Esophageal leiomyomatosis involving trachea: surgical resection and repair.

We report the case of a 26-year-old man with diffuse esophageal leiomyomatosis involving the trachea. The tumor was resected by total esophagectomy and partial resection of the trachea and the left main bronchus. The tracheobronchial defect was repaired with a free forearm skin graft with satisfactory outcome. This approach offers good long-term prospects.

Soft-tissue reconstruction in thoracic surgery.

BACKGROUND: Reconstructive techniques using omental and myocutaneous flaps are widely used in the treatment of infected sternotomy wounds. To illustrate their wider role in thoracic reconstruction, we have retrospectively reviewed our experience over the last 5 years. METHODS: We used complex omental and myocutaneous flaps in 30 patients: 19 men and 11 women with a mean age of 53 +/- 4 years (range, 43 to 75 years). In 18 patients, these techniques were used to provide soft-tissue cover after chest wall resection, and in 12 cases complex myocutaneous flaps were used to obliterate chronic intrathoracic cavities. Rectus muscle was used in 11 of 24 muscle flaps, and omentum was used in 12 cases. There were 23 rotational flaps and seven free myocutaneous flaps with microvascular anastomosis. RESULTS: There were no operative deaths, and there were three complications. In 2 patients with infected lesions, loss of the free flap required subsequent revision. In 1 patient, infection developed underneath a prosthesis, which was treated with drainage and rib resection. In all other cases, the primary aim of the operation was achieved without complications. CONCLUSIONS: The vascularity of the omentum should encourage its wider use, especially when infection exists preoperatively. Excellent results can be achieved when using the rectus muscle as a complex myocutaneous flap. The use of free flaps should be reserved for difficult cases and used only in the absence of infection.

Study of effects of porcine skin and bovine dermis on the healing of split-skin graft donor sites in humans.

A study was undertaken of the effects of heterografts (lyophilized porcine skin or bovine dermis) on the healing of split-skin graft donor sites. When compared with a petrolatum gauze dressing, no advantages were found. Some disadvantages developed, however, which led us to discontinue their use.

Use of apron flap incision for neck dissection.

Neck dissection is one of the most commonly performed surgical procedures in the management of head and neck cancer. Different skin incisions with various modifications have been described in the literature. Three commonly used but conceptually different incisions were compared with respect to the incidence of wound dehiscence in a retrospective review. There were 166 patients with 184 neck dissections carried out using a triradiate (n = 85), modified MacFee (n = 25), or an apron flap incision (n = 74). The incidence of wound dehiscence in the three groups was 11 percent, 8 percent, and 0 percent for the triradiate, modified MacFee, and apron flap incisions, respectively. There was a statistically significant difference in the incidence of wound dehiscence between the apron flap incision and the triradiate incision groups (p = 0.004). The difference in wound dehiscence was not statistically significant between the apron flap incision and the modified MacFee incision groups (p = 0.06). Overall, there was a significant increase in the incidence of wound dehiscence in previously irradiated necks (p = 0.02), but this was significant only for the triradiate incision (p = 0.005) when analyzed individually. Comparison of triradiate, apron, and MacFee incisions did not show a statistically significant difference between the incisions with regard to other postoperative complications in terms of seroma, hematoma, wound infection, and fistula formation. The apron flap incision is the recommended approach in the presence of previous neck irradiation as it gives easier access than the MacFee incision. The robustness of the flap is because of the absence of a trifurcate point as well as a good vascular supply arising from arterial territory of the external carotid artery.

Axillary hyperhidrosis: surgical cure with aesthetic scars.

By using a technique in which the hair-bearing skin of the axilla is undermined through three small incisions the eccrine glands can be methodically removed. The resulting scarring is minimal and is aesthetically acceptable. In a series of 25 patients (50 axillae) 23 were totally cured of their hyperhidrosis. The remaining 2 patients were sufficiently improved not to require any further treatment. The technique may be undertaken under either local or general anaesthesia.

The anaesthetic management of patients undergoing free flap reconstructive surgery following resection of head and neck neoplasms--a review of 64 patients.

A retrospective study was made of 64 patients who underwent free flap reconstructive surgery following resection of neoplasms, mainly in the head and neck region, over a period of approximately 4 years, from 1983 to 1987, in the Royal Marsden Hospital, London. A brief history of free flap surgery is presented, followed by a description of the anaesthetic technique used, and the results of the study. The various ways in which anaesthetic management may influence the results of surgery are discussed.

The successful closure of a colono-cutaneous fistula in the neck.

A case is presented of the successful closure of a colono-cutaneous fistula in the neck, which developed twenty-one years after pharyngo-laryngectomy. A pectoralis major muscle flap and a delto-pectoral skin flap were used.

Seeding of a parotid pleomorphic adenoma.

Recurrent pleomorphic adenoma of the parotid usually occurs in the distribution of the primary procedure. There are numerous reports of widespread local recurrence and a few reported cases of distant metastases. Extensive seeding throughout the entire ipsilateral neck is rare. Treatment involves a combination of radical surgery and radiotherapy. The potential for malignant transformation demands close follow-up of younger patients particularly.

The use of free tissue transfer in reconstruction following head and neck tumour resection.

Experience in the use of free vascularised tissue flaps in reconstruction following major head and neck resections for malignant disease has been described. The benefits of the use of free flaps are improved function and cosmesis with more rapid rehabilitation and reduced in-patient stay in a group of patients, many of whom had a limited life expectancy. The disadvantages of this technique are the need for special equipment and for medical and nursing staff trained and experienced in this type of work.

Aggressive cutaneous squamous cell carcinoma of the head and neck in patients with chronic lymphocytic leukaemia.

We describe multiple cutaneous squamous cell carcinomas of the head and neck in five patients with chronic lymphocytic leukaemia (CLL). When associated with CLL, cutaneous squamous cell carcinomata behave in a much more aggressive manner than otherwise expected. Four patients developed local recurrence after primary treatment. All five patients developed lymph node metastases containing squamous cell carcinoma. Three of five patients (60 per cent) had multiple primary lesions. Whereas the increased incidence of second cancers in CLL and notably of skin cancers is documented, little has been written to describe the aggressive behaviour of these tumours. It is important, when treating these patients, to be aware of the high tendency towards local recurrence and lymph node metastasis and to consider an aggressive management plan and careful follow-up.

The repair of defects in the head and neck region with the latissimus dorsi myocutaneous flap.

There are many different flaps available for head and neck reconstruction. The latissimus dorsi myocutaneous flap has been widely used in this unit on 80 occasions in the past three years, both as a pedicled and as a free microvascular flap following the excision of head and neck malignancy, the commonest pathology being intraoral squamous cell carcinoma. There were nine cases of complete or substantial flap loss requiring a further reconstructive procedure. Few of the patients who underwent total glossectomy suffered from overspill or aspiration and the fistula rate was low. Reference is made to the anatomy and the technique of raising this versatile flap which provides a large volume of tissue and has been particularly useful following total glossectomy when combined with a hyoid hitch.

Malignant triton tumour of the palate--a case report.

The malignant Triton tumour is a malignant schwannoma with rhabdomyoblastic differentiation. This is the first report of this type of rare, aggressive sarcoma arising in the maxilla and only the third report of this type of pathology arising outside the context of von Recklinghausen's disease. Aspects of clinical and histopathological diagnosis are mentioned.

Pre-auricular full-thickness skin grafts.

The use of the pre-auricular region as a donor site for full-thickness skin grafts is described. It provides a valuable source of skin for the medial canthal-nose, eyelid-cheek areas, providing a good colour and texture match.

Free flaps in head and neck reconstructive surgery: a review of 77 cases.

Recent advances in surgical technique and instrumentation have ensured that success rates for microvascular free transfer can now exceed 90%. This paper reviews a prospective study of 77 free flaps performed at the Royal Marsden Hospital under the care of one surgeon (NMB) over a 2-year period. 76 patients who underwent 77 free flaps were studied. 68 patients had malignant tumours and 8 had benign lesions. The flap success rate was 95% and the mortality rate 0%. The major complication rate was 20% and the most common complication was a salivary fistula (12%). Microvascular free transfer to the head and neck is not associated with increased morbidity and mortality. It offers single stage, reliable, effective reconstruction using a wide variety of donor sites and tissues.

Eusol: the plastic surgeon's choice?

Many products are currently promoted for use on wounds. Edinburgh University Solution of Lime (Eusol) has recently received adverse publicity regarding its use in wound management. One hundred and twenty-four consultant plastic surgeons were surveyed regarding their use of Eusol. Ninety-five replies were obtained (77%); of those who replied, 78 (82%) still use Eusol, while nine out of 17 who do not are prevented from using it as they are unable to obtain necessary supplies. In plastic surgery, Eusol is still being used by plastic surgeons in specific situations.

Treatment of desmoid tumours in Gardner's syndrome.

A 24 year old woman with Gardner's syndrome developed a massive chest wall desmoid tumour, which required radical excision and prosthetic reconstruction. In view of the local aggressiveness of this tumour and the fact that it does not metastasize a policy of radical surgery when possible is recommended.

Sternoclavicular joint swellings: diagnosis and management.

Five patients with sternoclavicular swellings are described. The group presents a variety of diagnoses which highlight the need for thorough investigation and appropriate management of swellings around the sternoclavicular joint. Although frequently assumed to be benign, this series demonstrates the potential occurrence of malignant disease, and the dangers of pursuing a simple conservative course. Conversely, a substantiated benign diagnosis may avoid the use of unnecessary surgical treatment.

Reconstruction of the mandible with autogenous bone following treatment for squamous carcinoma.

In a series of 24 patients treated for squamous carcinoma of the oral cavity and oropharynx, 26 mandibular reconstructions using 27 grafts or flaps were performed. Reconstruction was immediate in 23 cases and delayed in three. There were five 'simple' bone grafts, 10 pedicled compound myocutaneous flaps, and 12 vascularized free compound flaps. Operative mortality was 12% and complication rate 65%, but 70% of the grafts survived till death or follow-up of the patients. Three 'simple' bone grafts failed and were removed. Three of five compound pectoralis major flaps failed along with one of five pedicled compound latissimus dorsi flaps. Only one vascularized free compound flap was lost. The major cause of graft failure was intra-oral suture line dehiscence exposing the bone to saliva. Under these circumstances, bone graft necrosis occurred when blood supply to the bone was poor--viz. 'simple' grafts and compound pectoralis major flaps. The vascularized free compound flaps were most reliable but the need for jaw preservation where possible and better patient selection are recognized.