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The safety of lidocaine dosing in the tumescent technique has been well documented, but there is little evidence regarding the safety of combining tumescent lidocaine infiltration with subcutaneous lidocaine infiltration required in other aesthetic surgery. The safety of lidocaine and epinephrine dosing was investigated in 10 patients undergoing tumescent technique liposuction alone and in 10 patients undergoing tumescent liposuction with concurrent facial and aesthetic breast surgery by determining serum lidocaine and epinephrine levels at 3, 12, and 23 hours following infiltration of the tumescent solution and the subcutaneous lidocaine. The mean lidocaine dose of all patients was 22.3 mg/kg. All patients demonstrated safe lidocaine levels at all intervals, with the highest levels occurring in patients who received intravenous lidocaine at the induction of anesthesia. The peak epinephrine levels occurred at the 3-hour blood draw and were approximately four times physiologic. No patient demonstrated any subjective or objective signs of lidocaine or epinephrine toxicity.

In summary, vertical suspension of the malar fat pad has been a safe procedure that results in the creation of a more youthful cheek and a lessening of the prominence of the nasolabial folds. No complications were encountered in this series with the suture suspension of the malar fat pad.

Mandibular lengthening by distraction was performed in a 6-year-old tracheostomy-dependent Treacher-Collins syndrome patient. Detailed preoperative imaging revealed an occluded retrotongue base pharyngeal airway, which, following mandibular distraction, became patent and permitted tracheostomy removal. Mandibular distraction as a technique must be targeted toward clinical problems--management of upper-airway obstruction may be one such scenario.

We report the successful surgical treatment of a 24-year-old male with an aggressive metastasized eccrine poroma. The primary lesion was on the left plantar surface and resembled a pyogenic granuloma. Two months after we excised this lesion, the patient presented with a mass on the left groin, apparently a metastatic occurrence related to the tumor. We performed a radical lymph node dissection with no adjunctive treatment. Five years later, the patient is apparently free of any related disease.

The use of local transposition muscle flaps for coverage of the lower extremity has been overshadowed in recent years by the development of microsurgical techniques for tissue transfer. There are still definite indications for local muscle flaps in reconstruction of the lower extremity. An outline of criteria of selectivity as it applies to specific wounds and practical pitfalls of their use is presented.

This is the first case report of the clinical use of intraoperative streptokinase to promote free flap salvage. A latissimus dorsi free flap was mobilized to cover a scalping type injury. After 4 1/2 hours of ischemia and recurrent thrombosis, streptokinase was perfused into the thoracodorsal artery (7,500 units of streptokinase in 30 cc of normal saline). The free flap was exposed to this concentration of streptokinase for 10 minutes followed by drainage of the venous effluent in order to avoid possible deleterious systemic effects of the streptokinase. Good flow throughout the free flap resulted, and the flap remained viable, providing good coverage for the patient's skull. Controversies regarding the no-reflow phenomena and the use of various thrombolytic agents are discussed.

Chronic upper extremity arterial insufficiency is rare. Consequently, major reports specifically limited to the topic are scarce, and the clinical experience is small. In addition, symptomatology, diagnostic criteria, and guidelines for surgical management remain ill-defined. In the lower extremities, however, in situ vein bypass has been attempted for nearly three decades. This technique offers many advantages over traditional revascularization methods. Although the procedure has become popular for the lower extremity, no report of its use in the upper extremity is found in the literature. We report what may be the first case in which in situ bypass was used in the upper extremity for a threatened limb secondary to diabetic occlusive vascular disease complicated by a previous shunt used for hemodialysis. Revascularization of the upper extremity using the in situ vein bypass technique may offer a new alternative to traditional methods of revascularization.

Extensive scalping injuries offer a unique challenge for tissue coverage because of the wide expanse of bone and lack of deep soft tissue or significant perforating vessels. For smaller injuries, pedicle flaps offer ideal coverage. Larger defects can be covered by omental flaps. Coverage with a free muscle flap followed by split-thickness skin grafting offers optimal long-term coverage. Two new techniques are introduced. The wire-button technique offers stabilization, and the halo frame provides good support and protection for a new free-flap graft and may increase the success rate of flaps in patients with scalping injuries.

A 12-year-old boy suffered from a full-thickness traumatic amputation of his lower lip and chin following a horse bite. Microsurgical technique was used to reanastomose the inferior labial artery and a vein of the chin. The replanted flap remained viable, and the patient has done well despite some early problems with eating and drooling. The patient is now able to purse his lips and has regained sensation and the use of his orbicularis oris and musculus mentalis, even though no attempt was made to repair the motor nerves or sensory nerves. Because of the potential superior cosmetic and functional results following replantation, we recommend aggressive microsurgical attempts at arterial and venous anastomosis not previously described following traumatic amputation. The inferior labial artery may be considered for use as a nutrient artery for replantation and in future elective maxillofacial reconstruction and free-flap transfer.