Search

In a scenario involving a nuclear detonation during war or a terrorist attack, acute radiation exposure combined with thermal and blast effects results in severe skin injury. Although the cutaneous injury in such a scenario may not be lethal, it may lead to inflammation, delayed wound healing and loss of the skin barrier, resulting in an increased risk of infection. In this study, we tested the potential use of timolol, a beta-adrenergic receptor antagonist, to improve epidermal wound closure after combined burn and radiation injury using an ex vivo human skin culture model. Daily application of 10 μ M timolol after combined injury (burn and 10 Gy ex vivo irradiation) increased wound epithelialization by 5-20%. In addition, exposure to 10 Gy significantly suppressed epidermal keratinocyte proliferation by 46% at 48 h postirradiation. Similar to what has been observed in a thermal burn injury, the enzyme phenylethanolamine N-methyltransferase (PNMT), which generates epinephrine, was elevated in the combined thermal burn and radiation wounds. This likely resulted in elevated tissue levels of this catecholamine, which has been shown to delay healing. Thus, with the addition of timolol to the wound to block the binding of locally generated epinephrine to the beta-adrenergic receptor, healing is improved. This work suggests that by antagonizing local epinephrine action within the wound, a beta-adrenergic receptor antagonist such as timolol may be a useful adjunctive treatment to improve healing in the combined burn and radiation injury.

Introduction Plastic surgeons endure years of training yet remain poorly equipped to negotiate first employment contracts. Our aims were to evaluate typical plastic surgeon employment contracts and assess contract comprehensiveness. We sought elements that should be included to better preserve varied interests. Methods A brief, anonymous, e-mailed survey was sent to California Society of Plastic Surgeons members and responses collected over 2 months. We collected information such as years in practice, geographic area, types of practices and number of surgeons within them, and legal standing of partnerships. We asked whether respondents sought legal assistance and specific elements were elaborated. We asked how content they were with their contracts while allowing commentary. Results Our survey generated 113 responses. 50.0% of respondents reported being in practice for at least 20 years; 2.68% had been in practice for up to 5 years. 62.5% reported being in private practice and 27.7% reported being in academia. In-state geographic distribution of respondents accounted for 85.6%, whereas 14.4% reported practicing out-of-state.Practice size was diverse, with 41.4% of respondents having worked in a group practice of 3 or more, 27.9% in partnership, and 23.4% in solo practice. For partnerships, 29.9% had made formal legal arrangements, whereas 20.6% had made informal arrangements. 74.5% of respondents did not seek legal assistance.Malpractice coverage varied from 51.6% with claims-made, to 21.7% with tail, to 33.0% with no coverage at all. 63.9% reported having no group disability policy. 26.4% reported annual income of less than US $100,000; 49.1% reported US $101,000 to US $200,000; 17.9% reported US $201,000 to US $300,000; 6.60% reported greater than US $300,000. Using a 5-point scale, 7.69% of respondents reported being "extremely dissatisfied" with their first employment contracts (score of 1), whereas 24.0% were "perfectly happy" (5).Eighty-two respondents offered advice. Common themes included seeking legal counsel; considering eventual solo practice; planning long-term; seeking mentorship; and cautioning against third party interests. Conclusions New plastic surgeons will find themselves employed by institutions. Seeking attorneys familiar with the profession is advisable. Lack of awareness regarding malpractice options and disability coverage are 2 areas of concern. We reveal critical contract elements that surgeons should negotiate to ensure smooth transition to practice.

Although human exposure to low-dose ionizing radiation can occur through a variety of sources, including natural, medical, occupational and accidental, the true risks of low-dose ionizing radiation are still poorly understood in humans. Here, the global transcriptional responses of human skin after ex vivo exposure to low (0.05 Gy) and high (5 Gy) doses of X rays and of time in culture (0 Gy) at 0, 2, 8 and 30 h postirradiation were analyzed and compared. Responses to low and high doses differed quantitatively and qualitatively. Differentially expressed genes fell into three groups: (1) unique genes defined as responsive to either 0.05 or 5 Gy but not both and also responsive to time in culture, (2) specific genes defined as responsive to either 0.05 or 5 Gy but not both and not responsive to time in culture, and (3) dose-independent responsive genes. Major differences observed in ex vivo irradiated skin between transcriptional responses to low or high doses were twofold. First, gene expression modulated by 0.05 Gy was transient, while in response to 5 Gy persistence of modified gene expression was observed for a limited number of genes. Second, neither TP53 nor TGFβ target genes were modulated after exposure to an acute low dose, suggesting that the TP53-dependent DNA damage response either was not triggered or was triggered only briefly.

As the technique of autologous fat grafting is being refined and perfected, its clinical applications are expanding. The use of autologous fat grafting for primary breast augmentation is controversial due to a lack of clarity regarding its safety and efficacy. Most notably, concerns about interference with the detection of breast cancer have been raised, but these have not been clearly addressed in the literature. To help surgeons gain further insight, the authors conducted a systematic review of the literature, carefully comparing technique, clinical outcome, radiologic impact, and complications in all available data on this subject. Although an optimal method of autologous fat grafting for primary breast augmentation is yet to be standardized, further strong evidence-based studies are necessary to confirm the findings of this approach.

After studying this article, the participant should be able to: 1. Understand the evaluation of a patient with a lower extremity wound. 2. Determine when an attempt at wound salvage is likely to be successful. 3. Select an appropriate technique for wound management. 4. Anticipate and identify wound complications.Successful management of a patient's wound at or distal to the knee includes accurate site assessment, meticulous debridement, planning, and execution of a reasonable operative procedure. Outlining a reconstructive plan requires consideration of alternatives from basic to most complex, then selection of the simplest technique likely to achieve wound closure with minimal donor-site morbidity. Healing by secondary intention, with or without vacuum-assisted closure, demands few surgical resources. A skin graft may close a well-vascularized wound. A local skin, fasciocutaneus, or muscle flap can provide vascularized tissue to an otherwise ischemic area. A plastic surgeon may use free tissue transfer in the more difficult anatomic regions, particularly for defects of the distal one-third of the lower leg. Other issues demand consideration when treating a patient with a lower extremity wound. Anesthetic options range from none in the case of secondary intention healing, through prolonged general anesthesia in the circumstance of free tissue transfer. Early recognition of a complication makes successful treatment of that problem more rapid and more likely to be successful. Accurate CPT coding ensures appropriate reimbursement for the reconstructive surgeon and fairness to the payer. Finally, some wounds are so extensive and patients so ill from related or unrelated pathologic processes that attempts at reconstruction are ill advised. These patients are better served by early amputation and prompt rehabilitation.

Background: The purpose of this study was to determine whether seroma formation following abdominoplasty is associated with simultaneous liposuction of the flanks and to stratify the risk of developing seromas according to body mass index. Methods: A retrospective review was conducted of 118 consecutive patients who underwent abdominoplasty with or without flank liposuction from 1992 to 2002. Patients in the abdominoplasty with flank liposuction category were further substratified according to the use of conventional versus ultrasound-assisted liposuction. Data regarding patient age, body mass index, and the occurrence of seromas were collected and analyzed. Results: Fifteen of the 39 patients who underwent abdominoplasty alone (38 percent) developed seromas. This was comparable to the 23 of 79 patients (29 percent) who developed seromas after abdominoplasty combined with flank liposuction (p = not significant). Eight of 19 patients (42 percent) who had liposuction performed with ultrasound assistance developed seromas, compared with 15 of 60 patients (25 percent) who underwent conventional liposuction without ultrasound (p = not significant). When stratified according to body mass index, overweight or obese patients were more likely to develop seromas than patients of normal weight, whether liposuction was performed in the same setting or not [seromas in seven of 37 (19 percent) of normal weight patients versus 31 of 81 (38 percent) of overweight and obese patients, p Conclusions: Liposuction of the flanks in concert with abdominoplasty does not appear to increase the risk of seroma formation. Patients who are overweight or obese present a statistically significantly higher risk for developing seromas postoperatively than patients of normal weight.

Pneumothorax is a recognized complication of breast augmentation which, until now, was thought to be rare. The authors hypothesize that it is more common than generally appreciated.A fax survey was sent to 363 members of the California Society of Plastic Surgeons in 2001, questioning their experience with this complication.The survey response rate was 50 percent, revealing that one in three members of the California Society of Plastic Surgeons had at least one patient who experienced a pneumothorax, and one in 10 had experienced two or more complications of pneumothorax while performing breast augmentation. Sixty-two members reported a total of 83 separate pneumothoraces in their career. No local or hypodermic needle injections were used in 24 percent of these patients. Fifty-five percent of patients were hospitalized, with 71 percent of the cases paid for by insurance companies. Treatment consisted of observation and repeated chest radiograph in 33 percent, needle aspiration alone in 16 percent, and chest tube insertion in 47 percent.The cause is difficult to determine, but causes suspected by respondents included intraoperative laceration of the pleura (43 percent), needle puncture at the time of local injection (37 percent), ruptured pulmonary blebs during or after the procedure (16 percent), and high anesthetic ventilation pressures (3 percent). The authors believe the complication of pneumothorax is more common than generally appreciated and is not necessarily caused by negligence. The authors now include this complication in their consent form and recommend keeping an intracatheter, pigtail catheter, or Heimlich valve in surgical facilities for treatment of a possible tension pneumothorax.

"Pixie-ear" deformity is a postrhytidectomy sequela in which the ear lobe is pulled inferiorly. This deformity may be attributed to excessive skin excision inferior to the earlobe, direct suturing of the facial flap to lobule skin, or excessive scarring. When there is increased tension on the earlobe, the otobasion inferius (cephalic attachment point of lobe) migrates from a posterior cephalic position to an anterior caudal position. The authors present an operative technique to prevent pixie-ear deformity and optimize earlobe position in face-lifting.

Treatment of patients with infected median sternotomy wounds includes debridement and closure using vascularized tissue, most often the pectoralis major muscle. However, occasionally, surgeons use other flaps to close sternotomy wounds. The purpose of this study is to review 1 center's experience with infected median sternotomy wounds utilizing a less common technique, the rectus abdominis musculocutaneous flap.

The quality of a breast reconstruction is gauged by the symmetry achieved when the reconstructed and opposite breasts are compared. In order to produce a symmetrical appearance, it is often necessary to revise the contralateral, previously unoperated breast. A procedure on the opposite breast can be performed at the same time as breast reconstruction or can be delayed for several months. The purpose of this study was to compare the simultaneous TRAM flap and contralateral breast reduction/mastopexy with the TRAM flap alone according to selected parameters. Our results suggest that performing the combined procedure is safe and yields a satisfactory aesthetic result.

Health care disparities have been documented in rural populations. The authors hypothesized that breast cancer patients in urban counties would have higher rates of postmastectomy breast reconstruction relative to patients in surrounding near-metro and rural counties.The authors used the Surveillance, Epidemiology, and End Results database to identify patients diagnosed with breast cancer and treated with mastectomy in the greater Sacramento area between 2000 and 2006. Counties were categorized as urban, near-metro, or rural. Univariate models evaluated the relationship of rural, near-metro, or urban location with use of breast reconstruction by means of the chi-square test. Multivariate logistic regression models controlling for patient, tumor, and treatment-related factors predicted use of breast reconstruction. The likelihood of undergoing breast reconstruction was reported as odds ratios with 95 percent confidence intervals; significance was set at p≤0.05.Complete information was available for 3552 breast cancer patients treated with mastectomy. Of these, 718 (20.2 percent) underwent breast reconstruction. On univariate analysis, differences in the rates of breast reconstruction were noted among urban, near-metro, and rural areas (p0.001). On multivariate analysis, patients from rural (odds ratio, 0.51; 95 percent confidence interval, 0.28 to 0.93; p0.03) and near-metro (odds ratio, 0.73; 95 percent confidence interval, 0.59 to 0.89; p=0.002) areas had a decreased likelihood of undergoing breast reconstruction relative to patients from urban areas.Patients from near-metro and rural areas are less likely to undergo breast reconstruction following mastectomy for breast cancer than their urban counterparts. Differences in use of breast reconstruction detected at a population level should guide future interventions to increase rates of breast reconstruction at the local level.

We report nine cases in which the neuro-veno-adipo-fascial (NVAF) flap was used to perform reconstruction of foot wounds over a 7-year period. Complications occurred in five (56%) patients. One patient suffered total loss of the flap and four experienced partial loss of the NVAF flap. Complications are to be expected with the use of the NVAF flap for foot wounds, but in most cases the flap is salvageable. The NVAF flap is an option in foot reconstruction when free tissue transfer is not available, contraindicated due to patient factors or when a prior free flap has failed.

BACKGROUND Integrated plastic surgery residency training is growing in popularity, bringing new challenges to program directors and applicants. The purpose of this study was to identify characteristics of successful applicants and to obtain feedback from applicants to improve the integrated plastic surgery residency training application and interview process. METHODS An anonymous survey assessing applicant academic qualifications, number of interviews offered and attended, and opinions about the application and interview process was distributed electronically to the 2006 integrated plastic surgery residency training applicant class. The number of interviews offered was used as an indicator of potential applicant success. RESULTS A 38 percent survey participation rate (139 of 367) was achieved. United States Medical Licensing Examination Step 1 score correlated with number of interview invitations (p < or = 0.001). Successful Alpha Omega Alpha designation (p < or = 0.001), high class rank (p = 0.034), presence of a plastic surgery residency program at the participant's school (p = 0.026), and authorship of one or more publications (p < or = 0.001) were associated with receiving greater number of interview invitations. Geographic location was an important consideration for applicants when applying to and ranking programs. Applicants desired interviews on weekdays and geographic coordination of interviews. CONCLUSIONS Integrated plastic surgery residency training is highly competitive, with the number of interview invitations correlating with academic performance and, to a lesser extent, research. Applicant feedback from this survey can be used to improve the application and interview process.

Background Immediate breast reconstruction is being increasingly used after mastectomy, although it may increase the incidence of wound complications. The indications for chemotherapy in breast cancer are expanding and wound complications following mastectomy may delay the initiation of adjuvant chemotherapy. Hypothesis Immediate breast reconstruction after mastectomy for breast cancer does not lead to an increased incidence of wound complications nor delay the initiation of systemic chemotherapy. Design and Setting Retrospective medical record review at a tertiary care center. Patients One hundred twenty-eight women treated with a mastectomy for breast cancer over an 8-year period (January 1, 1995, through December 31, 2002). Main Outcome Measures Surgical site complications (infectious and noninfectious) and time to initiation of postoperative chemotherapy. Results One hundred forty-eight mastectomy procedures in 128 women with breast cancer were evaluated. We analyzed 4 subgroups according to whether or not immediate breast reconstruction was part of the surgical procedure (76 or 72 procedures, respectively) and whether or not postoperative adjuvant chemotherapy was administered (81 or 47 patients, respectively). There was an increased incidence of wound complications in patients who underwent immediate breast reconstruction compared with those who did not (6/72 [8.3%] vs 17/76 [22.3%]; P = .02). However, these complications did not delay initiation of postoperative chemotherapy. Conclusions Although we observed an increased incidence of wound complications when immediate breast reconstruction was combined with mastectomy, there was no delay in the initiation of adjuvant therapy. Immediate breast reconstruction should remain an important treatment option after mastectomy even when postoperative chemotherapy is anticipated.

Static suspension remains an option for certain patients with facial paralysis. Endoscopically assisted facial suspension obviates the need for a counter-incision at the oral commissure to distally inset the fascia lata graft as described in the standard technique. The endoscopic technique is simple, allows secure placement of perioral fascial strips, and can be performed as an outpatient.

A cadaver and clinical study was performed to determine the value of transantral endoscopy in diagnosis and treatment of orbital floor fractures. Six fresh cadaver heads were dissected using a 30 degree, 4-mm endoscope through a 1 cm2 antrotomy. In the cadaver, the orbital floor and the course of the infraorbital nerve were easily identified. The infraorbital nerve serves as a reference point for evaluation of fracture size; three zones of the floor are described that are oriented relative to the infraorbital nerve. In the clinical study, nine patients with orbital floor fracture initially underwent endoscopy at the time of fracture repair: three patients had comminuted zygomatico-orbital fractures, five had monofragmented tetrapod fractures, and one had an isolated orbital blowout fracture. Endoscopic dissection of the orbital fractures revealed seven fractures with an area > 2 cm2 and two fractures with an area of < 2 cm2. The isolated orbital floor blowout fracture had entrapped periorbital tissue, which was completely reduced endoscopically. A separate patient with a < 2 cm2 displaced fracture also had stable endoscopic reduction. In the remaining seven patients, the endoscopic technique assisted with the floor reconstruction by identifying the precise fracture configuration as well as identifying the stable posterior ledge of the orbital floor fracture. There have been no complications in any of our patients to date. We conclude: (1) Transantral orbital floor exploration allows precise determination of orbital floor fracture size, location, and the presence of entrapped periorbita. The information obtained through endoscopic techniques may be used to select patients who would not benefit from lid approaches to the orbital floor and may possibly eliminate nontherapeutic exploration. (2) Transantral endoscopic orbital floor exploration assists the reduction of complex orbital floor fractures and allows precise identification of the posterior shelf for implant placement. (3) Transantral endoscopic techniques can completely reduce entrapped periorbital tissue caught in a trapdoor type of fracture.

Ten adult cadavers were used to accurately detail the vascular anatomy of posterior thigh skin. Fourteen posterior thigh specimens were dissected after blue latex injection of the internal and external iliac arteries. Six posterior thigh specimens underwent selective dye injection of individual profunda perforating arteries and the inferior gluteal artery. The findings reveal an extensive fascial plexus nourished primarily by fasciocutaneous branches of the first and second profunda perforating arteries and secondarily by a terminal fasciocutaneous branch of the inferior gluteal artery. From 1989 to 1992, 24 posterior thigh fasciocutaneous flaps were performed in 24 patients. There were 5 early postoperative complications (21 percent). All but one patient went on to satisfactory healing and stable wound coverage. Three posterior thigh fasciocutaneous flaps were used successfully despite ligation of their inferior gluteal artery blood supply in a previous surgical procedure. These anatomic and clinical findings confirm the reliability of a posterior thigh fasciocutaneous flap based primarily on the first and second profunda perforating arteries. The posterior thigh fasciocutaneous flap can survive in the absence of a patent inferior gluteal artery. Knowledge of the vascular anatomy extends the clinical applicability of the posterior thigh fasciocutaneous flap to patients who might otherwise be excluded because of prior injury or operative procedure.

The technique of combined scapular/parascapular reconstruction of the below-knee stump wound allows three-dimensional contouring of fasciocutaneous tissue into a conical shape. The flap can supply durable cover to the circumference of the stump with good functional results. This technique should be considered for reconstruction of extensive circumferential defects of the below-knee stump.

Sternal osteomyelitis complicates recovery in a small number of patients following median sternotomy. Techniques for operative treatment have in common the wide debridement of devitalised tissue and administration of culture-specific antibiotics. The resultant wound can be managed by delayed primary closure or transposition of well-vascularised adjacent tissue. Omentum, pectoralis major muscle and rectus abdominis muscle are suitable for transposition either alone or in combination. Our series is composed of ten patients who underwent rectus abdominis muscle transfer for the treatment of sternal osteomyelitis. The rectus abdominis obliterates dead space in the lower third of the wound, a difficult area to reach with the pectoralis major muscle. Five patients had one rectus abdominis muscle alone transposed, avoiding the aesthetic and functional deficits of pectoralis major transposition and the risks of omental transfer. Wound healing occurred in every case with a minimum of postoperative complications.

Transfer of a free-muscle graft with application of a split-thickness skin graft is one of many techniques available for reconstruction of the massive foot injury. The durability of such a reconstruction has been questioned. We have treated nine patients suffering from foot injuries with extensive soft-tissue loss. Each patient underwent reconstruction using a free-muscle transfer covered by a split-thickness skin graft. A mean follow-up of 33 months (range 17 to 48 months) is reported for these nine patients. Each patient is ambulatory. One patient developed an ulcer on the plantar surface, which was treated successfully by flap revision and skin grafting. We feel this technique provides a durable reconstruction for significant soft-tissue loss of the foot.

Neurofibromas cause unsightly and crippling deformities. These locally destructive tumors arise along the distribution of peripheral and cranial nerves. The 2 patients presented here had neurofibromas of the external ear. In one patient, the lesion was limited to the auricle. In the other, the tumor extended into the facial nerve and parotid gland. Preoperative computed tomographic scanning, a postauricular approach to the tumor, and careful dissection produced an aesthetic debulking of the auricular neurofibromas with preservation of facial nerve function and improvement in hearing.

Two patients with squamous cell carcinoma of the perineum are presented. The carcinomas were treated by wide local excision using Mohs' fresh-tissue technique for control of the surgical margins. The wounds were closed using a gluteal thigh flap. In 1 patient the flap was extended across the midline for coverage of a contralateral perineal site. Healing was complete in each case. The combination of Mohs' fresh-tissue methods and the posterior thigh flap provided accurate identification and removal of the perineal tumor with stable wound coverage.

A patient with extensive loss of bone and soft tissue from the right heel is presented. The defect was reconstructed using an osteocutaneous flap based on the deep circumflex iliac vessels. Indications for this procedure include extensive loss of bone and soft tissue precluding the use of local flaps. A 30-month period has elapsed since her reconstruction. A single ulcer developed 13 months postoperatively that healed after flap revision. We feel that tailoring the flap to minimize redundancy at the initial operation, subsequent tissue excision if necessary, and reinnervation augment durability of the flap.

Major complications of radiation directed to the breast, axilla, and mediastinum were treated in 54 patients from 1974 to 1983. A classification of these complications facilitates both an understanding of the pattern of injury and the development of a treatment plan. Classification: I. Breast necrosis; II. Radionecrosis and Chest Wall Ulceration; III. Accelerated Coronary Atherosclerosis with Median Sternotomy Wound Failure After Coronary Revascularization; IV. Brachial Plexus Pain and Paresis; V. Lymphedema and Axillary Cicatrix; VI. Radiation-induced Neoplasia. The treatment has evolved during the 10-year study period to excision of the necrotic wound, including any tumor, and closure with a transposed muscle or musculocutaneous flap of latissimus dorsi (II, III, V) or rectus abdominis (I, II, VI). This strategy reflects a change from primary use of the omentum during the first years of the study. The vascularity, oxygen and antibiotic delivery of these muscle and musculocutaneous flaps promote wound healing, usually with one operation. The transfer of these muscles has not caused significant functional deficits.

Les syringomes sont des tumeurs annexielles benignes, souvent localisees sur la peau de la paupiere inferieure. Les patients reclament habituellement la resection pour des raisons esthetiques. L'electrodessiccation et le curettage de ces lesions assurent l'eradication locale tout en conservant la peau non atteinte de la paupiere

The tube pedicle flap is useful in reconstruction of an absent ear helix. However, immediate tubing of the flap may result in vascular compromise. By elevating a bipedicle flap in the postauricular region and shielding it with a silicone sheet, it is possible to allow the flap to assume a tubular shape while preventing adherence to the underlying suture line. Once mature, the flap maintains both a cylindrical shape and a sufficiently thin external diameter to provide adequate restoration of the ear helix.

Patients requiring reconstruction by muscle or musculocutaneous flaps often have an associated area of skin anesthesia. This skin is susceptible to trauma because of its insensibility. This study reports 3 cases in which patients sustained deep partial-thickness burns of anesthetic skin following flap reconstruction. All burns healed by reepithelialization. Following flap reconstruction, patients should be warned regarding the use of heating pads. Burns of this type represent a preventable complication of flap reconstruction.

We present a case of scalp avulsion treated with a transposition scalp flap utilizing a split-thickness skin graft from the flap. Using the flap as a donor site confined the operation to a single anatomic region and saved the patient an additional donor-site scar. The flap healed uneventfully with normal regrowth of hair, the donor site was well concealed, and there was complete take of the split-thickness skin graft.

Transfer of the latissimus dorsi muscle was useful in restoring contour and function to a child's acutely injured upper extremity. The procedure provided protection for exposed vital structures. A split-thickness skin graft covered the exposed muscle. Transposition of the latissimus dorsi insertion was not necessary to obtain adequate elbow flexion.

Osteoradionecrosis of the olecranon is an unusual pathologic entity, treated best by debridement and wound closure using vascularized tissue. Local skin is often unavailable for flap design and transposition. The radial forearm flap can be isolated on a proximal vascular pedicle and transposed to cover the wound. In the case presented, healing was brisk and complete, allowing early elbow mobilization. Although the donor site is not easily concealed, no functional impairment results from flap elevation and all full-thickness wounds are confined to the involved extremity.

The vertical trapezius musculocutaneous flap has been successfully utilized for reconstruction in 13 patients with complex posterior skull and neck defects. This flap based on its vascular pedicle, the descending branch of the transverse cervical artery, provides well-vascularized tissue for coverage of defects related to chronic osteomyelitis, tumor extirpation, osteoradionecrosis, and dehisced cervical laminectomy wounds. Emphasis on flap design, including the location of the skin island, allows adequate wound coverage, direct donor site closure, and muscle function preservation. With its large size and wide arc of rotation, the vertical trapezius musculocutaneous flap provides reliable coverage for posterior trunk, cervical, and skull defects.

Our work demonstrates that the "reverse" latissimus dorsi musculocutaneous flap has a predictable and consistent blood supply. A major portion of the muscle can be nourished by the dorsal perforating branches of the ninth, tenth, and eleventh intercostal vessels. The skin island based on the "reverse" latissimus dorsi muscle can be as large as 8 X 20 cm. This is confirmed by anatomic dissections and clinical cases. Knowledge of the blood supply facilitates elevation of the flap and extends its utility.

We present a congenital deformity of the right ear, characterized by absence of the central portion of the helix and antihelix. The deformity was reconstructed by advancing retroauricular skin and closing the resultant defect with a composite graft from the posterior aspect of the left ear. This technique was performed in a single stage and required no incisions on the anterior surface of either ear. Postoperative appearance of the right ear was satisfactory, and donor deformity was minimal.

The gluteus maximus island musculocutaneous flap has been described using a variety of designs. We employ an island whose long axis is directed toward the pressure sore, minimizing tension in wound closure. Skin overlying the greater trochanter is avoided. Previously undermined skin can be included in the flap. Fifty patients with ischial or sacral pressure sores have been managed by this technique. Superficial dehiscence occurred in 13 percent of patients, and deep dehiscence occurred in 10 percent. The dehiscence closed spontaneously in all but one patient. Forty-nine of the 50 patients experienced complete wound healing at the pressure sore site. The patients have been observed for an average of 20 months (range 3 to 38 months), with one recurrent pressure sore seen at 28 months postoperatively. The gluteus maximus musculocutaneous island flap has proven to be both reliable in healing and durable over the observed interval.

Reflex sympathetic dystrophy is an automatic dysfunction that occasionally complicates healing after trauma or surgery. The syndrome is characterized by pain, swelling, stiffness, and discoloration often out of proportion to the original injury. Early diagnosis and appropriate treatment are the most important factors in the successful outcome of this disabling condition. A case of longstanding, previously untreated reflex sympathetic dystrophy secondary to a minor injury is presented.

Closure of the meningomyelocele wound requires stable coverage of the dural repair. In the case presented, multiple conventional attempts at reconstruction failed. A modification of the "reverse" latissimus dorsi flap is presented that successfully managed this low lumbar defect.

A 4-year-old girl with an extensive soft tissue loss of the left heel is presented. Management by debridement followed by coverage with an innervated flexor digitorum superficialis musculocutaneous flap resulted in primary healing. Full weight-bearing ambulation was resumed 8 weeks postoperatively. The patient has been ambulating on the reconstructed heel for 18 months without difficulty. Technical aspects of the reconstruction are presented as well as a discussion of treatment alternatives.

A method of wound management following shoulder disarticulation is described. In this report, the primary lesion is a mycotic aneurysm of the axillary artery. The pectoralis major muscular flap provides satisfactory coverage and maintains shoulder contour. It can be performed in a single procedure. Preoperative arteriography is important to determine the extent of arterial damage as well as the vascular anatomy of the proposed flap.

A young adult male presented with an open tibia-fibula fracture, extensive circumferential soft tissue loss and exposed bone. Although the fracture sites were stabilised by an external fixator, chronic infection complicated this 2-week-old wound. Treatment by amputation was elected. Local skin alone was inadequate for coverage of a preferred below-knee amputation. As an alternative to above-knee amputation, the patient underwent coverage of a below-knee amputation using a musculocutaneous island pedicle flap of sensate plantar skin and muscle.

Knee and elbow injuries are seen frequently by the primary care physician and require prompt and careful treatment in order to prevent infection, preserve joint function, and avoid scarring. A thorough history and physical examination help to rule out more significant damage to the related joint, nerves, or tendons. Immobilization of the joint may be necessary to prevent dehiscence, and the patient should be instructed to return for further examination if signs of infection develop.

Poland's syndrome is a well-known constellation of congenital anomalies that includes varying degrees of hypoplasia involving the thoracic cage in association with anomalies of the hand. Although the latter are most frequently described as syndactyly with short or absent middle phalanges, many forms of expression were seen in a series of 20 patients. Thirty-one other anomalies were seen in this group in addition to those usually considered as part of the syndrome. Of special interest are those involving the spine and genitourinary tract that require special studies for early detection.