Galeal-pericranial flaps in head and neck reconstruction. Anatomy and application.

Head and neck deformities of congenital, traumatic, or neoplastic cause often require reconstruction. At the University of Virginia over the past 14 years, we have used galeal, temporalis fascial, and pericranial flaps to correct these defects in more than 150 patients. Dissection of these flaps on both cadavers and reconstructive patients had demonstrated new anatomic findings different from those reported in standard textbooks. The galea is the most superficial layer of fascia. The pericranium is the next tissue layer. It is continuous above and separate from the temporalis muscle fascia. We may, therefore, consider three separate fascial layers for reconstruction. A rich vascular plexus arises from branches of the external and internal carotid arteries. Blood flow is axial to the galea and temporalis fascia. Pericranium has a dual supply from peripheral axial vessels and from perforating vessels from the overlying galea. Galeal, temporalis fascial, and pericranial flaps are reliable, thin, and supple and have a good arc of rotation and minimal donor site morbidity. They may be used to cover bone, cartilage, or implants, may be folded for bulk, may be used to carry blood to poorly vascularized recipient sites, or may be used to nourish bone, cartilage, skin, and mucosal grafts. Their versatility permits a wide variety of potential applications in head and neck surgery.

Excision of multiple epidermal facial cysts in Gardner's syndrome.

A rhytidectomy incision is recommended to excise multiple facial epidermal cysts in patients with Gardner's syndrome. The advantage of this approach is that it permits excision of excess skin over the cyst with esthetically pleasing hidden scars. The alternative to this procedure, a separate incision over each cyst, results in disfiguring and conspicuous scars.

Surgical management of vascular malformations of the head and neck.

The evaluation and treatment of non-involuting hemangiomas with arteriovenous components and arteriovenous malformations of the head and neck remain difficult. Surgical excision is still the most important and effective method of controlling these lesions. Radiotherapy should never be used. It is ineffective, dangerous, and often complicates any later operation that may be required. Evaluation of vascular malformations with computerized tomography, arteriography, magnetic nuclear imaging, and Doppler mapping will aid diagnosis. Adjunctive hypotensive anesthesia, intraoperative embolization with Gelfoam, and temporary peripheral suture ligations have made the surgical task more manageable. The integration of reconstructive techniques into the surgical program is essential if optimum results are to be obtained. Incisions must be planned so that future flap patterns are preserved. Axial vessels may be needed later. Fascial slings, muscle transfers, nerve grafts, and tissue expansion of adjacent normal tissue may be needed to maintain and restore function and features. Above all, the treatment of each patient requires individual planning. The most common errors in the treatment of vascular hemangiomas result from missed diagnoses and faint-heartedness in tackling the surgical removal of such highly vascular tumors. Many patients go for years without finding a surgeon who will help them. We believe that aggressive surgical treatment offers much to many of these patients.

External cranioplasty: historical perspectives.

Selective external cranial vault remodeling has been practiced since antiquity. The variations, methods, and desired results of external cranioplasty are as pervasive as the practice is old.

Emergency department management of puncture wounds and needlestick exposure.

Puncture wounds are common and challenging problems facing the physician. In general, puncture wounds can be classified into two distinct types. In one type, a child usually sustains a puncture wound of the foot. The other type of puncture wounds occur among hospital employees. These seemingly innocuous injuries may have serious sequelae that can be averted by prompt appropriate care of the wound. The fundamental trends of treatment of puncture wounds include cleansing the wound, débridement of any necrotic or devitalized tissue, and appropriate immunoprophylaxis.

Toxic epidermal necrolysis.

Toxic epidermal necrolysis (TEN) is a symptom complex characterized by a devastating skin disorder, erosive involvement of two or more mucous membranes, and severe constitutional symptoms. The disorder shares features with erythema multiforme and is thought to be an expression of the syndrome. Although a wide range of etiologic factors have been incriminated in TEN, only a few cases have provided convincing evidence of a direct causal link. Most cases of TEN have been associated with drug administration.

Clinical syndromes caused by staphylococcal epidermolytic toxin.

Coagulase-positive staphylococci of phage group II produce an epidermolytic toxin that results in a spectrum of diseases that include localized bullous impetigo, generalized scarlatiniform syndrome without exfoliation, and staphylococcal scalded-skin syndrome (SSSS). The mechanism of action of the toxin occurs at the level of the lower stratum granulosum, resulting in intraepidermal cleavage. Generalized exfoliative dermatitis, or SSSS, is one of the most severe infections characterized by generalized epidermolysis with desquamation. Generalized scarlatiniform syndrome is an erythematous rash without exfoliation. A localized infection that results in a bulla larger than 5 mm in diameter is bullous impetigo.

The late treatment of vertical orbital dystopia resulting from an orbital roof fracture.

Traumatic fracture of the orbital roof is uncommon and it may be unrecognized at the time of injury. In this article we describe a patient with progressive vertical orbital dystopia four years after he sustained a fracture of his "frontal" bone. Surgical exploration revealed an orbital roof fracture complicated by a chronic dural leak. An intracranial-extracranial approach through a modified frontal craniotomy provided excellent visualization to elevate the bony orbit and globe safely and repair the dural tear. Our study illustrates the need to correct residual soft tissue deformity at a second operation. Orbital roof fracture is a complex injury and is best treated by a multispecialty team using the methods learned from the treatment of patients with congenital orbital dystopia.

Lawnmower injuries in children: lower extremity reconstruction.

Power lawnmower accidents are one of the most frequent causes of mutilating injuries in pediatric patients. Guidelines for the optimal surgical management of children differ from adult patients by several key anatomic, physiologic, and rehabilitative features. Small blood vessels in children less than 2 years old may prohibit microvascular surgery. Older children with larger vessels are often better candidates for microvascular flaps than their adult counterparts. Pediatric patients also resist recurrent ulceration of foot skin grafts, tolerate prolonged immobilization, and are rehabilitated more readily than adults. In considering these facts, we outlined an algorithm for surgical reconstruction. Split-thickness skin grafts are generally the first choice for coverage. The medial gastrocnemius is the workhorse of the knee and upper third leg. The soleus provides coverage for the middle third leg; microvascular flaps are used for large lower third leg defects. Crossleg fasciocutaneous flaps are good alternatives when microsurgery is not feasible. When possible, the weight-bearing surface of the foot should be covered with local vascularized sensate flaps; larger defects may require free flaps, crossleg, or gluteal-thigh flaps. Excellent functional rehabilitation has been achieved in our young patients through the combined efforts of the trauma service, plastic and orthopedic surgery, and physical and occupational therapy services.

The omentum as an untapped reservoir for microvascular conduits.

The use of the omentum as a source for vessel grafts is recommended when long or multiple vessel conduits are needed and when a combination of vessel grafts and soft tissue are needed. It is particularly suitable in reconstructing the superficial palmar arch but may also provide an immense graft reserve for the imaginative and careful surgeon.

A digit replantation model.

A simple, inexpensive, reproducible, and reliable model for digital replantation is described utilizing the rabbit ear. When compared to the human digit, it provides benefits over previous models. It is of similar tissue type and characteristics. The vessels closely approximate the digit in size and number. Results are easily quantified and the opportunity for a paired control in the same animal exists. Therefore, experimental design and statistical calculations may be simplified. The model can function for either replantation or revascularization with only slight changes in its preparation. Survival rates have been over 90%. In addition, the model provides an excellent forum for the development of technical expertise in the aspiring microvascular surgeon.