Otoplasty: the experience of 100 consecutive patients.

Although prominent ears are the most common congenital deformity in the head and neck region, only approximately 8 percent of patients who present for treatment of this deformity will have some family history of the abnormality. More than 200 techniques have been described for correction of this deformity, indicating that there is no single widely accepted procedure that has been adopted by most surgeons. The authors of this study present their choice of a procedure that combines the most beneficial features of three previously described techniques and that provides consistently satisfactory results. The surgical technique consists of scoring of the antihelical cartilage on its anterior surface in a subcutaneous position (as described by Stenstrom), suturing to recreate the fold of the antihelix (in the fashion of Mustarde), and concha-mastoid suturing applied to the back of the ear to decrease the concha-scaphoid angle (in the manner of Furnas). The last 100 consecutive patients operated on by the senior author (J.A.F.) over a 10-year period were evaluated. Follow-up data were analyzed using the Kaplan-Meier survival method. The postoperative analysis focused on the incidence of postoperative complications and the overall results of the technique.Most operations were performed bilaterally, on women, and with the patient under local anesthesia. There were few complications, and the incidence of complications was much lower than had been noted in previously reported series. All patients were very satisfied with the improvement in the appearance of their ears. The combined technique presented is safe, easy to perform, and has few complications, and its final outcome is reproducible and long-lasting. It can be considered a standard technique to be used for treating patients of any age and with any magnitude of defect.

The fate of free flaps used to reconstruct defects in recurrent head and neck cancers.

The purpose of this study was to assess free-flap viability in patients treated for recurrent head and neck cancers. A 10-year retrospective review identified 121 patients who had had prior head and neck cancers extirpated for cure, who subsequently presented with documented recurrent cancers that were removed, and who then underwent reconstruction with free flaps. The charts of these patients were reviewed for patient demographics, tumor types, location, flaps used for reconstruction, size of area requiring reconstruction, length of operation, previous radiation, and all postoperative morbidity and mortality. The time to recurrence ranged from 21/2 months to 21 years. The majority of tumors treated were squamous cell carcinomas (n = 82). Most of them were located intraorally (n = 75). Radiation therapy had been delivered to 88 patients before their free-flap reconstructions. In this series, 31 percent of all patients required additional surgery for complications, 14 percent of free flaps were lost, and 4 percent of patients died within 30 days of their operation. The significant findings were that a flap that was >4 cm in diameter was related to flap loss (p = 0.03 by the chi2 method) and that flap loss was related to operative times greater than 11 hours (p = 0.03 by the chi2 method). It was concluded that recurrent head and neck cancers with large postextirpation defects that required prolonged operative times yielded a significantly high tendency toward flap failure.

Use of microvascular free-tissue transfer following ablative surgery of the skull base.

The purpose of this study was to validate the use of free flaps in reconstruction of skullbase defects after extensive resection of advanced tumors, and to justify microvascular reconstruction to improve the quality of life and survival in this population. The treatment outcome after ablative resection of skullbase tumors with free flap reconstruction over a 7-year period (1988 to 1995) was studied. Complete removal of the tumor was originally attempted in all patients. All cases had immediate reconstruction. Criteria for reconstruction with free flaps were based on extensive defects in which local flaps were insufficient. Twenty patients were identified male:female, 11:9). The most common tumor was sarcoma, followed by squamous-cell carcinoma. Coverage of the dura was required in 12 patients. Muscles used were the rectus abdominis and latissimus dorsi. Complications included flap necrosis (n = 2) and ventral hernia (n = 2). Control of pain was achieved in 66 percent of cases. Patients with regional metastasis died within 2 years, and those with distant metastasis died within 18 months. Patients with primary tumors had an increased survival rate. The authors confirm the technical feasibility and success of free flaps to reconstruct extensive defects in the skull base. In patients with potentially complete resection of primary/recurrent lesions, overall survival justifies the procedure. Patients with regional/distant metastasis warrant an individualized approach.

Muscle flaps in osteomyelitis of the lower extremity: a 20-year account.

Between 1977 and 1993, 64 patients had local muscle flap transposition as an integral portion of treatment for lower-extremity osteomyelitis. All muscle flaps were performed by a single surgeon. There were 54 men and 10 women with an average age of 45 years (range, 16 to 87 years). Median follow-up period was 9.3 years (range, 5 to 21 years). The muscles used included medial gastrocnemius (n = 28), soleus (n = 19), lateral gastrocnemius (n = 13), and peroneus tertius (n = 1). At final follow-up, the recurrence free rates at 5, 10, and 15 years were 94, 92.5, and 86 percent, respectively. These long-term results support the use of local muscle flap transposition as an important management method in the treatment of lower extremity osteomyelitis; however, the risk of treatment failure may arise after extended periods of time.

A safe and rapid technique for modified neck dissection.

The technique of modified neck dissection presented here, by the very limited anatomic area it addresses of necessity shares aspects of techniques described by other authors. Developed over many years of teaching residents, it provides, if carefully followed, a simple, safe, and relatively rapid method of carrying out the procedure, having been used by the senior author and his residents in scores of patients both at our institution and in many overseas operations under rather primitive conditions without modification. It is not a new way of doing the procedure, but rather a combination of some of the simplest approaches and aspects which may be especially helpful to those without wide experience.

Sweat gland carcinoma: a clinicopathologic analysis of an expanded series in a single institution.

Primary adenocarcinoma of sweat glands is a rare tumor; approximately 220 cases have been reported in the last 30 years. We reviewed the charts of patients with primary diagnosis of this tumor treated at the Mayo Clinic between 1935 and 1995. We included only cases with initial histology slides available for re-examination. Tumors were classified into five recognizable histologic patterns (solid, ductal, mucinous, microcystic adnexal, and adenocystic carcinoma) and graded by the Broder system. Statistical analysis consisted of Kaplan-Meier product limit method and Cox multiple regression test. In total, 55 patients were identified, and age ranged from 13 to 85 years (mean 59 years). Thirty-six patients (65 percent) presented to the Mayo Clinic for initial treatment; all except one had disease limited to the primary site. Microcystic adnexal carcinoma was the most frequent type, and more than 50 percent were grade 2 tumors. Among these 36 patients, 4 had some type of recurrence. Patients who developed metastasis had a high-grade tumor in the initial biopsy. Nineteen patients were referred with recurrence; 13 had local recurrence, 4 had regional diseases, and 2 had distant metastases. The histologic distribution showed 47 percent solid tumors, and 37 percent of them were grade 3. Multiple regression analysis did not show a difference in recurrence or survival when gender, age, tumor location, or histologic pattern was evaluated. In addition, there was no difference in the outcome between wide surgical resection and micrographic surgery. The only predictive factor for distant metastases and/or death (p < 0.003) was histologic grade. Overall 10-year survival rate was 86 and 60 percent for primary and referred patients, respectively. We conclude that histologic diagnosis of sweat gland carcinoma must be complemented by clinical examination to evaluate metastases. Clinical behavior depends on the histologic type of tumor, degree of differentiation, and clinical stage. On recurrence, the likelihood of further recurrences and mortality increases dramatically. Aggressive initial local ablation with tumor-free margins is recommended. In high-grade tumors, prophylactic regional lymph node dissection may further characterize tumor aggressiveness and may justify adjuvant radiotherapy as part of the primary treatment.

Treating recurrence of parotid benign pleomorphic adenomas.

Treatment for recurrence after surgical removal of parotid benign pleomorphic adenoma (PBPA) has not been well defined and is often followed by further recurrence. Surgery is overwhelmingly the most common approach. The risk of facial nerve injury is greater at reoperation since the nerve is less well defined. The value of radiation therapy (RT) has not been determined and incurs with it the risk of possible late occurrence of malignancy or nerve damage. The charts of patients with recurrent PBPA treated consecutively by a single surgeon from 1965 to 1993 were reviewed. All patients had a histopathologically verified diagnosis of PBPA both at the time of primary and subsequent surgeries. Follow-up was obtained from clinical charts and correspondence communication. Recurrence curves were generated using the Kaplan-Meier method. Thirty-nine patients with recurrent PBPA (36 referred and 3 treated primarily at Mayo) were evaluated. The patients were classified according to the type of surgery: 14 patients had previously undergone some form of parotidectomy or had only resection of the tumor for recurrence, and 25 patients underwent parotidectomy since this had not been performed primarily. The mean age in the two groups was 49 and 50 years respectively. The mean follow-up was 10 years after the recurrence treatment. The mean time between initial resection and recurrence in the two groups was 14 and 15 years. The mean time between the recurrence treatment and a second recurrence was 7.5 years. Nine patients had RT in addition to the local resection. Of this group 3 patients (33%) developed another recurrence. Five patients had local resection only, and of this group 1 patient (20%) developed another recurrence. Of the group that had superficial parotidectomy, 3 patients had additional RT and one of these patients (33%) developed another recurrence. Twenty-two patients had superficial parotidectomy only, and of this group 3 patients (14%) developed another recurrence. Only 2 of the 39 patients had complications. One patient developed Frey's syndrome after superficial parotidectomy and 1 patient developed facial paralysis after RT. As in other series, the number of patients is inadequate to allow for firm conclusions. However, it appears that when previous parotidectomy has been performed, simple excision with a margin of surrounding tissue would seem appropriate. Parotidectomy should be carried out if not performed previously. In simple excision after previous parotidectomy, there is a greater risk to the facial nerve because of difficulty in distinguishing the facial nerve from surrounding scar tissue. Our preference is to use general anesthesia so that branches of the nerve are not paralyzed and stimulation of the nerve aids in safe dissection. The value of RT is still indeterminate.

Treatment outcome for 424 primary cases of clinical I cutaneous malignant melanoma of the head and neck.

BACKGROUND: Cutaneous malignant melanoma (CMM) is increasing in frequency. Surgery remains the primary and only curative treatment method. Our aim was to define prognostic factors and outcome predictors for patients with clinical stage I CMM of the head and neck. METHODS: Surgical treatment and outcome was analyzed for 424 patients with clinical stage I melanoma of the head and neck, completing initial treatment at the Mayo Clinic (1970-1990). The data were analyzed using the Kaplan-Meier product-limit method and Cox multiple-regression models. RESULTS: Overall, 180 (42%) patients underwent elective lymph node dissection (ELND) as part of the initial treatment; occult disease was demonstrated in 15 (8.3%). Among patients with tumor > 1.5 mm thick, occult regional disease was found in 15%. Failure of final treatment occurred in 152 (36%). Overall, 82% and 75% of the patients survived 5 and 10 years, respectively. CONCLUSIONS: Tumor thickness, extent of invasion, and the presence of occult region metastatic disease were the only independently predictive value (p < .005) of recurrence. The detection of disease by ELND did not appear to protect the patient from disease progression but identified those with regionally advanced disease and highest risk for recurrence. The development of recurrence significantly reduced but did not eliminate the potential for extended disease-free survival with subsequent treatment.

Paget's disease of the groin: report of seven cases.

Only 27 cases of Paget's disease of the groin have been reported to the present. Our aim was to describe the clinical behavior and treatment of this disease. A retrospective analysis of patients seen at the Mayo Clinic over a period of 25 years (January of 1970 to December of 1995) was undertaken. We included patients with lesions of the groin (isolated or associated with penile/scrotal locations) and with histologic confirmation of the diagnosis. We found seven patients, all male; three patients had isolated lesions. Their mean (SD) age was 73 (8.3) years. Special stains and immunohistochemistry confirmed the diagnosis in all patients. A wide local excision was performed in every patient. Three patients had recurrence; one of them died with multiple pulmonary metastases 4 years later. Two patients presented with history of associated malignancy (prostatic and renal cell carcinoma). Paget's disease of the groin is extremely infrequent. Its origin seems not to be a simple extension from the genital area. Most diagnoses can be made by light microscopy. Wide local excision with free margins is the treatment of choice. Local recurrence occurs in half of patients with tumor-free margins by frozen section; long-term follow-up is warranted. Distant metastases occur rarely, although they can be fatal.

Bullets and their role in sepsis after colon wounds.

The objective of this study was to determine the relation between the presence of a bullet (gunshot) after injury to the colon and the incidence of sepsis in its track and the soft tissue where it is retained. A retrospective review was carried out of the charts of consecutive patients admitted for abdominal gunshot wounds with proved colon injury during laparotomy where the bullet was either retained in the soft tissue or exited the body. The review covered a period of 4 years beginning January 1, 1990. Three groups were identified for analysis: (1) patients from whom the bullet was surgically removed, with additional cleansing and debridement of the area (n = 21); (2) patients who did not undergo surgical removal of the bullet (n = 81); and (3) patients in whom the bullet exited spontaneously and in whom only débridement of the skin was carried out (n = 83). Similar risk factors were noted among the groups (age, ATI score, colostomy rate), except for a higher incidence of shock in group 3 (p = 0.003). The incidence of sepsis in soft tissue was least in group 1. It was five and seven times greater in groups 2 and 3, respectively. After an abdominal gunshot with colon injury, the missile should be removed if feasible and the local tissue débrided. If the bullet has exited spontaneously, its internal track must be débrided and lavaged extensively.

Noma: a review.

Cancrum oris or noma is a condition not well known in western Europe and North America. It is, however, a relatively common cause of mortality and disability in children of undeveloped areas of Africa, Asia, and South America. This paper describes the experience at Galmi Hospital, in the sub-Saharan region of South Africa in the Niger Republic, with 50 operative patients out of a group of 300 who were referred. An extensive review of the literature is presented describing the epidemiological impact of the disease, the characteristics of the lesions, the pathogenesis, symptoms, sequelae, differential diagnosis, and preoperative preparation. Additionally, we review approaches to anesthesia, methods of reconstruction, and the most common causes of complications and mortality. Numerous photographs illustrating the devastating consequences of this problem are presented.

An atraumatic technique to fix the omentum after partial splenectomy.

During a partial splenectomy, the resultant bleeding of the remaining spleen is difficult to control; some techniques have been described to achieve complete hemostasis. The omentum has been traditionally used to promote hemostasis on raw surfaces of solid viscus, particularly during the repair of liver injuries. We present here a technique to fix the omentum to the spleen after partial resections; emphasis is made to perform it in an atraumatic way to avoid additional damage to the splenic capsule.

The sternocleidomastoid myocutaneous flap: a reappraisal.

The sternocleidomastoid myocutaneous flap was described 40 years ago. However, its reliability has been a matter of discussion, mainly because of its random blood supply and subsequent tendency to necrosis. This paper describes the use of the sternocleidomastoid island myocutaneous flap, superiorly based, in 10 patients with good results. In these patients, the superior thyroid artery was sacrificed and the skin paddle was incised directly over the muscle, as described by Ariyan. We believe this approach assures the usefulness of the flap and justifies its expanded utilization.

Conservative management of penetrating hypopharyngeal wounds.

OBJECTIVE: To demonstrate the applicability of nonoperative treatment to penetrating hypopharyngeal wounds. DESIGN: A prospective study. MATERIALS AND METHODS: An analysis of patients with penetrating hypopharyngeal wounds who were treated nonoperatively at the Hospital Universitario del Valle (Cali, Colombia) during 4 years (beginning January 1990) was performed. Patients older than 13 years with proven lesions produced by penetrating trauma were included. Patients with foreign-body-induced or iatrogenic lesions (orotracheal intubation, endoscopy) or immediate need for surgery (for associated lesions) were excluded. Nonoperative management consisted of nasogastric tube for feeding, suspension of oral intake, and parenteral antibiotics for 7 days. MEASUREMENTS AND MAIN RESULTS: Fourteen patients met the above criteria. Gunshot wounds (n = 11) were the most common trauma. An esophagogram/endoscopy demonstrated the lesions. The only complication in the group consisted of a cervical abscess, which presented in a patient during the first week of treatment. There were no complications such as fistula, leakage, and Horner's syndrome. CONCLUSIONS: Conservative management is a good and safe alternative when indicated in penetrating hypopharyngeal wounds.

Unnecessary use of pelvic x-ray in blunt trauma.

Pelvic radiography in blunt trauma patients is routinely used in most trauma centers. The purpose of this review was to evaluate the ability of physical examination alone to detect pelvic fractures. Among patients with blunt trauma admitted to the University Hospital del Valle in Cali, Colombia, over a 3-month period, 608 adult patients, with hemodynamic stability, without spinal involvement, and with a Glasgow Coma Scale score greater than 10 were evaluated. All patients had physical examination, pelvic x-ray and adequate follow-up. Fifty-nine (9.7%) patients had pelvic fractures, with 57 of these fractures detected by physical findings. The remaining two patients had stable fractures that required no treatment. After careful analysis, we conclude that a negative physical examination following blunt trauma has a negative predictive value of 99% probability in excluding pelvic fracture, provided that the patient is not a child, is not in coma, is hemodynamically stable without evidence of blood loss, and has no spinal cord injury. A selective use of pelvic x-ray in patients with blunt trauma is a cost-effective policy.

Tratamiento conservador de heridas de la hipofaringe / Conservative management of injuries to the hypopharynx

Se adelanto un trabajo de observacion clinica iniciado en 1990 en el Hospital Universitario del Valle, sobre el comportamiento y el subsiguiente tratamiento de las heridas de la hipofaringe, ocasionadas con arma de fuego y arma blanca. El proposito del estudio fue el de demostrar la conveniencia de no operar e instaurar un tratamiento conservador de tales heridas traumáticas de la hipofaringe. La investigacion incluyo 68 pacientes con lesiones traumáticas comprobadas de la orohipofaringe y el esofago cervical, de los cuales 49 (72 por ciento) fueron tratados quirurgicamente en forma obligatoria, y 19 (28 por ciento) recibieron tratamiento conservador, no quirurgico, en cuya evolucion clinica, como era obvio, hubo mucho menos morbilidad que la observada en el grupo sometido a cirugia. Mediante un completo examen clinico y paraclinico asociado a un juicioso criterio, el cirujano debe ser capaz de discemir sobre cuando no se debe operar un paciente con este tipo de lesiones cervicales.

Síndrome pospericardiotomía: informe de 1 caso y revisión de la literatura / Post-pericardiotomy syndrome: case presentation and literature review

Se define el sindrome pospericardiotomia y se califica una entidad infrecuente. Se presenta 1 caso documentado de este estado patologico, diagnosticado en un hombre de 25 años de edad quien habia sufrido una herida con arma cortopunzante en el area precordial. Se discuten aspectos historicos, etiologicos, fisiopatologicos, clinicos, paraclinicos, diagnosticos, terapeuticos y anatomopatologicos del sindrome pospericardiotomia. Por ultimo, se transcriben 21 referencias bibliográficas nacionales e internacionales sobre el tema.