Skin graft survival after external beam irradiation.

Difficulties with skin graft ulceration after radiation therapy for cancer have led many to question the suitability of this method of soft-tissue coverage and its cost-effectiveness. The objective of this study was, therefore, to assess skin-graft integrity subjected to postoperative external beam irradiation in a rat model. The model consisted of a rectangular full-thickness skin graft raised and reapplied to its original bed on the dorsum of each rat. Five groups of adult male Sprague-Dawley rats (n = 8 per group) were established. Group A was the control group and was not given postoperative irradiation. Groups B, C, D, and E received postoperative unfractionated cobalt60 irradiation 4 weeks after grafting for a total dose of 15, 20, 25, or 30 Gy, respectively. Weekly skin-graft evaluation was performed for the 4 weeks after irradiation (8 weeks after surgery) by measuring areas of graft loss using computerized planimetry. After the animals were killed, histologic samples were obtained from normal unirradiated skin and from both intact and ulcerated skin-graft sites. Graft loss after irradiation of < or = 20 Gy was similar to that of the unirradiated controls. Occurring as early as 1 week after treatment, a two-fold increase in graft ulceration was observed with doses of > or = 25 Gy (p = 0.0007). Only partial healing of ulcerations was noted by the fourth week after treatment. Histologic changes associated with the irradiation of skin grafts using doses of 25 Gy or higher included hyaline degeneration, fibrinoid necrosis, telangiectasia, and edema. Granulation tissue predominated as a mechanism of healing in areas of graft ulceration. The intensity of inflammatory cell infiltrate did not correlate with radiation dose. The authors concluded that postoperative, unfractionated irradiation can induce skin-graft loss at doses of 25 Gy or higher. Fractionated irradiation or longer intervals between grafting and irradiation may increase skin-graft tolerance; however, further studies are warranted.

Risk of recurrence after treatment of early breast cancer with skin-sparing mastectomy.

BACKGROUND: Skin-sparing mastectomy, combined with immediate breast reconstruction, has become increasingly popular. However, there are no published long-term data to support its oncologic safety. Our purpose was to evaluate the long-term oncologic risk of skin-sparing mastectomy. METHODS: The records of all patients who had undergone treatment of T1 or T2 breast cancer by mastectomy and immediate breast reconstruction, and who were followed for at least 5 years or developed recurrence of disease before that time were reviewed. Local and distant recurrence rates observed in patients treated by skin-sparing mastectomy were compared with those in patients treated by conventional, non-skin-sparing mastectomy. RESULTS: A total of 104 patients were treated with skin-sparing mastectomies. In that group, 6.7% developed local recurrences, 12.5% developed distant metastases, 88.5% remained free of disease, and 7.7% died of their disease. Among the 27 patients who did not have skin-sparing mastectomies. 7.4% had local recurrences, 25.9% had distant metastases, 74.1% remained free of disease, and 18.5% died of disease. These recurrence rates are similar to those reported elsewhere after treatment with conventional mastectomy and without reconstruction. CONCLUSIONS: Our findings suggest that skin-sparing mastectomy does not significantly increase the risk of local or systemic disease recurrence in patients with early breast cancer.

Tumoral calcinosis of the triangular fibrocartilage complex: a case report.

A case of calcium hydroxyapatite deposition in the triangular fibrocartilage of the wrist is presented. The deposit took the more unusual form of a tumor, posing diagnostic difficulties. Magnetic resonance imaging was helpful in delineating the lesion, but could not identify its nature. Surgical excision resulted in resolution of symptoms.

Orbital volumetric analysis: clinical application in orbitozygomatic complex injuries.

Fifteen patients with unilateral orbitozygomatic complex fractures and five with bilateral injuries were analyzed with respect to the differences in orbital volume between the affected and the uninjured, or other, side. The study was conducted using the ALLEGRO Workstation and software package from ISG Technologies, which was capable of calculating volume partitions from either axial or coronal images. Patients without postoperative enophthalmos demonstrated a maximum volume difference of 3.8%; those with enophthalmos demonstrated differences of 4% or greater. The Critical Volume Difference at which enophthalmos becomes clinically apparent (whereby the orbital-corneal distance measured by Hertel exophthalmometry is greater than 3 mm on the affected side) is in the range of 4% to 5%. Volume analysis of the orbits by manipulation of the computed tomography data may allow a better understanding of changes in orbital configuration, which can result in better-directed primary and secondary reconstructions.

Fingertip and nail bed injuries. Repair techniques for optimum outcome.

Most fingertip injuries can be treated in a procedure room, provided proper lighting and equipment are available. Sound judgment and knowledge of fingertip anatomy are essential. Determining the mechanism of injury is important, because it may indicate the degree of contamination, amount of tissue loss, and best treatment. Superficial wounds may be allowed to granulate and contract spontaneously. In children, even amputation may heal by secondary intention, with the fingertip sutured back in place as a biologic dressing. Split- and full-thickness skin grafts may be appropriate, but diminished sensibility limits their usefulness on volar surfaces. Local skin flaps are indicated when the wound bed is unsuitable for grafting or when skin is needed to cover exposed bone or tendon. Direct closure may be used in amputations of 2 to 3 mm. When the nail bed is lacerated, the nail plate must be removed and the wound repaired. Any free segments of nail bed should be sutured in place as a free graft. In children, treatment should be conservative, with emphasis on preservation of digital length.

Importance of crossover innervation in digital nerve repair demonstrated by nerve isolation technique.

This study was conducted to determine how testing of nerve repair using nerve isolation techniques compares with standard testing. Nerve isolation consisted of double-gloving, leaving the study finger free, and administering local anesthetic blocks to all other sensory contributions in the exposed digit. Ten patients with 13 single digital nerve repairs of equally severe injuries were studied at a mean of 41 months postoperatively. Standardized tests yielded an excellent result in 77% for static two-point discrimination (S2pd), 85% for moving two-point discrimination (M2pd), and 46.2% for Semmes-Weinstein monofilaments (SWMF). The same studies combined with nerve isolation yielded an excellent result in only 43% for S2pd, 43% for M2pd, and 0% for SWMF. These results indicate a statistically significant difference and the importance of crossover innervation from intact nerves in the long-term result of digital nerve repair. Nerve isolation study techniques are an important adjunct in assessing the outcome of nerve repair and are the only method of evaluating the true end result of nerve regeneration following neurorrhaphy.

Digital nerve repair: relationship between severity of injury and sensibility recovery.

The purpose of this study was to measure the relationship between severity of injury and sensibility outcome. This was done by a retrospective study of 37 digital nerve repairs in 26 patients, with a mean follow-up of 35 months. All patients underwent complete hand examination and standard nerve testing, including static and moving two-point discrimination, Semmes-Weinstein monofilaments (SWMF), object recognition, and the pick-up test. A hand injury severity scoring system based on wound characteristics, mechanism of injury, and number of structures involved was then developed. Severity grading led to three classes, and each study group was well matched. Subjectively, all patients considered their outcome as either good or excellent. Objective results are reviewed individually for each test, with the overall combined result of static and moving two-point discrimination being excellent (Highet S4) in 81% for class I, 41% for class II, and 31% for class III, all different at a statistically significant level. We concluded that the severity of injury in the hand can be graded and does have a relationship to the functional end result of digital nerve repair.

The combined composite pectoralis major and minor osteomusculocutaneous flap.

Combining the pectoralis major and minor into a single flap can provide a much longer vascularized segment of bony rib than if the pectoralis major is used alone. This result is possible because of the periosteal vessels emerging from the origins of the pectoralis major and minor. Both muscular attachments are contiguous. The particular characteristics of this flap make it useful for reconstructive surgery of the head and neck when transposed locally, or for other distant regions when microsurgery is attempted.

The circumflex scapular flap for reconstruction of mandibulofacial atrophy.

Dissection of the circumflex scapular vessels permits the use of a cutaneous flap of moderate thickness and broad extension because of the plexal arrangement of the two basic arterial components, the cutaneous scapular and the inferior scapular arteries. This flap may be considered as the treatment of choice in reconstructive surgery for facial atrophy of diverse etiology. The anatomic fundamentals and surgical technique for use of this flap are described.

Extensive distal subcutaneous metastases of a "benign" giant cell tumor of the radius.

A case of distant metastases of a giant cell tumor of the radius is presented. The tumor within the radius was excised, followed by arthrodesis of the wrist and bone grafting with tibia. At the time she came to us, the patient presented distal dissemination, so we performed curettage of each one of the multiple metastases of soft tissues of the hand. After 9 months, a local recurrence in the radius was resected, and reconstruction was done with a vascularized graft of fibula. Later treatment consisted of intraarterial chemotherapy. The patient is in satisfactory condition 1 year after surgery.

Glomus tumor of the metacarpophalangeal joint: a case report.

A case of a glomus tumor of the head of the third metacarpal bone is described. The metacarpophalangeal joint had to be opened to allow excision of the tumor.