Topical 5-fluorouracil as primary therapy for keratoacanthoma.

Keratoacanthoma is a common, benign cutaneous neoplasm that displays rapid growth on sun-exposed skin. Keratoacanthomas usually involute spontaneously after several months but rarely progress to squamous cell carcinoma. Because this is a benign, self-limited lesion of exposed skin, effective treatment should emphasize patient comfort and cosmetic results in addition to effectiveness. The authors present 2 patients with keratoacanthomas treated with topical 5-fluorouracil. Both patients had complete resolution of their lesions within 8 weeks. The cosmetic result was superb in both patients. Patient satisfaction with this therapy was excellent. Treatment can be instituted based on a clinical diagnosis; no diagnostic biopsy is necessary. Most keratoacanthomas respond to topical 5-fluorouracil therapy within 3 weeks, whereas squamous cell carcinomas respond poorly. Any lesion that shows a poor response after 3 weeks of therapy or that does not resolve within 8 weeks should undergo prompt excisional biopsy for definitive diagnosis and treatment. Topical 5-fluorouracil is an effective, convenient, relatively inexpensive treatment for keratoacanthoma that produces excellent cosmetic results. It should be added to the therapeutic armamentarium of all physicians who treat keratoacanthoma.

Collagenous fibroma (desmoplastic fibroblastoma).

Collagenous fibroma (desmoplastic fibroblastoma) is a recently described tumor that may arise in the subcutaneous tissue or skeletal muscle. We report a case of collagenous fibroma, occurring on the forehead of a 67-year-old man. An awareness of this entity is necessary to avoid confusion with other soft tissue neoplasms, especially extraabdominal fibromatosis.

Upper extremity salvage using the tensor fascia lata flap: report of two cases.

The tensor fascia lata pedicled flap was successfully used to salvage 3 severely injured upper extremities in 2 patients. Both patients had undergone 3 prior free tissue transfers without complete closure of their wounds. All 3 tensor fascia lata flaps (2 myocutaneous, 1 myofascial) survived entirely. We believe this flap offers a distinct advantage compared with the groin flap when pedicled flap coverage of the upper extremity is required.

Lag-screw technique in free osseous mandibular reconstruction.

The surgical registry was reviewed for mandibular reconstruction from 1988 to 1992. During this time, 51 patients underwent mandibular reconstruction. Of this group, 17 patients had their microvascular bone grafts secured with lag-screw fixation. An AO technique, utilizing 2.7-mm cortical screws, was used to provide rigid fixation. Mandibular defects ranged from 6 to 20 cm. AO vascularized bone grafts were studied with bone scans and remained viable. Follow-up revealed no flap losses or oral cutaneous fistulae. Lag-screw fixation, in conjunction with mandibular reconstruction, results in rigid fixation, obviates the need for mandibulamaxillary fixation, has the advantage of ease of application, and is safe to use.

An algorithm for maxillectomy defect reconstruction.

A maxillectomy defect creates a communication from oral cavity to nasal cavity that may extend to the orbit. Functional deglutition and speech problems with a significant soft tissue deficit ensue. This paper defines the reconstruction options for the spectrum of inferior partial maxillectomy defects to midface-orbital exonerations. Treatment protocols from maxillectomy patients treated in January 1991 to February 1996 at a major tertiary care institution were reviewed (n = 108). An ascension of care from dental obturator, nonvascularized graft, local flap, regional flap, and free tissue grafts (n = 28) is described. These data and experience were organized to provide a treatment algorithm to assist in presurgical planning for maxillectomy reconstruction.

Angiosarcomas of the head and neck: clinical and pathologic characteristics.

Between 1974 and 1992, 32 patients with pathologically diagnosed angiosarcoma of the head and neck were evaluated at our institution. The primary treatment group consisted of 24 patients who had the initial diagnosis made or confirmed at our institution, and the other 8 patients formed the salvage group. There were 23 men and 9 women. The median age in the primary treatment group was 63 years (range 18 to 91 years). The overall median survival among the primary group patients was 4.8 years, and the 3-year survival was estimated to be 57% (95% confidence interval 39% to 84%). The median follow-up was 2.1 years (range 83 days to 9.7 years). Patients who had tumors less than 7.0 cm in diameter and tumors with invasion only to the subcutaneous tissues had better overall survival and longer time to first adverse event. Diploid DNA content was a significant favorable prognostic factor for time to first adverse event. Mitotic activity was of borderline significance with both end points. Patients who had tumors of less than 1.5 cm were treated successfully with surgery alone. Patients treated with combined surgery and radiotherapy also tended to do better. Because most patients in whom regional recurrences developed had tumors larger than 7.0 cm, we conclude that patients with tumors of this size may benefit from regional neck node dissection at the time of primary excision or from elective neck irradiation.

Tissue expansion in the upper extremities.

In this article, the authors demonstrate current concepts of soft-tissue reconstruction using tissue expansion principles. History, pathophysiology, and biomechanics of tissue expansion are reviewed. Anatomic areas of expander use in the upper extremity have been delineated, as well as new concepts of nerve and arterial elongation using intraoperative expansion techniques. The authors outline their current technique of upper extremity tissue expansion in the preoperative, intraoperative, and postoperative settings, allowing the reader to appreciate the technique of tissue expansion and its role in soft-tissue reconstruction of the upper extremity.

Muscle flap reconstruction aids in urethral regeneration.

Traditional methods of reconstructing full-thickness urethral defects have employed a cutaneous component utilized to replace the lining of the urethra. These methods have failed to take advantage of the regenerative ability of urethral epithelium. This epithelium is capable of regenerating, eliminating the need for urethral lining reconstruction. Muscle flap reconstruction provides an environment that allows for complete regeneration of the urethral epithelium. A 56-year-old male presented with a 12-cm defect of the bulbous and penile urethra involving 180 degrees of the urethral circumference secondary to Fournier's gangrene. A proximally pedicled gracilis muscle was used to reconstruct the urethral defect. This healed without stricture or leak. Urethral biopsies showed satisfactory migration of the uroepithelium across the urethral defect.

Functional lower limb salvage with an osteocutaneous filet flap of the foot.

An osteocutaneous foot filet flap based on the posterior tibial vessels was successfully used to provide tibial coverage in a patient requiring a below-knee amputation following a high-voltage electrical injury. Addition of the calcaneus to the standard foot filet flap provided a vascularized bone graft that served to both lengthen the tibia and secure the flap via a tibial-calcaneal synostosis. The synostosis provided firm anchoring of the flap and allowed for a partial end-bearing, below-knee prosthesis.

Management of sacral and perineal defects following abdominoperineal resection and radiation with transpelvic muscle flaps.

PURPOSES: In this study we present our experience with treating persistent sacral and perineal defects secondary to radiation and abdominoperineal resection with or without sacrectomy. METHODS: Fifteen consecutive patients were treated with an inferiorly based transpelvic rectus abdominis muscle or musculocutaneous flap. RESULTS: Fourteen of the 15 patients achieved healing, and 7 patients had no complications. The remaining eight patients required one or more operative debridements and/or prolonged wound care to accomplish a healed wound. Our technique for the dissection and insetting of the transpelvic muscle flap is presented. CONCLUSION: The difficult postirradiated perineal and sacral wounds can be healed with persistent surgical attention to adequate debridement, control of infections, and a well-vascularized muscle flap. The most satisfying aspects for patients are the discontinuance of foul-smelling discharge, discontinuation of multiple, daily dressing changes, and reduction in the degree of chronic pain.

Autologous breast reconstruction with use of transverse rectus abdominis musculocutaneous flap: Mayo clinic experience with 147 cases.

OBJECTIVE: To assess the results of transverse rectus abdominis musculocutaneous (TRAM) flap reconstructions of the breast. DESIGN: We retrospectively reviewed 147 consecutive cases of TRAM reconstructions of the breast performed at the Mayo Clinic between 1981 and 1992. MATERIAL AND METHODS: The median patient age was 47 years, and the median duration of follow-up was 29 months. In 25 patients, both rectus pedicles were used, 15 of those for bilateral reconstruction. The other 122 patients had unipedicled unilateral reconstruction. Only 9% of the breast reconstructions were immediate. Analysis of risk factors in the patient population revealed smoking in 16%, preoperative irradiation of the chest wall in 20%, preoperative chemotherapy in 27%, and both radiotherapy and chemotherapy in 12%. RESULTS: The mean overall operative time was 4 hours and 43 minutes (4 hours and 20 minutes for unipedicled flaps and 5 hours and 46 minutes for bipedicled reconstructions). No blood transfusion was needed in 47% of patients; of those who received transfusions, 78% required 2 units or less. In 58 of the 147 patients (39%), an operation was performed on the contralateral breast. Follow-up operations were necessary in 71% of patients. The overall frequency of complications was as follows: hernia that necessitated surgical repair, 7.5%; full TRAM ischemic loss, 3.7%; partial TRAM loss, 9.9%; and fat necrosis, 11.7%. No pattern of increased complications was noted in subgroups of patients who smoked or who had received preoperative irradiation, chemotherapy, or both. In comparison with our early cases, the last 50 TRAM procedures were generally associated with fewer complications. The rates of occurrence of complications in our series of patients were similar to those reported in the literature. CONCLUSION: The TRAM flap provides satisfactory results for reconstruction of the breast.

Muscle-flap coverage for infected peripheral vascular prostheses.

Infection in a peripheral vascular prosthesis continues to be a serious complication in arterial reconstructive surgery and threatens the patient with loss of either limb or life. Infection rates at major centers are now low, ranging from 1 to 6 percent; however, limb loss and mortality rates for this complication range from 25 to 75 percent depending on the location of the graft and the extent of the infection. The use of muscle flaps in the management of acute wounds, infection-prone wounds, exposed orthopedic hardware, and osteomyelitis is now commonplace. Transposed muscle has been shown to be well-vascularized tissue that improves healing time and decreases local wound bacterial counts. After considering the preceding facts, we used muscle flaps for coverage of infected peripheral vascular prostheses in a highly select group of patients. These patients were "end of the line," and last-ditch efforts were made to salvage life or limb. Twenty-four infected vascular grafts in 20 patients have been analyzed. Ages ranged from 52 to 87 years. All patients had grade 3, stage I, II, or III peripheral graft infections, as previously defined by Szilagyi and modified by vonDongen. Aortofemoral reconstruction was the most common initial bypass procedure (14), followed by femoral popliteal (6), axillofemoral (2), iliofemoral (1), and subclavian/subclavian bypass (1). Staphylococcus aureus was the most common infecting organism. Muscles used for coverage were the rectus femoris (13), the sartorius (9), the rectus abdominis (1), and the pectoralis major (1). The graft material was composed of Dacron in 16 instances and polytetrafluoroethylene in 8.(ABSTRACT TRUNCATED AT 250 WORDS)

Tumor-ablative surgery, microvascular free tissue transfer reconstruction, and postoperative radiation therapy for advanced head and neck cancer.

OBJECTIVE: The objectives of this study were to determine whether the combination of complex tumor-ablative surgery and microvascular free tissue transfer reconstruction delays the onset of postoperative radiation therapy, whether free tissue transfers are lost after a course of radiation therapy, and what patterns of tumor recurrence and survival rates are present in patients who undergo this type of multidisciplinary treatment. DESIGN: A retrospective review was conducted in 37 patients who underwent tumor-ablative surgery and reconstruction between November 1987 and August 1991. MATERIAL AND METHODS: Of the 30 men and 7 women who underwent tumor-ablative surgery, microvascular free tissue transfer reconstruction, and postoperative radiation therapy, recurrent or T4 primary tumors were treated in 84%. Sixty-two percent of the patients had nodal metastatic disease. The median dose of postoperative irradiation was 60 Gy (range, 32.4 to 76.8). Follow-up in all patients was until death (21 patients) or for a median of 17.5 months (range, 4.1 to 43.2). RESULTS: The median duration of overall survival and the 2-year overall survival rate were 17 months and 46%, respectively. For cause-specific survival, the median duration and 2-year rate were 17 months and 50%, respectively. Local recurrence developed in 8 patients, neck recurrence in 10, and distant metastatic disease in 11. No microvascular free tissue transfers failed. CONCLUSION: Radiation therapy can begin in most patients within 8 weeks postoperatively, microvascular free tissue transfers seem to tolerate postoperative radiation therapy well at the doses administered, and the rates of local and neck control are reasonable relative to the advanced stage of the cancers treated.

Chylous fistula: an unusual occurrence after mastectomy with immediate breast reconstruction.

Postoperative lymphatic complications of mastectomy and immediate reconstruction are well documented, consisting predominantly of lymphorrhea, lymphocele, and chronic lymphoedema. Chylous fistula is a hitherto undescribed entity complicating breast surgery. It was managed successfully by cessation of oral intake and the use of intravenous fluids, as is recommended in the treatment of chylous fistulas occurring elsewhere in the body. Although these are exceedingly rare, all plastic surgeons doing breast reconstruction should be aware of chylous fistulas and their treatment.

Intrathoracic free flaps.

The utility of pedicled muscle flaps transposed into the thoracic cavity to reconstruct complex intrathoracic defects has been well documented. However, in some patients, local chest-wall muscles have already been either sacrificed or transected by previous thoracotomies and are not available for reconstruction. In these patients, we have successfully employed microvascular techniques to transfer distant muscle flaps into the thoracic cavity. Seven patients with complex intrathoracic defects were reconstructed with three latissimus dorsi, one omental, and three rectus abdominis free flaps. In each case, the microvascular anastomosis was extrathoracic, with the flap transposed into the thoracic cavity. Each of the flaps was revascularized successfully. Four of the five bronchopleural fistulas were sealed, with the remaining patient continuing to demonstrate a reduced but persistent air leak. No infections were encountered, and each flap transfer resulted in a healed wound. When local muscle flaps are not available to reconstruct complex intrathoracic wounds, microvascular transfer of distant muscle flaps can provide abundant well-vascularized tissue for reconstruction of any portion of the thoracic cavity. Versatility is afforded in flap selection and recipient vessel site location, making this technique an important option in the treatment of these difficult wounds.

Transfer of innervated latissimus dorsi free musculocutaneous flap for the restoration of finger flexion.

Transfer of functioning free muscle for the restoration of finger flexion is an uncommon procedure. We present our experience with five patients with severe forearm injuries in whom a latissimus dorsi musculocutaneous free tissue transfer was performed in an attempt to provide soft tissue coverage and active digital flexion. Four patients had active finger flexion with volitional control of the transferred muscle between the tenth and the fifteenth weeks. On average, active flexion lags were 2.0 cm in the index finger, 2.1 cm in the long finger, 2.3 cm in the ring finger, and 1.4 cm in the small finger. Although preoperative grip strength was doubled, postoperative strength was still only about 31% of that on the opposite side. All patients required at least one tenomyolysis or revision tenorrhaphy before the best clinical outcome was achieved.

The radial forearm flap donor site: should we vein graft the artery? A comparative study.

Controversy exists in the literature regarding reconstruction of the radial artery after elevation of the radial forearm flap. The literature suggests that reconstructing the radial artery with a vein graft is an important aspect in the use of this flap. In our experience, this has never been performed with no sequela. We examined 13 consecutive patients who underwent radial forearm flaps for head and neck reconstruction over a 28-month period. The patients were examined and questioned about the function of their upper extremities in hope of evaluating the postoperative vascular status in each. Median follow-up was 6 months, with a range of 1 month to 24 months. No patient had preexisting trauma or congenital abnormality of either arm, so that the nondonor arm could be considered as a control for each patient. Evaluation consisted of history and physical examination. The following parameters in each patient were carefully accumulated: grip strength, cutaneous blood flow measured by using a laser Doppler flowmeter, transcutaneous oxygen levels, digital/brachial blood pressure ratios, cutaneous temperature from thumb/index and thumb/small pinch, and rapid rewarming at 1-minute and 5-minute intervals after cold immersion for 2 minutes. The radial forearm flap was elevated in each patient in the nondominant extremity. Grip strengths ranged from 19 to 77 kg, with a median of 30 kg. Early rewarming of the thumb/index was also an average of 1.5 degrees less than the temperature in the control arm and was statistically significant to (p = .01).(ABSTRACT TRUNCATED AT 250 WORDS)