Nonoperative Treatment of a Tracheocutaneous Fistula in a Burn Patient.

Tracheocutaneous fistula (TCF) is a complication occurring after decannulation of a long-term tracheostomy and can lead to significant morbidity. We describe a case of a TCF in a burn patient treated without surgery. No previous cases have been described. A 65-year-old woman presented with symptomatic hypertrophic burn scar contractures of the anterior neck 6 months after undergoing excision and grafting of full-thickness burns to the neck and chest. She had a history of tracheostomy placement at the time of burn. Two months later, she was decannulated with no evidence of TCF. She subsequently underwent excision of hypertrophic burn scar contractures of the neck with placement of bilayer wound matrix followed by split-thickness skin grafting. Postoperatively she was noted to have a TCF with subgraft emphysema and difficulty in phonation and respiration. With local wound care, the TCF closed spontaneously and a new skin graft was placed uneventfully. At 18 months postoperatively, fistula closure was maintained with good functional and aesthetic outcome. Conservative management of an iatrogenic TCF in a burn patient may result in adequate soft-tissue coverage and allow for subsequent successful skin grafting. This method affords minimal morbidity to the patient and is a viable alternative to more elaborate flap reconstruction.

Implications of anomalous pectoralis muscle in reconstructive breast surgery: the oblique pectoralis anterior.

INTRODUCTION: Many case reports have described anatomical variants of the pectoralis muscles. However, there is a paucity of published literature on the consequence of such presentations in reconstructive breast surgery. METHODS: A 45-year-old female patient with breast cancer presented for left mastectomy and immediate reconstruction with tissue expander. During mastectomy, she was noted to have an extra muscle anterior to her pectoralis major muscle. This variant had not previously been described in the literature and was therefore named the oblique pectoralis anterior. After inspection of the aberrant musculature, the decision was made to release the inferolateral insertion of the accessory muscle with the inferior edge of pectoralis major. An adequate pocket for the expander was created. RESULTS: After routine expansion and implant exchange, muscular coverage of the implant from pectoralis major and the oblique pectoralis anterior muscle approximated 70%. The patient was left with good symmetry and a cosmetic result, despite the challenges presented by her anomalous chest wall musculature. DISCUSSION: Prior knowledge of the various anatomic aberrations described in the literature can prepare a surgeon to properly incorporate and utilize the variant anatomy, should it be encountered, to benefit the outcome of the operation.