Substernal goiter with superior vena caval obstruction.

Substernal goiter with vena caval obstruction remains an interesting diagnostic and therapeutic problem. Since 85 to 90 percent of superior vena caval obstructions are due to a malignant disease, an intrathoracic goiter represents one of the benign, curable causes of this syndrome. This report describes the clinical course of a 44-year-old woman who presented with this entity and was successfully corrected by surgical intervention. A discussion of diagnostic, operative, and prognostic considerations is presented.

Fibrin glue inhibits intra-abdominal adhesion formation.

To determine the effect of fibrin glue on intra-abdominal adhesion formation, 45 rats were randomized to three groups. Each animal received two adhesion models. Group 1 received no further treatment. Groups 2 and 3 had the adhesion models covered with fibrinogen from fresh frozen plasma (1.77 g/L) and cryoprecipitate (23.6 g/L), respectively. In group 1, 13 of 15 rats had high-grade adhesions in both models. In group 2, high-grade adhesions were noted in nine of 15 rats in model 1 and in 12 of 15 rats in model 2. In group 3, however, high-grade adhesions were seen in only three of 15 rats in model 1, with 11 rats having no adhesions, and in only two of 15 rats in model 2. Histologic analysis suggested accelerated healing in group 3. We conclude that (1) fibrin glue inhibits intra-abdominal adhesion formation in rats, (2) the inhibitory action is dependent on the fibrinogen concentration of the fibrin glue, and (3) adhesions are reduced by fibrin glue regardless of whether the peritoneal defect is closed.

Umbilicus preservation with total abdominal wall reconstruction in prune-belly syndrome.

A technique to preserve the umbilicus in abdominal wall reconstruction for prune-belly syndrome is presented. Our technique has been utilized in 5 cases with success.

Vaginal reconstruction.

Vaginal reconstruction can be an uncomplicated and straightforward procedure when attention to detail is maintained. The Abbé-McIndoe procedure of lining the neovaginal canal with split-thickness skin grafts has become standard. The use of the inflatable Heyer-Schulte vaginal stent provides comfort to the patient and ease to the surgeon in maintaining approximation of the skin graft. For large vaginal and perineal defects, myocutaneous flaps such as the gracilis island have been extremely useful for correction of radiation-damaged tissue of the perineum or for the reconstruction of large ablative defects. Minimal morbidity and scarring ensue because the donor site can be closed primarily. With all vaginal reconstruction, a compliant patient is a necessity. The patient must wear a vaginal obturator for a minimum of 3 to 6 months postoperatively and is encouraged to use intercourse as an excellent obturator. In general, vaginal reconstruction can be an extremely gratifying procedure for both the functional and emotional well-being of patients.

Surgical management and reconstruction of extensive chest wall malignancies.

Seven patients aged 8 to 77 years underwent massive resection for chest wall malignancies. Two had chondrosarcoma, one recurrent breast cancer, one malignant hemangioepithelioma, one embryonal cell sarcoma, one metastatic osteogenic sarcoma, and one lymphangiosarcoma. The smallest surgical defect was 17 by 19 cm, the largest 35 by 45 cm. Closure was done with Marlex mesh, full-thickness muscle flaps, or free island pectoralis or latissimus dorsi flaps. The rotation of myocutaneous island flaps (bilateral in two patients) greatly facilitated reconstruction. No infection, pulmonary compromise, or operative morbidity or mortality was encountered. The age of the patients and the location or size of the lesions were not significant factors. Designing a surgical strategy which provides adequate full-thickness margins and immediate reconstruction is critically important. Massive chest wall resection for malignancy should be pursued aggressively whenever these lesions are encountered. The operations can be performed safely and can be curative, and the benefits to patients in terms of comfort and prolonged survival justify this extensive surgery.

Correlation of compound action potential and electromyography with facial muscle tension.

Functional electric stimulation is a new method for dynamic rehabilitation of paralyzed muscles. The output of such prosthetic devices needs to be modulated by some index of the muscle movement. In facial paralysis a measure of the muscle contractions of the normal contralateral side seems to be an appropriate input. In the rabbit, we simultaneously measured the compound action potential of the buccal branch of the facial nerve, the electromyogram of the zygomaticus major muscle, and the muscle twitch tension through strain gauge. The compound action potential, electromyogram, and strain gauge each had a sigmoidal relationship to stimulus intensity. The compound action potential peak-to-peak amplitude was found to have a linear correlation to the peak twitch tension of the corresponding facial muscle. The electromyogram response, although more variable, also had a linear correlation with muscle contraction. The possibility of predicting the contraction of facial muscles before they actually occur is discussed in the context of available and future functional electric rehabilitation models.

Successful replantation of lower leg and foot, with good sensibility and function.

The successful replantation of the lower part of a leg with the foot is reported in a 17-year-old boy. Adequate protective sensibility was obtained, and he walks well with a 3-inch lift on that shoe. He is also able to hike, climb, swim, dive, and engage in most normal activities. The pros and cons of leg replantation are considered.

A new "puppet procedure" for functional movement of totally deanimated tri-nerve paralysis below the elbow.

A new procedure has been described to provide functional reconstruction in the rare occurrence of paralysis of the median, ulnar, and radial nerves below the elbow. When the only function that remains is elbow flexion and extension, various tenodeses can be accomplished to use the elbow motion to power finger flexion and extension against a nonmoving thumb acting as a functional post.

Conservative treatment of cutis aplasia.

Three cases of cutis aplasia are presented. The defects involved include full-thickness defects of scalp and cranium as well as full-thickness skin defects of the abdomen and thigh. All patients were treated conservatively with the use of Silvadene cream dressings. Healing was obtained in all patients.

A technique for correcting witch's chin deformity.

A new technique for soft-tissue correction of the retraced submental fold in the Witch's Chin deformity is described. An illustrative case report demonstrating our technique, results, and the pathogenesis of this condition is presented. An anatomical analysis of the underlying etiology of the condition and tailored treatment strategies are outlined.

Correction of asymmetric nostrils (alae) by columella transposition.

A new method for correction of asymmetric alae is presented. Asymmetric alae frequently follow nasal, columellar, and alar reconstruction, and the resulting distortion can pose a reconstructive dilemma. Correction of these deformities can require complex composite grafting or tissue rearrangement procedures. By transposing the columella, we have equalized asymmetric nostrils without introducing new tissue to the region. Although not appropriate to all types of alar discrepancy, this novel method, where applicable, is safe, reliable, and does not produce significant visible scarring or donor site morbidity.

Secondary correction of the too-high areola and nipple after a mammaplasty.

Two cases of nipples placed too high by reduction mammaplasties have been corrected by a combination of maneuvers--including (1) shortening the distance from the nipple to the inframammary line, and (2) repositioning of the areola-nipple component or putting in an implant to make the main projection of the breast directly behind the nipple.

Malignant hyperthermia in plastic surgery.

Malignant hyperthermia is a seemingly rare genetic myopathy. Hypermetabolic crisis accompanied by a rise in body temperature to as high as 44 degrees C is its hallmark. Malignant hyperthermia is usually triggered by potent inhalated anesthetics and/or depolarizing muscle relaxants. Because of the extraordinary risk of death in patients who are at risk, plastic surgeons may be reluctant to operate on these patients. Five such patients were referred to the Plastic Surgery Service and the UCLA Malignant Hyperthermia Center for anesthetic and surgical management following plastic surgical procedures aborted for first episodes of malignant hyperthermia. They were anesthetized with nitrous oxide, barbiturates, opiates, tranquilizers, and nondepolarizing muscle relaxants. The patients were not treated prophylactically with dantrolene. Cardiac monitoring, end-tidal pCO2, and rectal temperatures were followed. After completion of their plastic surgical procedures, all five patients had a vastus lateralis muscle biopsy performed and subsequent caffeine/halothane contracture studies completed. The contracture study was positive in all patients studied. No anesthetic or surgical complications were encountered. This study demonstrates that patients at risk of developing malignant hyperthermia crisis can have plastic surgical procedures performed safely while undergoing appropriately selected general anesthesia.

Muscle-flap coverage of exposed endoprostheses.

A well-entrenched tenet in the orthopedic community is that dehiscent wounds overlying exposed endoprostheses should be treated by implant removal and delayed reconstruction. A new management protocol utilizing thorough soft-tissue debridement and myocutaneous or muscle-flap coverage was evaluated in four patients at the UCLA Medical Center who presented with exposed endoprostheses. These prostheses were placed for total-joint replacement or limb salvage surgery. All four prostheses and extremities were salvaged without the need for endoprosthesis removal or exchange, and no infections developed. The results suggest that late aseptic wound dehiscence with an exposed endoprosthesis need not be managed with prosthetic removal, arthrodesis, or amputation. This one-stage procedure avoided infection, allowed early mobilization, and shortened hospitalization.

Familial lymphedema praecox: Meige's disease.

Familial lymphedema should be classified in two categories depending on onset. Milroy's disease, or congenital hereditary lymphedema, is present from birth, painless, without tendency to ulcerate, and may have cholestasis or intestinal lymphangiectasia associated with it. Meige's disease, hereditary lymphedema praecox, is lymphedema with onset in the first or second decade, often presenting with inflammation, and may have a number of associated related anomalies including distichiasis, extradural cysts, vertebral anomalies, cerebrovascular malformation, yellow nails, and sensorineural hearing loss. Both types follow an autosomal dominant pattern. This paper presents a family of 39 persons in 5 generations with 13 affected persons having Meige's disease. The importance of recognizing this type of familial lymphedema is discussed.

"Sensible" flap coverage of pressure sores in patients with meningomyelocele.

Restoration of sensibility in the paraplegic patient is the optimal therapy for the management and prevention of debilitating pressure sores. In patients with an absence of sensibility below the L3 spinal level, a locally transposed arterialized neuromyocutaneous gracilis flap may be uniquely utilized for ischial restoration of sensibility. Two patients with meningomyelocele-induced ischial pressure sores underwent local innervated neuromyocutaneous gracilis flap transposition to insensate areas from below the anatomic level of recipient insensibility. A 10-year follow-up revealed maintenance of sensibility in the flap and spread of sensibility to adjacent insensate areas with no evidence of pressure sore recurrence. Cadaver dissection and clinical Xylocaine injection demonstrated that the cutaneous sensory innervation to this flap is by means of a consistent sensory branch from the deep neurovascular pedicle, which coincides with the L1-L3 dermatome.

A new nerve pedicle for finger sensibility: the dorsal digital sensory nerve.

Restoration of sensibility to the traumatized finger can be a difficult problem. Two patients with insensibility to the volar distal finger after trauma underwent delayed digital nerve repair. In the first patient, the dorsal branch of the radial proper digital nerve was approximated to the distal stump as a pedicle to span a 12-mm gap resulting from neuroma excision. The second patient had a 14-mm defect after scar-tissue excision 8 months following primary neurorrhaphy after trauma. Reconstruction was performed by approximating the dorsal branch of the radial proper digital nerve to the distal stump. Both patients had fingertip sensibility restored 1 year postoperatively, as documented by two-point discrimination. Anatomic dissections of 12 fresh cadaver fingers revealed a consistent pattern. Of the 24 proper digital nerves dissected, 23 had a distal dorsal sensory branch arising at the midportion of the proximal phalanx. The dorsal branch-vascularized pedicle of the proper digital nerve has not been described previously as a method for restoring finger sensibility in cases not amenable to primary neurorrhaphy. We believe this technique should be added to the repertoire of the practicing hand surgeon.

Management of large scalp defects with local pedicle flaps.

Recent reports have emphasized free-flap reconstruction for large defects of the scalp and calvarium following resection of tumors, infection, or trauma. In most cases, however, a carefully planned local transposition or rotation flap may be equally effective, and the technical difficulties and donor-site problems associated with microsurgical tissue transfer are then avoided. We present 10 patients whose full-thickness scalp defects covered an average area of 241 cm2, or 27 percent, of the skull surface. Although this series included defects as large as 450 cm2, or 50 percent, of the skull surface area, each was easily managed with a local pedicle flap transfer. Four patients were reconstructed with parietal scalp transfer, four with an occipital scalp flap, and two with temporal scalp transfer. The technique and results are discussed.