Soft-Tissue reconstruction of the face using the folded/multiple skin island radial forearm free flap.

Resection of malignant soft-tissue tumors of the face often results in defects of skin, lining, and contour. When local tissues are unavailable, the folded/multiple skin island forearm free flap has been used to correct complex lining, skin, and contour defects concomitantly. This study is a retrospective review of all patients reconstructed with folded/multiple skin island forearm flaps from 1992 to 2000. Facial defects included facial skin, mucosal lining, and intervening soft tissue. Reconstruction was immediate and was not combined with another local flap. There were 17 patients (mean age, 61 years). Five patients had cutaneous malignancies and 12 patients had either mucosal or salivary gland malignancy. Defects were of the cheek and nose either alone or in combination. Defects ranged from 9 to 54 cm2. Nine patients had defects of either the skin or the mucosa with an associated soft-tissue component. These were reconstructed with a folded forearm flap with one skin island. Eight patients had full-thickness defects and were reconstructed with a folded flap with two skin islands. Flap survival was 100%. One case required reexploration for hematoma. Aesthetic results were good to excellent in 76% of patients. Delayed wound healing at the donor site occurred in 2 patients (11%). The folded/multiple skin island forearm flap is a useful tool for single-stage reconstruction of complex facial defects requiring replacement of skin, lining, and intervening soft tissue. Good to excellent aesthetic results can be expected in most patients.     

Effect of intravenous hyperalimentation on established delayed hypersensitivity in the cancer patient.

Forty-seven cancer patients were selected for study based on their candidacy for hyperalimentation. Each patient received selected skin test antigens intradermally in the forearm prior to the initiation of hyperalimentation, and at 7-day intervals throughout treatment with either chemotherapy, radiation therapy or surgery. Of 23 patients who received chemotherapy, 17 initially had negative skin tests. Thirteen of these patients had positive skin tests after an average of 11.4 +/- 5.5 days of hyperalimentation. Response to chemotherapy occurred only in hyperalimentation. Response to chemotherapy occurred only in those patients whose skin tests were positive, and conversion of skin test reactivity to positive occurred before clinical regression of metastatic disease. No patient who received radiation therapy developed or retained positive skin test reactivity, although nutritional repletion was considered satisfactory in each patient. Surgical patients whose skin tests converted to positive or remained positive preoperatively had an uncomplicated postoperative recovery, whereas 2 of 4 patients whose skin tests remained negative expired postoperatively. Absence of established delayed hypersensitivity in the cancer patient who is treated with chemotherapy or surgery is probably secondary to generalized malnutrition, and established cell-mediated immunity can be restored by proper nutritional repletion.     

Acitretin for prophylaxis of cutaneous malignancies after cardiac transplantation.

BACKGROUND: Heart transplant recipients have an increased risk of developing actinic keratoses and non-melanotic skin cancers when compared with the general population. Systemic retinoids have been shown to be beneficial in the treatment of such lesions in recipients of other organs, but as of yet the heart transplant model has rarely been studied. In this investigation we describe our experience with the use of acitretin in a group of heart transplant patients. METHODS: Five heart transplant recipients with multiple new skin cancer presentations were treated with acitretin at doses of either 10 or 25 mg/day. Inclusion criteria were based on progressive actinic keratoses, recurrent skin malignancies or continuous lesions despite treatment with appropriate topical therapies. Patients were excluded if they were women of child-bearing age, had severe hepatic or renal impairment or were taking contraindicated medications. RESULTS: Over the treatment period all patients showed a reduction in the number of new non-melanotic skin cancers excised and histologically confirmed. Three patients had a very large reduction and 2 patients had a more moderate reduction in the number of new presentations. All patients had an objective decrease in the number of actinic keratoses. All patients tolerated the drug well with only 1 patient transiently discontinuing the Acitretin due to side effects. No significant alterations in the biochemical tests or serum lipids were reported. CONCLUSIONS: Over the treatment period, low-dose acitretin proved a valuable addition in the long-term strategy of reduction and treatment of non-melanotic skin cancers in heart transplant recipients with multiple skin cancers and actinic keratoses.     

Penile and scrotal Paget's disease: 130 Chinese patients with long-term follow-up

OBJECTIVES

To report a retrospective series of 130 Chinese patients with penoscrotal extramammary Paget’s diseases (EMPD), with a long‐term follow‐up, and thus improve the diagnosis and therapy of this disease.

PATIENTS AND METHODS

The history, clinical presentation, pathology, treatment, and prognosis of 130 patients were analysed. All cases were confirmed by skin biopsy, and then the patients had local wide resection to remove the involved skin and subcutaneous tissue. The large defective wound was reconstructed using a split‐thickness skin graft or local flap.

RESULTS

Forty‐five patients were evaluated by frozen‐section biopsy of the margins during surgery, five of whom had positive margins and then had an extended resection immediately. Most of these patients had local skin or adjacent scrotal flaps to cover their skin defects. Of the 130 patients, 81 had a mean (range) follow‐up of 3.2 (0.5–10) years after surgery. Five of nine patients with positive margins and three (4%) of 72 with negative margins had tumour recurrence. Five patients died from metastatic disease.

CONCLUSIONS

Penoscrotal EMPD needs be differentiated from other chronic dermatitis. A 3 cm surgical margin should be sufficient and frozen‐section pathological examinations are necessary for some complicated conditions. Skin grafts or local flaps are good for large skin defects.     

A ventral rotational skin flap to improve cosmesis and avoid chordee recurrence in epispadias repair

OBJECTIVE: To describe a technical modification that facilitates dorsal skin closure, improves cosmesis and eliminates chordee recurrence secondary to contracture of the dorsal penile skin in the repair of epispadias. PATIENTS AND METHODS: Eleven patients with penopubic epispadias (mean age 1.8 years) had the epispadias repaired using a modified ventral penile skin flap. Four patients had isolated epispadias and seven had had a previous primary closure of bladder exstrophy. Nine patients underwent the Cantwell-Ransley technique, leaving the meatus in a glanular position. Two patients were repaired using the penile disassembly technique of Mitchell and B?gli, because they had a short urethral plate. A ventral island skin flap was fashioned, starting at the base of the penis. Dissection was carried ventrally into the scrotum to allow for adequate dorsal flap transposition. The flap was rotated laterally to shift the suture line from the midline and to cover the dorsal aspect of the penis with untouched penile shaft skin. Redundant ventral foreskin was discarded. RESULTS: All patients had an uneventful course after surgery. Dorsal penile skin was viable in every case and no patient developed recurrence of chordee or a urethrocutaneous fistula. The cosmetic result was excellent in all patients. CONCLUSIONS: Dorsal skin closure using lateral rotation of ventral penile skin flap improves cosmesis after epispadias repair and eliminates the recurrence of chordee secondary to midline dorsal scarring.     

Surgical management of post-burn skin dyspigmentation of the upper limb

The technique and results of surgery in 23 patients with skin dyspigmentation of the upper limb are presented. The study population was divided into two groups. Group A (n=15 patients) had hyperpigmented skin grafts in the palm or the palmar aspect of the digits. All patients underwent excision of the hyperpigmented grafts and coverage with split-thickness plantar skin grafts. The plantar grafts gave an excellent colour and texture match and all patients were satisfied with the result. Group B (n=8 patients) had post-burn hypopigmentation on the dorsal aspect of digits, hand or forearm. These patients underwent dermabrasion and thin split-thickness grafting harvested from the upper thigh or buttock. All grafts healed well with no residual hypopigmentation. However, the graft was slightly hyperpigmented when compared to the surrounding skin. Despite this complication, all patients were satisfied and considered this slight hyperpigmentation much better than the preoperative hypopigmentation. The pathogenesis of skin dyspigmentation and other treatment techniques are discussed.     

Utility of skin biopsy in the diagnosis of IgA nephropathy

Thirty-seven patients with the diagnosis of IgA nephropathy were evaluated with punch skin biopsies of non-sun exposed skin. Biopsies were performed regardless of clinical activity. Biopsies were positive for IgA immunofluorescence in two patients. In an effort to enhance positivity of biopsies, patients were pretreated with 0.1 mL of histamine and then repeat biopsies were performed on 14 patients with previously negative skin biopsies. All 14 patients had negative repeat skin biopsies for IgA immunofluorescence. A review of the literature revealed 76 positive skin biopsies in a total of 138 patients with IgA nephropathy. Positive skin biopsies were also reported in 169 of 510 patients with other renal diseases. We conclude that a 4 mm punch skin biopsy with or without histamine is an insensitive and non-specific test for diagnosing IgA nephropathy.     

An assessment of the relationship between congenital transverse deficiency of the forearm and symbrachydactyly

PURPOSE: A relationship between symbrachydactyly and transverse deficiency has been suggested but has not been critically investigated or established by scientific studies. The purpose of this investigation was to evaluate a large group of patients with transverse deficiency of the forearm for clinical and radiologic features typically seen in patients with symbrachydactyly. METHODS: A retrospective review of the medical records of 291 patients with a diagnosis of upper-extremity transverse deficiency at the level of the forearm was performed. Patient charts, photographs, and radiographs were evaluated for manifestations of symbrachydactyly; specifically, we clinically assessed for the presence of nubbins and skin invaginations and radiologically assessed for hypoplasia of the proximal radius and ulna. RESULTS: Two hundred seven patients had soft tissue nubbins at the end of their amputation stumps including 38 with the additional finding of skin invagination at the distal end. Another 36 extremities had a skin invagination alone. Twenty-nine of the extremities without nubbins or skin invaginations had hypoplasia of the proximal radius and ulna. Thus, 272 of the 291 extremities with transverse deficiency had manifestations of symbrachydactyly. CONCLUSIONS: The majority of patients with the diagnosis of transverse deficiency have soft tissue nubbins, skin invaginations, or hypoplasia of the proximal radius and ulna at the end of their amputation stumps. These clinical and radiologic features support the concept that transverse deficiency through the forearm represents a proximal continuum of symbrachydactyly.     

吻合血管股前外侧筋膜瓣的临床应用

目的探讨吻合血管股前外侧筋膜瓣修复前臂及手部创面的临床应用。方法2000年9月-2003年12月收治前臂及手部软组织缺损13例,男8例,女5例;年龄19-43岁。机器碾压伤3例,皮带绞伤4例,重物压伤6例。软组织缺损部位前臂掌侧6例,手背部6例,食指桡、背侧1例。缺损范围17.5cm×7.7cm-4.6cm×3.4cm,其中4例合并前臂、手部骨折,9例合并前臂、手部伸肌腱损伤。患者均急诊行清创、骨折复位内固定,修复损伤的神经、肌腱及血管,术后抗感染治疗3-5d后,采用吻合血管的股前外侧筋膜瓣联合中厚皮片植皮修复软组织缺损。结果术后患者均无血管危象发生。1例第4、5指蹼处约2.0cm×1.0cm植皮坏死,经换药及再次取全厚皮植皮后成活,余患者筋膜瓣及植皮均成活。全部获3-12个月随访,修复后的创面外形均良好,无皮肤挛缩。按中华医学会手外科学会上肢部分功能评定标准优9例,良2例,可1例,差1例,优良率85%。结论吻合血管股前外侧筋膜瓣联合植皮修复前臂及手部创面外形好,不需再次手术整形,远期无皮肤瘢痕挛缩发生,供区处理简单,创伤小。     

Surgery for head and neck skin tumors in the elderly

BACKGROUND: Our aim was to determine the surgical characteristics of an elderly cohort of patients undergoing resection of head and neck skin neoplasms. METHODS.: All cases of patients with head and neck skin neoplasms (excluding malignant melanoma) who underwent surgical resection in a regional referral center over a 10-year period were retrospectively reviewed. The study group comprised 152 patients (208 cases) aged >or=80 years. They were compared with 311 patients (430 cases) aged <80 years. RESULTS: Elderly patients had higher Charlson comorbidity index, American Society of Anesthesiologists' physical status scores, dementia, and aspirin intake (all p < .05). They also had a higher incidence of scalp involvement and lower incidence of nasal involvement (both p < .05). Elderly patients had a larger lesion size at presentation and required sacrifice of a greater area of skin (both p < .05). However, they also underwent more local anesthetic procedures, although the need for local flap or skin graft repair was not increased. Two elderly patients had intraoperative tachyarrythmias induced by local anesthesia. However, no patient died within 30 days of surgery, and wound complication rate and disease-free survival were comparable to younger patients. CONCLUSION: With careful attention to comorbid illness and perioperative monitoring, surgical resection of head and neck skin neoplasms is safe in the elderly. Lesions are more advanced at presentation and hence require sacrifice of a larger area of skin to obtain macroscopic clearance. Yet for the majority of lesions, local anesthesia is adequate and surgical resection and simple skin closure can be accomplished without the need for complex flap or skin graft reconstructions.     

Proximal humeral fractures due to blunt trauma producing skin compromise

We identified 16 patients with a mean age of 56.5 years (31 to 86) from a large consecutive series of patients with proximal humeral fractures over a 15-year period, who had sustained a fracture with skin compromise after a blunt injury. The study group represented 0.2% of 7825 proximal humeral fractures treated during this period and all had a displaced Neer two-part fracture pattern. Two patterns of skin injury were identified: in ten patients there was skin penetration at the time of the original injury, and the other six patients initially had closed injuries. These six patients had fracture fragments penetrating the muscular envelope to lie subcutaneously producing either early skin tethering (two patients) or delayed skin penetration and sinus formation (four patients). The pattern of injury to the soft-tissue envelope and the fracture pattern were similar for all injuries. Treatment of these injuries was determined by the initial severity of the soft-tissue injury and the medical status of the patient. We currently favour open reduction and internal fixation of these fractures wherever possible, owing to the high rate of nonunion with non-operative management.     

Evaluation of implant losses and skin reactions around extraoral bone-anchored implants: A 0- to 8-year follow-up.

This is an 8-year follow-up of a group of 214 patients who underwent surgical insertion of titanium implants in the mastoid process for the retention of bone-anchored hearing aids and auricular prostheses. The skin reactions around the implants and the various factors dealing with implant loss were evaluated. The number of patients who never had any episode of adverse skin reactions during the 8-year period is 70% and is about the same as previously reported. The frequency and degree of adverse skin reactions were noted to be decreasing with time. The young age group had the highest incidence of adverse skin reactions, and this high frequency is consistent with results of earlier reports. None of the remaining group of patients (30%) who had 1 or more episodes of adverse skin reactions lost their implants because of this problem; most implant losses were primarily the result of loss of integration. The probability of losing an implant because of adverse skin reactions is quite low; however, these skin reactions, if left untreated, may eventually lead to implant loss or withdrawal.     

乳房皮下切除与自体组织即刻乳房再造

目的探索乳房皮下切除与几种方法的乳房再造术，即腹直肌肌皮瓣或背阔肌肌皮瓣加乳房假体或局部皮瓣等即刻再造乳房的方法。方法选择乳腺导管内原位癌10例和巨大乳腺良性肿瘤5例，顺乳晕切口活检，病理检查确立诊断后，采用经乳腺切口行乳癌或巨大肿瘤的乳房皮下切除术，若乳癌或良性肿瘤体积较大，另于腋窝部加做顺腋下皱襞的附加切口，以便于取出切除的组织及切除乳腺的腋尾部，同时可以切取腋淋巴结行冰冻切片活检。然后，应用腹直肌肌皮瓣或背阔肌肌皮瓣加乳房假体或局部皮瓣即刻行再造乳房，充填乳房切除后的空间，仅以少量的肌皮瓣皮肤修复乳头、乳晕切除后的缺损，并在此转移皮瓣上再造乳头、乳晕。结果经过多专科协作共完成15例，随访结果良好，无肿瘤复发。此法再造的乳房易与健侧乳房对称，保留了原有乳房皮肤的良好感觉，外观形态自然，再造乳房瘢痕较少，且手术切口瘢痕隐蔽。结论在严格选择手术适应证防止乳腺癌复发的前提下，乳房皮下切除与即刻乳房再造法，对乳腺导管内原位癌和巨大乳腺良性肿瘤患者I期完成肿瘤切除和乳房再造术，具有积极有效的意义。     

The versatility of the inferior dermal flap in implant/expander-based immediate breast reconstruction and its application in augmentation–mastopexy

The inferior dermal flap technique with the Wise pattern skin resection has been used in the authors practice, mainly in patients who required bilateral or unilateral risk-reducing mastectomy for prophylaxis. The versatility of this procedure allowed the senior authors (MPS and PL) to extend its applicability for vertical scar augmentation–mastopexy in asymmetrical breast and for Wise pattern skin resection mastopexy–augmentation in massive weight loss. Between 2006 and 2009, the inferior dermal flap was performed in 18 patients with a total of 34 breasts, 20 of which had the Wise pattern skin resection following risk-reducing mastectomy, two of which were unilateral, six had a Wise pattern skin resection after massive weight loss and six had a vertical skin excision for asymmetrical breasts. No haematoma, infection or seroma were seen with this technique. No breakdown at the T junction was reported. One patient had a capsular contracture which required a capsulectomy and replacement of implants. We report our experience of this technique in patients undergoing unilateral skin-reducing mastectomies for prophylaxis and we demonstrate the versatility of the dermal flap when applied for vertical scar augmentation–mastopexy in the asymmetrical breast and for Wise pattern skin resection mastopexy–augmentation in massive weight loss.     

Results of myocutaneous flap for extensive skin defect in the external genitalia

We reviewed 12 patients who underwent myocutaneous flap plasties to reconstruct the genital skin. The patients included 9 who underwent a radical excision of malignant tumor involving the genital, inguinal or sacral skin, 1 with an extensive radiation ulcer of the genitalia and 2 with an ulcerating cancer of the scrotum or groin. In the latter 2 patients the plasty was intended to cover an unresectable ulcerating cancer. A gracilis myocutaneous flap was used in 10 patients, and a tensor fascia lata myocutaneous flap in 2 patients. Postoperatively, partial or total necrosis of the skin of the flap developed in 8 patients. In 4 of these, infection complicated the necrosis. Although debridement, resuture or free skin transplantation was needed in these patients, wound healing was ultimately achieved in 10 patients who underwent radical excision of malignant tumor or radiation ulcer. In contrast, the intended coverage of an unresectable ulcerating cancer was unsuccessful in two other patients. No patients had motor disturbance after wound healing. However, one patient developed stricture of the urethra and vagina which had been opened through the flap, and another patient complained of gait disturbance and difficult defecation because of an swelling of the flap around the anus. Incision or excision was required to relieve the complaints in these 2 patients. These results indicate that a myocutaneous flap is useful to cover an extensive skin defect of the genitalia, but may be accompanied by postoperative complications particularly before wound healing. Appropriate management is necessary to achieve the intended reconstruction.     

Power of the pinch: pinch lower lid blepharoplasty

Lower lid blepharoplasty is performed with great variation in technique. Conventional lower lid blepharoplasty with anterior fat removal via the orbital septum has a potential lower lid malposition rate of 15% to 20%. Lower lid malposition and the stigma of obvious lower lid surgery have led plastic surgeons to continue to change their approach to lower lid rejuvenation. In recent years, some surgeons have come to rely on alternative procedures like laser resurfacing alone or in conjunction with transconjunctival fat removal and canthopexy in an effort to avoid such complications. The pinch blepharoplasty technique removes redundant skin without undermining. This allows for more controlled wound healing, predictable recovery, and potential for simultaneous laser resurfacing. The combination of pinch blepharoplasty with transconjunctival fat removal leaves the middle lamella intact and reduces the chance of scleral show or ectropion. The purpose of this series is to demonstrate that pinch excision of redundant lower eyelid skin can be safely performed and that it can be used with laser resurfacing and/or transconjunctival fat removal for optimal treatment of the aging eye. A retrospective review of 46 consecutive patients who underwent pinch blepharoplasty, either in isolation or with other periorbital procedures was performed. Follow-up was at least 4 months (range of 4-24 months). In addition, we performed a prospective study of 25 consecutive patients to quantify the amount of skin removed and evaluate results and complications. An average of 8 mm of skin was resected (range of 4-12 mm) with the pinch blepharoplasty technique. Of these patients, 5.6% also underwent transconjunctival blepharoplasty, laser resurfacing, and/or fat grafting of the nasojugal groove. Despite the addition of simultaneous laser resurfacing, we did not see an increase in lower lid malposition. Three of the 71 patients had temporary scleral show that resolved with lower lid massage. In total, only 4 patients had isolated pinch lower lid blepharoplasty. Twelve patients had orbicularis suspension and 15 had either canthopexy or canthoplasty. Five patients who had orbicularis suspension, canthopexy, or canthoplasty had periorbital edema. Two also had pronounced chemosis. Four patients had mild rounding of the lower lid. Pinch blepharoplasty is a versatile technique that produces consistent results. This study confirms that more skin from the lower lid can be resected than classically described. Pinch blepharoplasty can be performed safely in combination with other procedures to enhance lower lid appearance. The absence of skin undermining allows for safe simultaneous laser resurfacing. Preserving the middle lamella and supporting it when necessary allows one to resect significant amounts of lower lid skin without significant risk of scleral show, lower lid rounding, and ectropion. Patients with poor lid tone or laxity may benefit from supportive procedures such as the canthopexy or canthoplasty.     

Long term results of vein valve transplants placed in the popliteal vein for intractable post-phlebitic venous ulcers and pre-ulcer skin changes

Most patients with chronic venous ulceration or severe pre-ulcer damaged skin have incompetent popliteal valves and a high ambulant venous pressure (AVP). Competency can be restored by a vein valve transplant taken from the arm and placed in the popliteal fossa, with subjective and objective improvement. In this study 23 patients with post-phlebitic syndromes received 25 vein valve grafts as part of management. Seventeen patients had large recurrent ulcers after unsuccessful venous surgery: 6 patients had extensive pre-ulcer skin damage. Fifteen of 17 patients healed their ulcers, and all 6 patients with skin damage showed rapid improvement with relief of symptoms. Falls in the AVP, ranging from 10 to 40 mmHg occurred in 19 patients. All vein valve transplants were patent, after 18 months, but 5 grafted valves have evidence of venous reflux. These results suggest a functioning valve replacement in the popliteal fossa may lower the AVP sufficiently to heal intractable venous ulcers or severely damaged skin. Vein valve transplants function well long term, and the falls in the AVP are usually maintained. The popliteal fossa may be the ideal site since a component popliteal valve has been shown to limit adverse post-phlebitic changes.     

Skin cancer in renal allograft recipients--experience in different ethnic groups residing in the same geographical region

Cancer is a recognized long-term complication of kidney transplantation. Skin cancer is the most common post-transplant malignancy in developed countries but information is limited on the nature of skin cancer in allograft recipients from developing countries followed up over an extended period. The records of all patients (n = 542) who had received kidney transplants (n = 623) at our institution over a 23-yr period were reviewed and those with skin cancer were identified. Demographic, clinical, and pathologic details were collected. After a mean follow up of 6.3 yr 11 (5.9%) white patients had skin cancer of whom nine (82%) were male. No non-whites had skin cancer. In white patients skin cancer accounted for 68% of all post-transplant malignancies. Squamous cell carcinoma was the most common malignant skin lesion and 84% of all lesions occurred in sun-exposed areas. Specific immunosuppression did not appear to influence the number of lesions or the interval from transplantation to cancer development. Patients responded well to treatment with no mortality related to the skin cancer. Skin cancer is relatively unique to patients of European origin.     

Face burn reconstruction--does early excision and autografting improve aesthetic appearance?

Despite improvements in functional rehabilitation secondary to better control of scar and contractures, aesthetic rehabilitation of the extensively burned face has remained a difficult problem. This study was undertaken to evaluate both technique and aesthetic results of early excision and split thickness autografting (STAG) of full skin thickness face burns. Twenty-five patients with full skin thickness face burns were operated on between days 4 and 14 post-burn. Thirteen patients had excision and STAG in one stage. Twelve patients had a two-stage procedure-excision and coverage with a biological dressing followed 24-72 h later by STAG. Seven of these patients had a pressure dressing in the form of a silicone face mask applied at the second stage. Early cosmetic results were encouraging in all patients. Twenty-five per cent of patients later required either contracture release or skin resurfacing. Preliminary results are encouraging and warrant evaluation by surgeons at other centres. When early excision of full skin thickness face burns is undertaken, cautious optimism as to the ultimate aesthetic result, both by the surgeon and the patient, is advisable.