Scrotal reconstruction for giant inguinal hernias.

A case of inguinal hernia with massive scrotal enlargement is presented. Walking and voiding had become extremely difficult for the patient; only one testicle could be palpated, and the penis could not be delivered from the scrotal mass. Surgical reduction of the massive hernia was accomplished. The right testis with its spermatic cord had to be sacrificed; the left one was normal, although the cord was elongated. The main bulk of the enlarged scrotum was excised, and a neoscrotum was created from perineal skin; orchiopexy on the left was carried out. Healing has been uneventful.

Extra-adrenal intrathoracic functioning paraganglioma (pheochromocytoma) in childhood.

Extra-adrenal pheochromocytomas are more common in children (30%) than in adults (10%). Of the extra-adrenal sites, the intrathoracic site is the most rare. A 15-year-old boy had a pheochromocytoma successfully removed from the left paraspinal region of his chest. Four years before removal, he had radiation therapy of 3,500 rads to the tumor because of its apparent nonresectability. After therapy, there was transient clinical and biochemical improvement. Preoperative angiography and computed tomography helped define the anatomy of the tumor vessels and the relationship to the thoracic aorta of the tumor. These studies also aided in discounting any other site for the pheochromocytoma, either adrenal or extramedullary. A slow-growing pulmonary metastatic lesion was subsequently identified and successfully excised.

Pancreatic cystadenoma. A clinicopathologic study of 45 cases.

Forty-five patients with pancreatic cystadenoma were treated surgically at the Mayo Clinic between 1939 and 1975. Each lesion was classified as mucous or serous. The most frequent lesion site was the tail of the pancreas. The typical patient was a middle-aged woman with upper abdominal pain and a palpable mass on initial examination. Total extirpation of the cystadenoma was the treatment of choice; internal drainage or external drainage of these cysts should not be done. Occasionally, the nearness of the tumors to the mesenteric vessels precluded excision. The mucous type had malignant potential whereas the serous does not. None of the cystadenomas subsequently underwent malignant degeneration. Because of the slow-growing characteristics of the tumor, undue operative risks should not be taken.

Scrotal reconstruction for giant inguinal hernias.

Giant inguinal hernias require special consideration for repair of the abdominal wall. The associated greatly thickened, enlarged scrotum should be discarded and a neoscrotum should be reconstructed from the uninvolved perineal-scrotal skin. A cloverleaf design flap is used for this reconstruction.

Subungual osteochondroma.

Subungual osteochondromas are rare tumors that occur in the toes and fingers. This case report of a large subungual tumor of the right ring finger demonstrates the classic radiologic features and successful management of a large tumor by complete excision of the nail bed and the tumor and reconstruction of the distal nail bed with a split-thickness nail bed graft from the great toe.

Aesthetic vaginal labioplasty.

Labia minora that protrude past the labia majora are aesthetically and functionally unsatisfactory to some women. Historically, female circumcision has been practiced in Islamic/Arabic countries for many centuries and is still commonly practiced in these countries. Three case reports present middle-aged women who were dissatisfied with the size and protuberance of the labia minora, and an aesthetic labioplasty was performed in these three women. The technical aspects of this procedure are outlined, and a representative case with 3-month follow-up is presented pictorially.

Extensor digitorum turn-down muscle flap.

When the extensor digitorum longus--a multisegmentally vascular-supplied muscle--is rotated distally, its origin can be used for covering defects in the lower one-third of the leg. We have used this technique successfully in four consecutive patients, and it has resulted in osteomyelitic cavity obliteration in three and a stable skin coverage in all four.

The pectoralis major myocutaneous flap for intraoral reconstruction: a word of warning.

The pectoralis major myocutaneous flap is an extremely versatile flap in head and neck reconstruction. However, failure to drain adequately the neck and chest wounds may lead to serious trouble should a fistula develop. A case report is presented as a cautionary tale.

Medial thighplasty, prevention of scar migration, and labial flattening.

As more people seek body contour surgery spurred on by the media's great interest in suction lipectomy and the seemingly increasing numbers of satisfied patients, we should re-examine an area where results of body contour surgery have been less satisfying, the inner thigh. In those patients whose problem remains skin flabbiness rather than excessive fat, either alone or after successful or partially successful suction lipectomy, an inner-thigh procedure is indicated.

The olecranon bone graft for nasal augmentation.

The olecranon bone graft offers an alternative to the cranial bone when autogenous material is preferred in the repair of moderate deficiencies of the nasal dorsum. The predictably thick cortex of the olecranon allows the crafting of a customized implant, and minimal donor site morbidity makes it a safe alternative to the cranial graft.

Chest wall deformities and their correction in bodybuilders.

Torn pectoralis major muscles are either treated acutely by orthopedic surgeons or, if neglected, result in deformities of the pectoralis muscle. These deformities are visible, with pectoralis muscle asymmetry, especially on muscle contraction. Bodybuilders prone to this injury accentuate the asymmetry by contracting the pectoralis muscles together. Late repair is not usually possible, and cosmetic improvement relies on removing the bulging, unattached muscles or camouflaging the underlying exposed ribs with a customized implant. Similar customized implants are used to repair pectus excavatum. Techniques must take into consideration the desire for accentuation of the pectoralis muscle with minimal visible scarring. The surgeon and the anesthesiologist should be aware of the possibility of anabolic steroid ingestion in the male body-builder.

Umbilicoplasty: conversion of "outie" to "innie".

The protuberant "outie" umbilicus is regarded by some patients to be unattractive and undesirable. Surgical conversion of the protuberant umbilicus to a tubular structure is accomplished by excising the mass of umbilical scar and utilizing 2 skin flaps, one to line the reconstructed tube and the other to form the superior hood of the tubular "innie" umbilicus.

Buckled upper pole breast style 410 implant presenting as a manifestation of capsular contraction.

Recent experience with the cohesive gel implant has shown an interesting variation of capsular contracture. Instead of spherical contraction, the capsule formation around the 410 implant seems to cause a buckling of the superior pole of the implant. This buckling has been observed in four implants and presented clinically in 2 of 50 patients with a superior pole mass. The capsular contraction around the implant and the buckling are probably camouflaged by a subpectoral implantation and this presentation should be recognized by the surgeon, especially when considering placement of the cohesive gel implant in a subglandular position. Histological sections of a capsule around the implant show fragmented silicone, with a cellular reaction around the fragmented silicone.

Reconstruction of the upper lip with lip switch (Abbe flap reconstruction).

The lip switch operation (Abbe) is useful for full thickness defects of the upper lip. Careful design of the flap with pedicle take-down and inset of the flap after 2 weeks, leads to a predictably good reconstructive result. The flap is most useful for 30-50% full thickness defects of the upper lip.

Chest wall implants: their use for pectus excavatum, pectoralis muscle tears, Poland's syndrome, and muscular insufficiency.

Solid customized and prefabricated silicone implants have been used by the author for 15 years in a wide range of chest wall deformities. Chest wall implants are often used in males seeking to augment a muscularly deficient or underdeveloped chest; however, their greatest use has come in a variety of deformities both congenital and acquired, such as pectus excavatum, Poland's Syndrome, and pectoralis muscle tears. The implants can be either customized using a moulage technique or are prefabricated, manufactured implants which can be modified on the operating table to repair the contour deformity. The immediate postoperative problem of seroma and subcutaneous implant "show" has been minimized by careful planning, gentle technique, deep insertion, improved patient positioning on the operating room table, and the use of oral anti-inflammatory medications. The long-term results of these implants seem very satisfactory. The patients are usually physically active, and the implants show no long-term sequelae such as seroma, infection, displacement, or rupture.

The use of mimetic musculature in facial reconstruction.

Skin malignancy of all types is prevalent in Australia and the incidence is rising. Reconstruction of post-surgical excision defects in the face can be facilitated by the use of myocutaneous flaps using facial mimetic musculature. The mimetic musculature can be partially sacrificed without the loss of discernible facial tone or expression. Examples of their use include the frontalis, orbicularis oculi, nasalis, procerus, levator labii superioris, mentalis, orbicularis oris, platysma and SMAS. Myocutaneous flaps in the face enjoy the same advantages of increased skin viability as they do elsewhere in the body. Their use in the face is superior to the cosmetic results obtained by skin grafting alone or distant skin flap giving better colour match, increased vascularity and appropriate bulk when subcutaneous tissues and muscles have also been sacrificed in the initial extirpation of the skin malignancy.