Malignant Peripheral Nerve Sheath Tumour in the Urinary Bladder of a Dog.

A 15-year-old neutered male miniature pinscher was presented with a pedunculated mass (4 × 1 cm) in its urinary bladder. Exploratory cystotomy revealed that the mass was located at the trigone of the bladder and projected into the lumen. The cut surface of the mass was homogeneous grey to tan in colour with focal brown pigmentation. Microscopically, the mass was predominantly composed of neoplastic spindle cells characterized by moderate cellular pleomorphism, invasion into the muscular layer of the bladder wall and few mitotic figures. The neoplastic spindle cells formed interwoven bundles intersecting at various angles. Immunohistochemically, these cells were negative for cytokeratin 7 and α-smooth muscle actin, but strongly expressed S100 and vimentin, confirming a diagnosis of a malignant peripheral nerve sheath tumour (PNST). To the best of our knowledge, this is the first report of a primary malignant PNST in the urinary bladder of a dog.

Efficacy and Safety of Ethanol Ablation for Branchial Cleft Cysts.

BACKGROUND AND PURPOSE: Branchial cleft cyst is a common congenital lesion of the neck. This study evaluated the efficacy and safety of ethanol ablation as an alternative treatment to surgery for branchial cleft cyst. MATERIALS AND METHODS: Between September 2006 and October 2016, ethanol ablation was performed in 22 patients who refused an operation for a second branchial cleft cyst. After the exclusion of 2 patients who were lost to follow-up, the data of 20 patients were retrospectively evaluated. All index masses were confirmed as benign before treatment. Sonography-guided aspiration of the cystic fluid was followed by injection of absolute ethanol (99%) into the lesion. The injected volume of ethanol was 50%-80% of the volume of fluid aspirated. Therapeutic outcome, including the volume reduction ratio, therapeutic success rate (volume reduction ratio of >50% and/or no palpable mass), and complications, was evaluated. RESULTS: The mean index volume of the cysts was 26.4 ± 15.7 mL (range, 3.8-49.9 mL). After ablation, the mean volume of the cysts decreased to 1.2 ± 1.1 mL (range, 0.0-3.5 mL). The mean volume reduction ratio at last follow-up was 93.9% ± 7.9% (range, 75.5%-100.0%; P < .001). Therapeutic success was achieved in all nodules (20/20, 100%), and the symptomatic (P < .001) and cosmetic (P < .001) scores had improved significantly by the last follow-up. In 1 patient, intracystic hemorrhage developed during the aspiration; however, no major complications occurred in any patient. CONCLUSIONS: Ethanol ablation is an effective and safe treatment for patients with branchial cleft cysts who refuse, or are ineligible for, an operation.

Refinement in aesthetic contouring of the prominent mandibular angle.

Oriental women, in general, greatly desire a more delicate and feminine facial shape. This can be obtained by contouring the prominent mandibular angles that give a strong, masculine image. Western authors regarded masseteric muscular hypertrophy the main cause of a square facial appearance, so they usually corrected it by partially excising the masseter muscle. In the authors' view, a square facial appearance in the Oriental is not due to masseteric hypertrophy but to a posterior projection and lateral flaring of the mandibular angle. However, it is sometimes difficult to make the square face narrow and ovoid by using only the conventional curved-angle osteotomy. We divided patients, whose chief complaint was a square facial appearance, into three groups after clinical, photographic, and radiographic evaluation. We applied different contouring methods to each of the three groups and obtained cosmetically improved facial appearance in both lateral and frontal views.

Profiloplasty of the lower face by maxillary and mandibular anterior segmental osteotomies.

Maxillary and mandibular anterior segmental osteotomies (ASO) are ways to correct disharmony in the lip (contour, lip seal, and profile) and occasional dentoalveolar malocclusion. We performed 23 maxillary setback ASO, three maxillary advancement ASO, 21 mandibular setback ASO, and six mandibular advancement ASO in 28 patients to improve their lower facial profile. Other combined operative procedures include nine LeFort 1 osteotomies, four bilateral mandibular ramus osteotomies, two genioplasties, four mandibular angle contouring procedures, two reduction malar plasties, two piriform augmentations with bone graft, and a facelift for correcting of long faces, asymmetric faces, severe malocclusions, microgenias, prominent mandibular angles, prominent malar eminences, piriform recessions, and an aging face. Twenty five patients were satisfied with the results. Two patients complained of an over-recessed lip region, and one of septal deviation. There were no other significant complications or relapses throughout the followup period (9-30 months). Maxillary and mandibular ASO are effective, selective, relatively safe, and simple methods for correcting lower facial profile disharmony to attain a satisfactory aesthetic facial contour.

Successful digital replantation after 42 hours of warm ischemia.

Previously, 6 to 10 hr were believed to be an acceptable limit of warm ischemia for successful digital replantation. The longest warm ischemia time ever reported was 33 hr. This report presents successful replantations of two fingers after 42 hr of warm ischemia.

Ten-digit and nine-digit replantation (4 cases).

Ten or nine-digit amputation is a very rare injury. From March, 1987 to June, 1988, we replanted two cases of ten-digit complete amputation and two cases of nine-digit complete amputation with success. The maximum ischaemic time was 39 h and the operation time was between 25 and 31 h. All digits survived completely except for partial necrosis of one finger. The follow-up has been 13-20 months, and all the patients have a pair of good, functional and aesthetically acceptable hands.

Reduction malarplasty.

Reduction malarplasty is one of the common aesthetic procedures performed in the Orient, although it is rarely performed in the West. Previously described techniques for malar reduction include shaving the prominent portion and contouring the outer surface of the malar complex utilizing a variety of surgical approaches. We describe a technique for malar reduction involving a coronal approach followed by either an in situ transposition osteoplasty or the removal of the malar complex and contouring of the bone with replacement as a free bone graft. We have performed this procedure on 94 patients with good results.

Oriental blepharoplasty: single-stitch, nonincision technique.

The facial features of Orientals and Caucasians are different in many respects. In Orientals, the concept of beauty differs in each country depending on the cultural background. At present time, blepharoplasty in the Oriental eye is the most common aesthetic procedure performed in Korea and Japan. The objective should not be the caucasianization of the Oriental eye, where desired modifications are usually quite subtle. Generally, patients prefer more defined and invaginated folds, but not necessarily a very high fold, since the latter will often look unnatural or overdone in the Oriental face. We have found several different types of eyelids in the Oriental population. The purpose of this presentation is to present our nonincision technique to create aesthetically pleasing supratarsal folds. Seven-hundred and sixty-two patients were reviewed. We have found that our single-suture method is very reliable and allows the construction of a more even, smooth, and symmetrical fold.

The prominent mandibular angle: preoperative management, operative technique, and results in 42 patients.

A prominent mandibular angle is considered to be unattractive in the Orient because it gives the face a square and muscular appearance. While described infrequently in the United States, this entity is commonly encountered in the Orient owing to different facial characteristics and different aesthetic sensibilities. We present a retrospective study of 42 female patients who presented requesting the reduction of a prominent mandibular angle for cosmetic reasons. We describe our approach, which utilizes formal planimetry, cephalometric tracings, and Panorex mandibular radiographs. We utilize the intraoral approach and use an oscillating saw to resect the predetermined segment of bone. In 18 of the 42 patients, we resected muscle as well. We also describe using the preauricular incision in a patient undergoing a concomitant rhytidectomy. Our cosmetic results have been generally satisfactory, with only one inaccurate osteotomy. We had three infections which resolved without sequelae.

Experimental studies in the survival of venous island flaps without arterial inflow.

The authors have studied the effects of various circulatory settings on flap survival. The dog model was used to study the survival of venous flaps without arterial inflow both as island and free flaps. Venous flaps were compared with arterial flaps without venous outflow and standard island flaps with arterial inflow and venous outflow. Attempts were made to study their vascular morphology and blood gas changes. The venous flaps without arterial inflow survived with normal hair growth and wound healing, as did the standard island flaps. These observations suggest that capillary diffusion can occur without the continuous flow of blood through a capillary. Several possible mechanisms to explain survival of the venous flaps without arterial inflow were discussed. These observations could be important in providing an animal model to study microcirculation and a possible new area for microsurgical transfer of a skin flap.

Vascular island skin-flap tolerance to warm ischemia: an analysis by perfusion fluorometry.

Fiberoptic perfusion fluorometry and assessment of ultimate viability were used to analyze the tolerance to warm ischemia of rat vascular island skin flaps. Both acute flaps and flaps raised 24 hours previously and then reraised were subjected to 0 (control), 6, 8, 10, and 12 hours of vascular pedicle clamping. Following clamp release, serial fluorometry documented the progressive delay in effective reflow resulting from extended periods of ischemia. Fluorometry, furthermore , suggested that flaps constructed 24 hours previously had an improved hemodynamic status with a significantly reduced period of poor reflow following clamp release. The improved hemodynamics were associated with increased viability, confirming the increased tolerance of 24-hour-old flaps to warm ischemia.

Tracheal reconstruction with a pleuroperiosteal flap.

Reconstruction of extensive tracheal defects remains a difficult surgical problem. In many experiments restoration of tracheal mucosa by autogenous or homologous soft tissue grafts has usually failed because of rejection or tracheal obstruction. This experimental work employed a two-stage surgical procedure that allowed reconstruction of extensive circumferential full-thickness defects of the trachea. Stage I involved the creation of a vascularized pleuroperiosteal flap that was formed into a rigid tube around a Silastic stent. Stage II consisted of creation of a full-thickness circumferential tracheal defect and repair with the flap in those animals in which a suitable rigid tube had been formed. The results of these experiments argue strongly that a vascularized composite pleuroperiosteal flap can produce an adequate tracheal replacement.

Flap reconstruction of the upper face: free flaps vs. lower trapezius myocutaneous flap.

The immediate one-stage reconstruction of the upper facial cutaneous defects were performed by using two different flaps. In the first representative patient a microvascular free flap was used; in a second case, the lower trapezius myocutaneous flap was used. Free flaps probably are ideal for the correction of such defects in one stage. This procedure requires specially trained surgical teams and longer operative time. A reliable alternative is the lower trapezius myocutaneous island flap. This offers a flap that is thin, hairless and of uniform thickness. The length and thickness of its pedicle allows excellent mobility and leaves no bulky neck deformity. Both these reconstructive techniques satisfy the need for viable replacement in large upper facial and scalp defects coupled with a satisfactory cosmetic outcome.

Two new cutaneous free flaps: the medial and lateral thigh flaps.

Two new cutaneous free-flap donor areas are described on the medial and lateral sides of the thigh. The medial thigh flap is supplied by an unnamed artery from the superficial femoral artery and is drained by the accompanying venae comitantes. Its nerve supply is from the medial femoral cutaneous nerve. The lateral thigh flap has its vascular pedicle from the third perforating artery of the profunda femoral artery and its accompanying vein. The lateral femoral cutaneous nerve provides sensation over the area. These flaps provide a large surface area of both skin and subcutaneous tissue without the usual bulk of subcutaneous fat and muscle. Their desirable features include long vascular pedicles with large vessel diameters and potential of being neurovascular flaps with specific sensory nerve supply and predictable anatomy. The principal disadvantage is that the donor site may leave a slight contour defect with primary closure or require grafting when a large flap is taken. We predict that these flaps will become important donor sites for reconstructive problems requiring resurfacing of cutaneous defects in various anatomic areas.

Total glossectomy. A technique of reconstruction eliminating laryngectomy.

A series of 15 patients undergoing total glossectomy for advanced carcinoma of the tongue was analyzed with regard to operative management, oral reconstruction, rehabilitation of deglutition and speech, and survival. While patients often underwent elective total laryngectomy to prevent aspiration previously, a method of laryngoplasty has now been devised that permits retention of the larynx with preservation of swallowing and speech. This technique of laryngoplasty may be used for the management of chronic aspiration of any cause.

An analysis of 133 pectoralis major myocutaneous flaps.

Our experience with 133 consecutive pectoralis major island myocutaneous flaps in 126 patients is reviewed. The incidence of complications has been relatively low. Among the 133 flaps used in the head and neck area, 11 flaps (8 percent) failed to accomplish the intended purpose and required secondary repair. The pectoralis major myocutaneous flap with its abundant tissue and excellent blood supply and anatomic proximity provide a simple, reliable, and versatile method of primary reconstruction of various head and neck defects.

Experience with immediate and delayed mandibular reconstruction.

The functional disability and cosmetic deformity after jaw and neck dissection can be very severe due to soft tissue and mandibular loss. Reconstruction of the mandible alone without soft tissue coverage can be complicated with prosthetic exposure, infection and, finally, rejection. We attempted to reconstruct the mandible at the time of tumor resection in a group of patients, using titanium mesh with marrow, rib, scapular spine, and clavicle. We used myocutaneous flaps in order to obtain intraoral coverage of the mandibular grafts. In a second group of patients, delayed reconstruction of the jaw was performed 6 months to 2 years after tumor resection. Titanium mesh prostheses were used for reconstruction of the mandible in conjunction with myocutaneous flaps for soft tissue augmentation. Osteomyocutaneous flaps were also used. The results and complications in 54 patients are presented.