediatric burn patients that can be multiply harvested with minimal morbidity. Healing complications, however, may include alopecia and chronic folliculitis. To investigate scalp donor-site morbidity, a consecutive series of 2478 pediatric burn patients treated over a 10-year period were reviewed. A total of 450 of these patients had scalp donor sites for wound closure. Percent of total body surface area burned was 46+/-23 percent (mean+/-standard deviation), and the mean number of sequential scalp donor-site harvests was 2.2+/-2 (range, 1 to 10) with mean intervals between harvesting of 6+/-0.6 days. Ten patients (2.2 percent) had related complications. Eight patients developed scalp folliculitis, with Staphylococcus sp as the predominant organism (80 percent). Two patients were managed successfully with wound care alone; the other six patients required surgical debridement and split-thickness skin grafting to achieve wound healing. These eight patients developed varying degrees of alopecia. Two patients developed alopecia without previous folliculitis. Six patients required reconstructive surgery, which consisted of primary closure (3), staged excision (1), and tissue expansion (2). A number of variables were examined to determine any differences in the group that had complications compared with the group of patients that did not. No differences in age, sex, race, burn type, burn size, septic episodes, time to wound closure, or number of times the scalp was harvested were detected. Healed second-degree burns to the scalp that were subsequently taken as donor sites seemed to be a risk factor (p < 0.05) for folliculitis and alopecia. Our study confirms that scalp donor sites are reliable with low morbidity. Complications include alopecia and chronic folliculitis that can be avoided by meticulous technique and avoidance of previously burned areas.     

Teleconsultation with the mobile camera-phone in digital soft-tissue injury: a feasibility study

The purpose of this study was to examine the feasibility of teleconsultation using a mobile camera-phone to evaluate the severity of digital soft-tissue injury and to triage the injury with regard to management recommendations. With a built-in 110,000-pixel digital camera, pictures of the injured digit(s) or radiograph were taken by surgical residents in the emergency room and transmitted to another camera-phone to be viewed by the remote consultant surgeon. A brief medical and trauma history of each patient was relayed also by mobile phone. The consultant surgeon then reviewed all of these patients in the emergency room shortly after the initial telemedicine referral. Separate triaging for each digital injury into three groups was recorded during remote teleconsultation and according to actual treatment by the attending surgeon as follows: group I, the injury could be managed with conservative treatment, such as secondary intention wound healing, or primary closure with or without bone shortening; group II, skin grafting or local flap coverage was required for management of the injury; and group III, microsurgery such as replantation or free flap coverage was necessary to deal with the injury. Later, triaging was also performed individually by three junior plastic residents according to image review and patient referral information. Teleconsultation through a mobile camera-phone was performed for 45 patients with injuries of 81 digits from January to May of 2003. Of these 81 digital injuries, there were 12 cases (15 percent) where disagreement of triaging occurred between the teleconsultation and the actual treatment by the attending surgeon. In image reviewing, there was 79 percent sensitivity and 71 percent specificity in remote diagnosis of the skin defect and 76 percent sensitivity and 75 percent specificity in remote identification of the bone exposure regarding the concordance of opinions of all three surgeons; there was significant discordance in triaging in 20 cases (25 percent), and the difference in triaging was partly attributed to the inability to show instances of tiny exposed digital bone or tendon in some cases under the low-resolution digital image and the situation of a bloody oozing wound. In some cases, the difficulty in evaluating the probability of primary closure of severely avulsed skin edges or the probability of executing replantation for finger amputation also contributed to different triaging outcomes. Two neglected diagnoses of transected digital nerves were found and influenced triaging, highlighting the importance of on-site physical examination during teleconsultation. The telemedicine system using a mobile camera-phone based on the global system for mobile communication is feasible and valuable for early diagnosis and triaging of digital soft-tissue injury in emergency cases, with on-line verbal communication and review of the transmitted captured image. This system has the advantages of ease of use, low cost, high portability, and mobility. With advances in hardware for digital imaging and transmission technology and the development of the third-generation advanced mobile phone system in the foreseeable future, this system has potential for future applications in telemedicine and telecare.     

The effects of depowered airbags on skin injuries in frontal automobile crashes

The purpose of this study was to determine the effects of depowered frontal airbags on the incidence of skin injuries. The National Automotive Sampling System database files from 1993 to 2000 were examined in a study including 2,246,524 occupants exposed to airbag deployment in the United States. There was no significant difference between full-powered and depowered airbags, with 60.2 percent of those exposed to a full-powered deployment sustaining a skin injury versus 59.5 percent of occupants exposed to a depowered airbag (p = 0.19). Whether occupants were exposed to a full-powered airbag (1,936,485 occupants) or a depowered airbay (310,039 occupants), the majority of skin injuries were to the upper extremity and the face. Regardless of airbag power, the overwhelming majority of the skin injuries were minor (99.8 percent). There was not a significantly greater risk of injury from any source for occupants exposed to a depowered airbag or a full-powered airbag (p = 0.87). The data suggest that the implementation of depowered airbags did not affect the number, seriousness, location, or source of skin injuries.     

Bicycle spoke injuries in the lower extremity

This study reports the authors' 5-year experience with treating lower extremity injuries in bicycle passengers caused by the spokes. This patient group was selected from 716 lower extremity injuries that received treatment at our outpatient plastic surgery clinic. A total of 26 patients were treated during the study. Patients ranged from 2 to 19 years old, with a mean age of 5.6 years. The authors treated more female passengers (62 percent) than male passengers. The right foot (52 percent) was involved more often than was the left. Most patients were injured in the afternoon, from 2 to 7 PM (62 percent), and between May and October (77 percent). The rear wheel (89 percent) injured the majority of patients. The Achilles tendon was the most common site of injury (63 percent). The typical types of wounds observed included the following: type I, laceration with partial avulsion of skin and subcutaneous tissue (41 percent) and laceration forming a distally based flap (33 percent); type II, abrasions with ecchymoses and friction burn from the shearing effect of the spokes creating a partial- to full-thickness skin defect (26 percent). Of the type I injuries, full-thickness skin lacerations (33 percent) were closed primarily. Partial-thickness skin lacerations, abrasions, ecchymoses, and skin defects (67 percent) were treated conservatively with wound irrigation and dressing. The wound healing time for type I injuries was 29 days; for type II injuries, it was 27 days. These healing times were prolonged compared with healing by first intention. No significant difference was found in healing time when comparing both types of injury. Four patients required hospitalization. No patient required skin grafting. No fractures were noted because these patients were selected from the outpatient plastic surgery clinic and did not include patients from the emergency room. Since the first report of bicycle spoke injuries a half-century ago, prevention has not improved.     

The role of intrinsic muscle flaps of the foot for bone coverage in foot and ankle defects in diabetic and nondiabetic patients

Local muscle flaps, pioneered by Ger in the late 1960s, were extensively used for foot and ankle reconstruction until the late 1970s when, with the evolution of microsurgery, microsurgical free flaps became the reconstructive method of choice. To assess whether the current underuse of local muscle flaps in foot and ankle surgery is justified, the authors identified from the Georgetown Limb Salvage Registry all patients who underwent foot and ankle reconstruction with local muscle flaps and microsurgical free flaps from 1990 through 1998. By protocol, flap coverage was the reconstructive choice for defects with exposed tendons, joints, or bone. Local muscle flaps were selected over free flaps if the defect was small (3 x 6 cm or less) and within reach of the local muscle flap. During the same time frame, the authors performed 45 free flaps (96 percent success rate) in the same areas when the defects were too large or out of reach of local muscle flaps. Thirty-two consecutive patients underwent local muscle flap reconstruction for 19 diabetic wounds and 13 traumatic wounds. All wounds, after debridement, had exposed bone at their base, with osteomyelitis being present in 52 percent of the diabetic wounds and in 70 percent of the nondiabetic wounds. Wounds were located in the hindfoot (47 percent), midfoot (44 percent), and ankle (9 percent). Vascular disease was more prevalent in the diabetic group, in which 42 percent of the affected limbs required revascularization procedures before reconstruction (versus 7 percent in the nondiabetic group). Subsequently, 83 total operations were required to heal the wounds, of which 46 percent were limited to debridement only. Thirty-four pedicled muscle flaps were used: 19 abductor digiti minimi (56 percent), nine abductor hallucis (26 percent), three extensor digitorum brevis (9 percent), two flexor digitorum brevis (6 percent), and one flexor digiti minimi (3 percent). An additional skin graft for complete coverage was required in 18 patients (53 percent). One patient died and one flap developed distal necrosis, for a 96 percent success rate. The complication rate was 26 percent and included patient death, dehiscence, and partial flap or split-thickness skin graft loss. Twenty-nine of the 32 wounds healed. One patient died in the postoperative period; in two others the wounds failed to heal and required below-knee amputations, for an overall limb salvage rate of 91 percent. Diabetes did not significantly affect healing and limb salvage rates. Diabetes, however, did affect healing times (twofold increase), length of stay (2.7 times as long), and long-term survival (63 percent survival in diabetic patients versus 100 percent in the trauma group). Local muscle flaps provide a simpler, less expensive, and successful alternative to microsurgical free flaps for foot and ankle defects that have exposed bone (with or without osteomyelitis), tendon, or joint at their base. Diabetes does not appear to adversely affect the effectiveness of these flaps. Local muscle flaps should remain on the forefront of possible reconstructive options when treating small foot and ankle wounds that have exposed bone, tendon, or joint.     

Cranial reconstruction for metastatic breast cancer

All women with advanced breast cancer who are medically stable despite their disease are candidates for tumor extirpation and reconstruction. Advanced breast cancer today is incurable, and many prognostic factors can be used to try to predict a clinical course and response to therapy; however, no guidelines are available. Our case report most likely represents a metastasis to the calvarium with intracranial extension, reported to occur in about 3 percent of primary breast cancer patients. As demonstrated here, tumor ablation with immediate, one-stage reconstruction of large scalp defects is possible without the need for free tissue transfer or a delay in adjuvant therapy. Local tissue rearrangement has been employed for coverage of defects up to 50 percent of the cranium. The resulting donor defects can be closed with split-thickness skin grafts over pericranium. Serial tissue expansion and rearrangement can be used secondarily to replace skin grafts with hair-bearing scalp. Bony defects can be managed with either autogenous or alloplastic materials. Split-calvarial bone grafts can be harvested from the same operative field and cover small to medium-sized defects. Other sources of autogenous grafts include split ribs and iliac bone. Metals, calcium ceramics, and polymers such as methylmethacrylate can be used to cover intracranial contents and restore calvarial contour when defects are large or when autogenous material is not available. Palliation from tumor burden, prevention of pathologic fracture and oncologic emergencies, controlling pain, and enhancing quality of life are the goals of the oncologic and reconstructive surgeons in cases of advanced breast cancer. These goals are becoming even more important as new forms and combinations of chemotherapy, radiation, and gene therapy are extending the life expectancy of women with breast carcinoma.     

Patterns of maxillofacial injuries in powered watercraft collisions

Because of the widespread popularity of water sports, plastic and reconstructive surgeons can expect to manage an increasing number of injuries associated with these activities, particularly those related to powered watercraft vehicles. Although seat belts for motorists and helmets for motorcyclists may be efficacious, such devices currently do not serve a similar role in powered watercraft sports. In this study, a retrospective chart review of 194 consecutive patients who presented to the University of Miami/Jackson Memorial Hospital (Level I trauma center) as a result of powered watercraft collisions is presented. The purpose of this investigation was to assess the incidence, cause, demographics, and available management options for head and neck injuries secondary to powered watercraft. Identified were 194 patients who presented because of watersports-related injuries during the period January 1, 1991, through December 31, 1996. From this group, 81 patients (41.8 percent) sustained injuries directly attributable to powered watercraft collisions, including 41 personal watercraft collisions (50.6 percent), 39 boat collisions (48.1 percent), and 1 airboat collision (1.2 percent). The patient population, as expected, tended to be young and male with an average age of 29 years (range, 8 to 64 years old). Interestingly, 41 of the patients (50.6 percent) who presented to this trauma center as a result of powered watercraft collisions also sustained associated head and neck trauma. Of 74 injuries 24 were facial fractures (32.4 percent), 18 were facial lacerations (24.3 percent), 14 were closed head injuries (18.9 percent), 8 were skull fractures (10.8 percent), 4 were scalp lacerations (5.4 percent), 4 were C-spine fractures (5.4 percent), 1 was an ear laceration (1.4 percent), and 1 was a fatality (1.4 percent). Le Fort fractures were the most commonly identified facial fracture in this series. The number of these injuries seen in hospital emergency rooms will most likely increase in the future as the popularity of water-related recreational activities becomes even more widespread. Based on these findings, it is strongly recommended that future efforts be directed toward the prevention of these injuries through patient education and the eventual development of efficacious and safe protective equipment.     

Fine needle aspiration cytology of metastatic scalp nodules

OBJECTIVE: To analyze cases of palpable cutaneous/ subcutaneous scalp nodules and evaluate the clinical features and role of fine needle aspiration cytology (FNAC) in their diagnosis. STUDY DESIGN: A total of 1,022 cases of metastatic malignancies at various sites were analyzed over a period of two years. FNAC was performed as a routine outpatient procedure for palpable lesions and under ultrasound or computed tomographic guidance for nonpalpable, internal sites. Histologic correlation was done when possible. RESULTS: Eighteen cases were found to be metastatic scalp nodules. The scalp as a metastatic site constituted 1.76% of all metastatic sites, 7.72% of extranodal sites, and 15.3% of extranodal and extrahepatic sites. Of the 18 cases, 7 (38.9%) had primaries in the head and neck region (thyroid, 3; orbit, 1; tonsil, 1; tongue, 1; and parathyroid, 1). Cutaneous/subcutaneous metastasis was encountered in 58 patients, and the 18 cases of scalp metastasis constituted 31.03% of all cutaneous sites. CONCLUSION: Careful examination of the skin on the entire body, with particular attention to the scalp, should be done when a primary internal malignancy or recurrence is suspected. FNAC is a very helpful and cost-effective modality in determining the nature of such lesions.     

Isolation of dermatophytes,Candida species and systemic fungi from dermatologic specimens in Montréal, 1963 to 1973.

Of 10 057 specimens of scrapings from skin, nails and scalp examined for dermatophytes, yeasts, pityriasis versicolor and systemic mycoses between 1963 and 1973, 30.4 percent were positive for fungi. Skin produced the highest proportion (68.6 percent) of positive scrapings, scalp the lowest (4.2 percent). Trichophyton rubrum was the predominant species (23.6 percent); of lesser prevalence were Microsporum canis (9.3 percent), T. mentagrophytes (8.4 percent) and Epidermophyton floccosum (4.8 percent). Double infections were encountered on 102 occasions; T. rubrum and Candida parapsilosis were the most frequent cohabiting species. The introduction in 1966 of periodic acid-Schiff staining for routine examination of scrapings resulted in better diagnostic results, particularly in the case of culturally nonproductive specimens and cases of pityriasis versicolor. Blastomyces dermatitidis and Cryptococcus neoformans were isolated from two patients in the course of routine investigation for dermatophytes.     

Outcomes of brachial plexus reconstruction in 204 patients with devastating paralysis.

Thus far, devastating injuries of the adult brachial plexus have had a poor prognosis. This article presents the possible outcomes of aggressive microsurgical reconstruction in the largest series of patients in North America to date. It should change the pessimistic outlook that has surrounded these lesions. In this study, the outcomes of surgery were analyzed in relation to the type and level of injury, the age of the patient, and the denervation time; stronger donors for neurotization in relation to the various targets were delineated. The results were analyzed in 204 patients with adequate follow-up from a total of 263 patients who were operated on between 1978 and 1996. The mean age of the patients was 25.9 years, and the injuries were caused by high-velocity motor accidents involving avulsion in 55 percent of the patients. Nerve reconstruction included 577 nerve repairs (140 direct neurotizations and 437 cases of nerve grafting). Microneurolysis was performed in 89 cases. Vascularized nerve grafts were used in 120 repairs. Muscle transfers (29 pedicled and 78 free) were used to enhance function. The results were good or excellent in 75 percent of suprascapular nerve reconstructions, 40 percent of deltoid reconstructions, 48 percent of biceps reconstructions, 30 percent of triceps reconstructions, 35 percent of finger-flexion reconstructions, and 15 percent of finger-extension reconstructions. The majority of the patients had protective sensation and pain relief postoperatively.     

A rational approach to nasal reconstruction in leprosy

Destruction of the nasal septum and nasal bones by Mycobacterium leprae and subsequent infection is still seen regularly in leprosy endemic areas. The social stigma associated with this deformity is significant. Many different procedures have been developed to reconstruct the nose. Patients operated on at Anandaban Hospital and the Green Pastures Hospital and Rehabilitation Center between 1986 and 2001 were reviewed. There were 48 patients with an average age of 47 years. Five deformities were mild, 22 were moderate, 13 were severe, and eight were not graded. Bone grafting with nasolabial skin flaps was performed in 14 cases, bone grafting alone was performed in 10 cases, flaps alone were performed in seven cases, and cartilage grafting was performed in 10 cases. In three patients, a prosthesis was inserted, and in three patients a gull-wing forehead flap was performed. Overall, excellent or good cosmetic results were obtained in 83 percent of cases. Grafting with conchal cartilage was associated with the best cosmetic results and had minimal complications. Bone grafting with or without nasolabial flaps was associated with a 50 percent complication rate of infection or graft resorption. In mild to moderate deformities, cartilage grafting is recommended; for more severe deformities, bone grafting with bony fixation and skin flaps is recommended. Perioperative antibiotics must be used, and these procedures should be performed by an experienced surgeon. In very severe cases with skin deficiency, reconstruction with a forehead flap gives good results.     

One-stage reconstruction of composite bone and soft-tissue defects in traumatic lower extremities

Management of bone loss that occurs after severe trauma of open lower extremity fractures continues to challenge reconstructive surgeons. Sixty-one patients who had 62 traumatic open lower extremity fractures and combined bone and composite soft-tissue defects were treated with the following protocol: extensive debridement of necrotic tissues, eradication of infection, and vascularization of osteocutaneous tissue for one-stage bone and soft-tissue coverage reconstruction. The mechanism of injury included 49 motorcycle accidents (80.3 percent), five falls (8.2 percent), three crush injuries (4.9 percent), two pedestrian-automobile accidents (3.3 percent), and two motor vehicle accidents (3.3 percent). The bone defects were located in the tibia in 49 patients (79 percent; one patient had bilateral open tibial fractures), in the femur in seven patients (11.3 percent), in the calcaneus bone in four patients (6.5 percent), and in the metatarsal bones in two patients (3.2 percent). The size of soft-tissue defects ranged from 5 x 9 cm to 30 x 17 cm. The average length of the preoperative bony defect was 11.7 cm. The average duration from injury to one-stage reconstruction was 27.1 days, and the average number of previous extensive debridement procedures was 3.4. Fifty patients had vascularized fibula osteoseptocutaneous flaps, six had vascularized iliac osteocutaneous flaps, and five patients had seven combined vascularized rib transfers with serratus anterior muscle and/or latissimus dorsi muscle transfers. One patient received a second combined rib flap because the first combined rib flap failed. The rate of complete flap survival was 88.9 percent (56 of 63 flaps). Two combined vascularized rib transfers with serratus anterior muscle and latissimus dorsi muscle flaps were lost totally (3.2 percent) because of arterial thrombosis and deep infection, respectively. Partial skin flap losses were encountered in the five fibula osteoseptocutaneous flaps (7.9 percent). Postoperative infection for this one-stage reconstruction was 7.9 percent. Excluding the failed flap and the infected/amputated limb, the primary bony union rate after successful free vascularized bone grafting was 88.5 percent (54 of 61 transfers). The average primary union time was 6.9 months. The overall union rate was 96.7 percent (59 of 61 transfers). The average time to overall union was 8.5 months after surgery. Seven transferred vascularized bones had stress fractures, for a rate of 11.5 percent. Donor-site problems were noted in six fibular flaps, in two iliac flaps, and in one rib flap. The fibular donor-site problems were foot drop in one patient, superficial peroneal nerve palsy in one patient, contracture of the flexor hallucis longus muscle in two patients, and skin necrosis after split-thickness skin grafting in two patients. The iliac flap donor-site problems were temporary flank pain in one patient and lateral thigh numbness in the other. One rib flap transfer patient had pleural fibrosis. Transfer of the appropriate combination of vascularized bone and soft-tissue flap with a one-stage procedure provides complex lower extremity defects with successful functional results that are almost equal to the previously reported microsurgical staged procedures and conventional techniques.     

Tissue expansion in head and neck reconstruction

The present study reviews our clinical experience with tissue expansion in head and neck reconstruction. The clinical series consists of 33 expansions performed in 29 patients between 1983 and 1986. The results of tissue expansion in the head and neck were distinguished by a high complication rate, necessitating some revision in the original treatment plan in 48 percent of patients. Despite this high incidence of complications, sufficient tissue was generated to successfully complete the planned reconstruction in 79 percent of patients. Specific complications were observed with particularly high frequency within distinct anatomic sites. The highest incidence of complications occurred in the cheek and neck (69 percent) and forehead (50 percent) regions. Complications in the eyelid region (33 percent) and scalp (17 percent) were less common. Implant exposure was the most frequently observed complication. Other sequelae noted in this series included intractable pain, infection, and bone resorption.     

Single-stage approach to skin grafting the exposed skull

Four patients are presented who suffered full-thickness loss of the scalp, exposing the skull. Removal of the outer table, immediate application of a split-thickness skin graft, and treatment with the VAC for 3 to 4 days resulted in approximately 100 percent graft take in each case without complications. When compared with the usual two-stage approach to skin grafting the exposed skull, this method spares the patient a longer hospital stay and a second operative procedure, and it results in a significant cost savings.     

Subunit principles in midface fractures: the importance of sagittal buttresses, soft-tissue reductions, and sequencing treatment of segmental fractures

The patterns of midface fractures were related to postoperative computed tomography scans and clinical results to assess the value of ordering fracture assembly in success of treatment methods. A total of 550 midface fractures were studied for their midface components and the presence of fractures in the adjacent frontal bone or mandible. Preoperative and postoperative computed tomography scans were analyzed to generate recommendations regarding exposure and postoperative stability related to fracture pattern and treatment sequence, both within the midface alone and when combined with frontal bone and mandibular fractures. Large segment (Le Fort I, II, and III) fractures were seen in 68 patients (12 percent); more comminuted midface fracture combinations were seen in 93 patients (17 percent). Midface and mandibular fractures were seen in 166 patients (30 percent). Midface, mandible, and nasoethmoid fractures were seen in 38 patients (7 percent). Frontal bone and midface fractures were seen in 131 patients (24 percent). Split-palate fractures accompanied 8 percent of midface fractures. Frontal bone, midface, and mandibular fractures were seen in 54 patients (10 percent). The midface, because of weak bone structure and comminuted fracture pattern, must therefore be considered a dependent, less stable structure. Its injuries more commonly occur with fractures of the frontal bone or mandible (two-thirds of cases) and, more often than not (>60 percent), are comminuted. Comminuted and pan-facial (multiple area) fractures deserve individualized consideration regarding the length of intermaxillary immobilization. Examples of common errors are described from this patient experience.     

Auricular repair with autogenous rib cartilage grafts: two decades of experience with 600 cases.

The purpose of this paper is twofold: to present a sound approach to auricular construction using methods that have evolved through two decades of my personal experience with 600 cases and to discuss pertinent information I have gleaned from a questionnaire sent to my operated patients. This series comprises 546 completed ears in 500 microtia patients (46 bilateral) and 75 completed ears in acquired deformities. Follow-up ranges from 1 to 17 years. Major complications such as infection, hematoma, or skin loss with cartilage exposure occurred in only 1.6 percent of cases and were limited to the perioperative period of 12 days. None have occurred in the last 9 years (481 frameworks). This paper describes the evolution and rationale for my current management of total ear repair and covers preoperative planning, how to fabricate the rib cartilage framework, how to modify the framework for specific deformities, and how to cover the framework, i.e., how to assess and use local skin and vestiges or when to supplement the coverage by recruiting fascial flaps or using tissue expansion. When considering fascial flaps, patient selection was found to be particularly important because of long-term effects on the donor scalp; expansion was found to be most useful intraoperatively. This paper also covers how to manage the hairline, how to stage the surgery, when to combine procedures, and how to manage bilateral microtia in a team approach. The survey revealed that autogenous cartilage frameworks grow, are durable, retain their detail over the years, and withstand trauma well. More than 40 severe traumas occurred in surgically constructed ears, and all healed without incident. Ears constructed in young patients generally grew to keep pace with the opposite normal side; 41.6 percent actually overgrew by several millimeters. Emotional and psychological benefits were universal, and patient satisfaction was high. Among patients who were classified as "severely affected" by the original deformity, 100 percent were pleased with the result. When considered "moderately disturbed" by the microtic defect and operated on by age 14, 95.5 percent of patients were satisfied with the surgical repair; 83.3 percent of adolescents between the ages of 15 and 20 who did not consider themselves "severely affected" by the deformity were pleased with the outcome, and the rest were "undecided."     

A classification system and algorithm for reconstruction of maxillectomy and midfacial defects

Maxillectomy defects become more complex when critical structures such as the orbit, globe, and cranial base are resected, and reconstruction with distant tissues becomes essential. This study reviews all maxillectomy defects reconstructed immediately using pedicled and free flaps to establish (1) a classification system and (2) an algorithm for reconstruction of these complex problems. Over a 5-year period, 60 flaps were used to reconstruct defects classified as the following: type I, limited maxillectomy (n = 7); type II, subtotal maxillectomy (n = 10); type IIIa, total maxillectomy with preservation of the orbital contents (n = 13); type IIIb, total maxillectomy with orbital exenteration (n = 18); and type IV, orbitomaxillectomy (n = 10). Free flaps (45 rectus abdominis and 10 radial forearm) were used in 55 patients (91.7 percent), and the temporalis muscle was transposed in five elderly patients who were not free-flap candidates. Vascularized (radial forearm osteocutaneous) bone flaps were used in four of the 60 patients (6.7 percent) and nonvascularized bone grafts in 17 (28.3 percent). Simultaneous reconstruction of the oral commissure using an Estandler procedure was performed in 10 patients with maxillectomy and through-and-through soft-tissue defects. Free-flap survival was 100 percent, with reexploration in five of 55 patients (9.1 percent) and partial-flap necrosis in one patient. Seven of the 60 patients (11.7 percent) had systemic complications, and four died within 30 days of hospitalization. Fifty patients had more than 6 months of follow-up with a mean time of 27.7 (+/- 15.6) months. Postoperative radiotherapy was administered in 32 of these patients (64.0 percent). Chewing and speech functions were assessed in 36 patients with type II, IIIa, and IIIb defects. A prosthetic denture was fixed in 15 of 36 patients (41.7 percent). Return to an unrestricted diet was seen in 16 patients (44.4 percent), a soft diet in 17 (47.2 percent), and a liquid diet in three (8.3 percent). Speech was assessed as normal in 14 of 36 patients (38.9 percent), near normal in 15 (41.7 percent), intelligible in six (16.7 percent), and unintelligible in one patient (2.8 percent). Globe and periorbital soft-tissue position was assessed in 14 patients with type I and IIIa defects. There were no cases of enophthalmos, and one patient had a mild vertical dystopia. Ectropion was observed in 10 of 14 patients (71.4 percent). Oral competence was considered good in all 10 patients with excision/reconstruction of the oral commissure; however, two patients (20 percent) developed microstomia after receiving radiotherapy. Aesthetic results were evaluated at least 6 months after reconstruction in 50 patients. They were good to excellent in 29 patients (58 percent) for whom cheek skin and lip were not resected, and poor to fair (42 percent) when the external skin or orbital contents were excised. Secondary procedures were required in 16 of 50 patients (32.0 percent). Free-tissue transfer provides the most effective and reliable form of immediate reconstruction for complex maxillectomy defects. The rectus abdominis and radial forearm flaps in combination with immediate bone grafting or as osteocutaneous flaps reliably provide the best aesthetic and functional results. An algorithm based on the type of maxillary resection can be followed to determine the best approach to reconstruction.     

Closed degloving injuries: results following conservative surgery.

Closed degloving wounds are uncommon but important injuries because they may be overlooked in the multiply injured patient and, if not treated correctly, may give rise to significant morbidity. This prospective study reports the results of a conservative surgical management policy in 16 patients with closed degloving wounds treated during a 1-year period in a tertiary referral center. Motor vehicle accidents caused most of the injuries, 69 percent of which occurred on the lower limb. The extent of injury ranged from 2 to 12 percent (mean 4.9 percent) of the total body surface area. The diagnosis of closed degloving wound was missed at initial assessment in one-third of patients. A uniform management policy with drainage of the degloved area through a small incision followed by compression bandaging was applied. The volume of blood and necrotic fat evacuated ranged from 15 to 800 ml (mean 120 ml). One patient with necrotic skin initially had excision and primary wound closure performed. Delayed necrosis occurred in one patient in whom extensive degloving occurred and effective compression could not be applied. Ultimate flap viability using this technique was excellent, since only 1 of 16 patents required skin grafting.     

Cicatricial eyebrow reconstruction with a dense-packing one- to two-hair grafting technique

Scarring eyebrow loss is usually repaired with a hair-bearing island scalp flap or scalp strip grafting technique. The results, however, are usually not desirable with regard to appearance. In this article, a one- or two-hair graft with a dense-packing technique was developed for cicatricial eyebrow reconstruction. It was carried out by harvesting a scalp strip close to the hairline of the back, then dividing it into a series of one- or two-hair grafts, and finally implanting the grafts into the prepared recipient holes of the eyebrow with a desired hair direction. With the authors' experience in treating 96 patients (154 eyebrows) in cases of burn, skin grafting, traumatic scarring, and chemical peeling scar after tattoo removal, the eyebrows could be restored in only one session. In general, 150 to 200 grafts with 200 to 250 hairs were needed for a complete male eyebrow reconstruction and 100 to 150 grafts with 150 to 200 hairs were needed for a complete female eyebrow reconstruction. The maximal hair density was 91.5 hairs/cm per session. Over a 6-month follow-up period, the mean graft survival rate reached 98.1 percent. All of the patients achieved satisfactory results, with a very natural appearance. These results indicate that the above-mentioned technique could be a practical, effective, and probably ideal method for cicatricial eyebrow reconstruction.     

Metastatic follicular thyroid carcinoma diagnosed by fine needle aspiration cytology: a report of 3 cases

BACKGROUND: Follicular thyroid carcinomas (FTCs) usually have a benign clinical course, with an excellent long-term prognosis and a propensity for vascular invasion. The most common sites of metastases are lung and bone. Only a few reports are available on fine needle aspiration biopsy findings from metastatic lesions of FTC. CASES: A 68-year-old man presented with a thyroid mass and skin nodule on the scalp. Skin nodule aspiration revealed metastatic FTC. A 52-year-old woman and 60-year-old man were investigated for chronic anemia. As part of the routine investigation, bone marrow aspiration and biopsy were performed from the posterior iliac crest and diagnosed as metastatic FTC. Further questioning revealed that the patients had undergone thyroidectomy 10 and 13 years earlier. The aspiration material in all 3 cases revealed epithelial cell clusters with marginal (fire-flare) vacuoles. CONCLUSION: Cytologic diagnosis of metastatic FTC has been reported rarely. Marginal (fire-flare) vacuoles aid in making the diagnosis of metastatic FTC.