Total ear replantation.

Since the first report of successful microsurgical ear replantation in 1980, there have been 12 other cases reported in the English literature. As the number of trained microsurgeons increases, the opportunity to treat the amputated ear with microsurgical techniques should become more common. The reported cases have involved a variety of different mechanisms of injury and methods of treatment. There have been three techniques used to revascularize the amputated ear successfully: primary vascular repair, vein grafting, and use of the superficial temporal vessels as a pedicled vascular leash. Through our own experience and a review of the literature, we have been able to identify certain clinical characteristics that help dictate which technique to use. We report four cases of successful ear replantation, review the various techniques that have been used successfully, and provide treatment recommendations for future consideration.

Necrotizing periorbital cellulitis.

We report traumatic necrotizing periorbital cellulitis attributed to group A beta-hemolytic streptococci in a 4-year-old child. The infection was successfully treated via surgical cleansing, drainage, and grafting. The virulence of this organism requires an aggressive approach to the patient with periorbital cellulitis, which is refractory to intravenous antibiotics. Early treatment may limit extensive eyelid necrosis, the resultant secondary deformity, and the need for multiple reconstructive procedures.

Cryoglobulinemia: dilemma for the reconstructive surgeon.

Cryoglobulinemia was initially noted to occur predominantly in patients with myeloma, but it is now being detected in a growing number of infectious, collagen-vascular, and lymphoproliferative disorders. Two patients with leg ulcers due to cryoglobulinemia are presented. The reconstructive surgeon should consider cryoglobulinemia in the differential diagnosis of skin necrosis that is refractory to conventional therapy, since they may be consulted for wound management. In the vast majority of instances, the patient will be referred with a diagnosis of cryoglobulinemia having already been established. In other circumstances, patients may present to the plastic surgeon with no known history of cryoglobulinemia. The informed reconstructive surgeon can make the diagnosis on the basis of clinical findings. Combination therapy (corticosteroid, immunosuppression, and plasmapheresis) may be of use when areas of skin necrosis, typically in the form of leg ulcers, fail to heal with routine measures.

Benign mesodermal tumors producing nasal deformity.

Tumors of neurogenic (ectodermal) origin are well-described causes of nasal deformity. We present a patient with a benign mesodermal tumor (unclassified spindle cell) producing nasal deformity. A retrospective review of the two senior authors' records provided an additional three patients with nonvascular benign mesodermal nasal masses (fibroma and leiomyoma). Benign mesodermal masses can occur in the midline of the nose and need to be differentiated from dermoids and gliomas. Misdiagnosis is the rule. Excisional biopsy is required for definitive diagnosis. In addition, excisional biopsy is curative and can help to minimize the subsequent nasal deformity if performed early in the disease process. Immunohistochemical and electron microscopy may be required for comprehensive diagnosis and treatment.

Immunologic associations of keloids.

The mechanisms underlying the pathogenesis of keloids have not been fully characterized despite extensive past and present research. Results of past and present studies have shown that the immune system is actively involved in the development of these lesions. Future investigations into the biochemistry and immunologic factors of keloids are anticipated and expected to produce additional insight. The inability to identify cellular (fibroblast) abnormalities has led most investigators to focus on the humoral regulators of wound healing, that is, biochemical substances, immunologic mediators and growth factors. Future studies are needed to confirm or refute the presence of AFA. AFA, if they exist, may prove to be useful as immunologic markers of keloids and may help distinguish keloids from hypertrophic scar in the early stages of wound healing. The influence of immunologic mediators may be more impressive early in the development of scars. "Young" or "early" is defined as less than two years of age, whereas "old" or "late" keloids are more than two years of age. We suggest that future studies stratify keloids into early versus late and also measure the rates of collagen synthesis of fibroblasts derived from the normal and abnormal specimens from the same patient. Analysis of the leukocyte factors will clarify the role the immune system has in the regulation of collagen synthesis. Preliminary investigations have shown that immunotherapy may be of value in the treatment of keloids. The role of fibroblast heterogeneity needs to be investigated. It is not known which aspects of fibroblast heterogeneity are responsible for the localized and accelerated rates of collagen synthesis of keloid fibroblasts.