13例肢端恶性黑色素瘤的治疗

目的对肢端恶性黑色素瘤患者的整形外科治疗作初步的临床分析。方法自2000年2月至2003年11月,对13例患者的肢端恶性黑色素瘤行功能性根治切除后,采用皮瓣覆盖的方法修复创面。其中治疗性淋巴结清扫者4例,选择性淋巴结清扫者3例。结果术后随访1~5年,观察肿瘤根治效果及手足功能及外观状况。13例患者中12例得到随访,10例患者无恶性黑色素瘤复发,手足功能及外观良好。结论对肢端恶性黑色素瘤原发灶行整形外科治疗,在保证肿瘤根治效果的同时可获得更好的手足功能及外观。     

Acral melanoma with satellitosis,disguised as a longstanding diabetic ulcer: a great mimicry

Acral lentiginous melanoma affects the palms, soles, and nail apparatus. Around 3–15% of all cutaneous melanomas are located on the foot and have a poorer prognosis than melanoma elsewhere. Possible reasons for this prognostic difference may be omitting this area during routine skin check by both the patient and the physicians, in addition to misdiagnosis of melanoma as other benign skin lesions. We describe here an elderly female patient treated for a non‐healing foot ulcer interpreted as a diabetic ulcer, which after 2 years was diagnosed as acral melanoma with satellitosis. Histopathological examination of the amputated distal phalanx revealed an advanced stage melanoma with 1·2 cm Breslow thickness and of Clark level 5. Dermoscopy of the bluish papulonodules scattered on the dorsal foot showed characteristic findings described for metastasis of skin melanoma. This case underlines the importance of considering skin malignancies in case of chronic, non‐healing ulcers in diabetic patients. Furthermore, we point out the critical significance of skin examination as a whole, and dermoscopy being an important tool in the diagnosis of melanoma and/or cutaneous melanoma metastasis.     

Subungual melanoma: An important tip

Acral lentiginous melanoma is rare, representing approximately 1% of malignant melanomas. Overall 5 year survival is disproportionately poor (25-51%) compared to other histological subtypes. This has been attributed to diagnostic delay resulting in more advanced presentation. Subungual presentation in the fingers is uncommon, reported in 1-13% of all acral lentiginous melanomas. We report a unique and diagnostically challenging case. Contrary to previously reported examples in the literature, the actual neoplastic pathology was detected in the less pigmented finger tip skin rather than the deeply pigmented nail bed germinal and sterile matrix that showed no evidence of malignancy. We therefore advocate that in cases where skin surrounding the nail is involved, this surrounding skin should also be biopsied, even if it is less pigmented than the primary lesion.     

Plantar lentiginous melanoma: a distinctive variant of human cutaneous malignant melanoma

The neoplastic system of human cutaneous melanoma includes three generaly recognized variants: lentigo maligna, superficial spreading melanoma, and nodular melanoma. Lentiginous melanomas other than lentigo maligna constitute a fourth group, of which plantar lentiginous melanoma qualifies as an anatomic subgroup. Histologically and clinically, plantar lentiginous melanoma (PLM) is characterized by a period of radial growth and often by one or more foci of regression. In 27 of 33 plantar melanomas, a characteristic lentiginous, radial component of melanocytic proliferation was noted. In the remaining six cases, histological material failed to document a radial component. Eighteen of the 27 patients with PLM were blacks, and 18 patients died of distant metastasis. Tumors invasive to level II did not metastasize, but at levels IV and V and in tumors with a high mitotic rate, the prognosis was poor. The presence of lymph node metastases at the time of initial therapy correlated with a poor prognosis group.     

The current management and prognosis of acral lentiginous melanoma.

A computer-aided retrospective analysis was performed on 359 patients with stage I and II melanoma at the time of diagnosis (disease confined to the primary melanoma), at the University of South Florida (Tampa, FL). Eighteen patients were identified with primary melanoma in acral locations, most being acral lentiginous melanoma. A comparison of actuarial survival curves of patients with melanoma in four different locations (acral, head and neck, trunk, and other extremity site) was performed. The patients with melanoma in acral locations did not have a statistically different actuarial survival than those with primary melanoma in other sites. When actuarial disease-free survival curves were constructed, however, acral primary melanoma had a shorter interval to recurrence than those located on the trunk or other extremity sites. Differences between actuarial disease-free survival for the head and neck and for acral primary sites were not significant. To identify prognostic factors responsible for the decreased disease-free survival of the acral lentiginous population, a regression analysis was performed. Three prognostic factors were analyzed for stage I and II melanoma, including Breslow tumor thickness, ulceration of the primary lesion, and primary site location. In the univariate analysis, with each prognostic factor acting independently, tumor thickness (p less than 0.01) and ulceration (p = 0.02) were significant variables influencing the disease-free interval. Primary site did not, however, add prognostic information to the model (p = 0.54). A stepwise multivariate analysis confirmed this finding.     

Prelaminated forearm flap for nose reconstruction

Various different procedures for partial or total reconstruction of the nose have been described, the methods of residual nasal tissue, and of buccal, frontal and temporal flaps being most widely used. Reconstruction of the nose with free vascular transplants is rarely used. Reconstruction of a nasal defect due to war injury of the nose with the use of prelaminated fasciocutaneous forearm flap with preserved allogeneic cartilage is described.     

Perforator-based fasciocutaneous flap for pressure sore reconstruction

Abstract

Pressure sore reconstruction is always a challenge for plastic surgeons due to its high recurrence rate. In addition to the myocutaneous flap, the perforator-based fasciocutaneous flap has become a new entity used for pressure sore reconstruction. This study presents a series of 26 perforator-based fasciocutaneous flaps for pressure sore reconstruction, with good outcomes in 21 patients from July 2008 to April 2011. The flaps were advanced, transposed, or rotated to obliterate the defects. Twenty of 26 flaps healed uneventfully without complication. One patient had a flap that totally necrosed, one had partial flap necrosis (flap rotated 180° in the above two cases), one had infection and healed by a secondary flap, one had minor wound dehiscence, one died of pneumonia 1 week postoperatively, and recurrence developed in one patient. The perforator-based fasciocutaneous flap is a reliable method and produced good results in this series. These flaps are well vascularised, have enough soft tissue bulk, and have a high degree of mobilisation freedom.     

Modified gate flap for lower lip reconstruction

Summary One of the latest techniques advocated for total lower lip reconstruction is thegate flap described by Fujimori in 1980 [3]. This technique has been modified and used in two patients. With this modification, it is no longer necessary for the lateral margins of resection to extend beyond the commissure for technical purposes, and the shape of the resection does not have to be rectangular. Thus, unnecessary resection of normal tissue and macrostomia are prevented. Widely used reconstruction techniques for large lower lip defects were compared and an attempt was made to explain how to choose the proper technique for a given defect.     

Total reconstruction of the upper lip after resection of a malignant melanoma

The upper lip was totally reconstructed with a radial forearm sensory flap and vermilionplasty using medical tattooing after resection of a malignant melanoma. Three courses of chemotherapy (dacarbazine, nimustine, and vincristine) were given postoperatively. The reconstructed lip had good contour, colour, and sensory recovery.     

Measurement of c-myc oncogene expression provides an accurate prognostic marker for acral lentiginous melanoma.

Acral lentiginous melanoma is a particularly aggressive tumour with a worse prognosis than other varieties of primary cutaneous melanoma. In order to study the biology of this disease, the activity of the c-myc oncogene was studied in tumours from 45 patients using flow cytometry. High levels of oncoprotein were found in all tumours and exceeded that documented in other varieties of cutaneous melanoma. Survival analysis with stratification of patients according to oncogene activity provided a useful prognostic marker with shorter disease free interval (Log-Rank test, chi 2 = 16.7, P < 0.0001) and overall survival (Log-Rank test, chi 2 = 8.9, P = 0.002) in tumours with high oncoprotein levels. Multivariate analysis revealed c-myc oncogene expression to be more accurate in predicting clinical outcome than all existing clinicopathological parameters including the Breslow depth (Cox's proportional hazards model, P = 0.0011). This study provides biological evidence to explain the aggressive behaviour of acral melanoma and supports the application of oncogene measurement as an accurate prognostic marker.     

The angel flap for nipple reconstruction

Creation of an aesthetically pleasing nipple plays a significant role in breast reconstruction as a determining factor in patient satisfaction. The goals for nipple reconstruction include minimal donor site morbidity and appropriate, long-lasting projection. Currently, the most popular techniques used are associated with a significant loss of projection postoperatively. Accordingly, the authors introduce the angel flap, which is designed to achieve nipple projection with lasting results. The lateral edges of the flap and the area surrounding the top of the nipple are de-epithelialized and the flaps are wrapped to create a nipple mound composed primarily of dermis. Decreasing the amount of fat within core of the nipple and enhancing dermal content promotes long-lasting projection. Furthermore, the incision pattern fits within a desired areolar size, preventing unnecessary superfluous extension of the incisions. Thus, the technique described herein achieves the goals of nipple reconstruction, including adequate and long-lasting projection, without extension of the lateral limb scars.     

The faciocervicopectoral flap for non-oncological cases of cheek reconstruction

IntroductionMajor facial defect has been a challenging case for plastic surgeons in terms of wound healing and covering technique for a long time.MethodsEight faciocervicopectoral (FCP) flaps were performed for reconstruction of major cheek defects due to handmade explosive and gun injuries. They were evaluated perioperatively and postoperatively with regard to operative time and operative blood loss as well as the function and cosmetic appearance.ResultsThe technique showed marvellous cosmetic results but encountered minor postoperative flap complications.ConclusionsThe FCP flap is one of the best solutions for coverage of a simple or complex cheek defect. Application of the FCP flap is easy and rapid.     

跖肌腱扇形膜片和腓肠肌腱瓣V-Y成形术治疗陈旧性跟腱断裂

目的　研究跖肌腱扇形膜片和腓肠肌腱瓣V -Y成形术治疗陈旧性跟腱断裂的术式及结果。方法　对 14例平均 89d陈旧性跟腱断裂患者采用跖肌腱扇形膜片和腓肠肌腱瓣V -Y成形术治疗 ,跟腱缺损范围为 3 6～ 7 3cm ,平均为 5 2cm ,跟腱缺损范围较大时 (大于 6 5cm) ,可加用跖肌腱加固术。结果　平均随访 2年 4个月 ,按Arner-Lindholm疗效评定标准评估 ,优 11例 (78 6 % ) ,良 2例 (14 3% ) ,优良率为 93%。结论　跖肌腱扇形膜片和腓肠肌腱瓣V -Y成形术治疗陈旧性跟腱断裂 ,临床疗效满意 ,值得推广。     

耳后联合筋膜皮瓣全耳廓再造的临床研究

目的：探讨颞顶筋膜瓣、耳后筋膜瓣两瓣（简称：耳后联合筋膜瓣）包裹Medpor支架行先天性小耳畸形全耳再造术的方法和效果。方法：手术分为两期：I期采用颞浅动静脉顶支为血管蒂的岛状筋膜瓣,植入残耳乳突区耳后剥离的皮下腔穴,然后植入皮肤扩张器与耳后筋膜皮瓣进行同期同步扩张;II期取出扩张器,将扩张耳后联合筋膜皮瓣包裹Medpor支架行全耳廓再造术。结果：38例患者中,经6个月～3年的随访,再造耳形态结构稳定,颜色与周围皮肤相近,微细结构清晰,颅耳角良好与健耳对称。结论：该方法既可解决覆盖支架的难题,又将手术并发症减少到最低限度,避免支架外露。是目前较为理想的全耳廓再造术的一种新方法。     

Iliac crest free flap and submental island flap for maxillary reconstruction

Abstract

The iliac crest free flap is one of the most reliable flaps for maxillary reconstruction because of the large amount of bone provided and the chance to harvest both muscle and skin. However, reconstruction of maxillary through-and-through defects requires special skills to be managed. Simultaneous replacement of oral lining and external tissue with the same features as the resected skin is difficult to achieve with conventional techniques and the use of flaps association is often necessary to ensure acceptable cosmetic and functional results. In the case presented the submental island flap was a good choice to overcome these difficulties.