Search

Two patients with advanced perineal hidradenitis suppurativa, complicated by fecal incontinence and squamous cell carcinoma, are presented. The first patient was a 58-year-old man who had a 30-year history of chronic recurring perianal abscesses and perineal sinuses. At the time of presentation, he had extensive perineal suppurative disease, and scarring and fixation of the anal sphincters with resultant fecal incontinence. He was treated with wide excision and skin graft closure. The second patient was a 27-year-old man with an 11-year history of recurrent gluteal abscesses and perineal sinuses. At the time of presentation, his inflammatory disease was only mildly active, but he had a nonhealing gluteal lesion. The nonhealing lesion was diagnosed as a squamous cell carcinoma and was managed with wide excision and primary closure. The inflammatory disease was excised and grafted. Complications of advanced hidradenitis suppurativa can be debilitating and life threatening. We review the etiology, pathophysiology, complications, and treatment options of hidradenitis suppurativa, including a literature review of the association with malignancy. We propose that the incidence of disabilities and complications may be reduced by early diagnosis and treatment, by emphasis on prevention of recurrence, and by more aggressive surgical intervention for recurrent and extensive disease.

Subcutaneous injection of epinephrine markedly reduced local tissue pO2 levels and blood flow while increasing tissue pCO2 in a rat model. The duration and magnitude of these effects were correlated with prolonged elevation of tissue levels of epinephrine and were proportional to the amount of epinephrine injected.

Primary squamous cell carcinoma of the plantar surface of the foot is a rare lesion. Four case reports are summarized and a comparison made with similar cases presented elsewhere. Diagnostic work-up and review of similar lesions are used as a means of making suggestions for treatment.

Injection of a chemical irritant into the radial artery at the wrist causes acute discoloration of the skin, edema, and pain in the hand. Subsequent damage due to vasospasm, endarteritis, particulate embolization, and vascular thrombosis may result in ischemic contractures, amputations, and other functional hand deficits. Injection of a street cocaine preparation into the radial artery of a 22-year-old man produced a constellation of signs and symptoms similar to that described for other irritants. Current thoughts with regard to the pathophysiology and treatment of these injuries are reviewed.

Rats subjected to a standard electrical burn of 250 volts for 10 seconds receive a severe injury stimulating a pronounced systemic circulatory response. Initial postinjury hyperemia is replaced by a low perfusion state within 24 hours. Our study demonstrates the difficulty in isolating regional microcirculatory alterations under such circumstances. Modification of the burn model or the method of fluid resuscitation may minimize the influence of this dynamic systemic response.

Unlabelled: Benzopyrones are a class of drugs which have been used clinically and experimentally in Europe and Australia to reduce tissue swelling caused by high-protein edema states. These drugs are not available nor have they been investigated in the United States. This pilot experiment was designed to determine if one of these compounds, 5,6 benzo-alphapyrone, is effective in reducing traumatic edema from thermal and crush injury., Method: One hind limb of 34 Sprague-Dawley rats was immersed for 30 seconds in 55 degrees C water and the animals divided into three groups as follows: Group I--no treatment; Group II--17 cc saline/kg body weight IP; Group III--25 mg 5,6 benzopyrone in 17 cc saline/kg body weight IP. In another 30 S-D rats, the soft tissue of the posterior aspect on one hind limb was crushed in a Servistor vise (jaws to within 1 mm of each other) for 5 minutes. They were divided into three groups and treated as in the thermal injury group. After 24 hours both limbs were amputated, weighed, dried, and reweighed. Crushed and burned rat hind limbs treated with benzopyrone after injury had significantly greater dry weights (less edema) than did untreated or saline treated limbs. Benzopyrone appears to be effective in reducing edema following crush and thermal injury in this experimental system. Further studies are being conducted to elucidate the mechanism of action of benzopyrones, their potential activity in other postinjury edema, and their effect on tissue survival.

A case of angiokeratoma circumscriptum in an unusual location is described and the literature reviewed. Angiokeratoma's clinical resemblance to malignant melanoma is emphasized. Excisional biopsy is advocated as treatment when the diagnosis is in doubt.

Six cases of major soft-tissue injuries to the mid or base of thumb are presented. In each case, pedicle reconstruction of the soft tissues was necessary in order to preserve thumb length. A variety of techniques was used, including distant tissues and local tissues. We have illustrated the superiority of local pedicles and cross-finger pedicles in thumb reconstruction and have emphasized the following points: 1) Preservation of thumb length is an important goal. 2) Conservation of the soft tissues in the initial management plays a key role in thumb reconstruction. 3) Local pedicles and cross-finger flaps have given better results than distant flaps, as evidenced by: a. better sensory capacity in the pedicle skin; b. more stable skin on the reconstructed thumb; c. less bulkiness of the pedicle skin; d. reconstruction is less time consuming.

A method is described to reconstruct a unilateral asymmetrical defect of the tip of the nose resulting from burn scar contracture and alar loss by utilizing an appropriate full-thickness rotation of tissue of similar consistency to the defect derived from the opposite side of the nose. This transfer led to the use of similar, but normal tissue, by subtracting from the dimensions of the normal side to add to the shortage of tissue on the abnormal side. This method was designed because of the lack of normal adjacent tissue available for transfer and demonstrates a relatively simple solution to a difficult problem.

Radiologists trained in selective angiography can now deliver sclerosing or occluding materials to the arterial supply of vascular tumors. Such skills require special training and there are limitations to the use of these materials. Specific obliteration can be carried out if this technique is quality controlled. Materials being used for embolization are continually being studied and are changing as new materials are developed. Radiologists can assist surgeons in managing some of these very difficult problems. A large series of patients with various vascular lesions treated at the Oregon Health Sciences University was reviewed. The complications of embolization used for cavernous hemangiomas have tempered our enthusiasm for it as an adjunct form of therapy. We do feel that this method of treatment remains useful in selected cases. The occlusion achieved caused a decrease in both symptoms and size of lesions treated. The decrease in size excluded the need for surgery in 3 cases, aided resection in 1, but caused significant complicating slough in 1. Five cases are presented to demonstrate problems of tissue necrosis encountered.

The literature on familial multiple lipomatosis is reviewed, and a striking case is described. The associated family history is outlined. Excisional biopsy is advocated when there is doubt in terms of diagnosis, pain, or functional impairment.

Utilizing the techniques of biostereometric photography and current state-of-the-art computergraphics, topographic contourgrams have been generated in a series of patients with complex craniofacial malformations. These contourgrams are considered useful in diagnosis and treatment planning and as an aid in postoperative follow-up. We hope that the technique will provide a means to study longitudinal growth in unoperated and operated patients with craniofacial malformations. Comparisons between these groups and normal patients are currently being investigated.

We have presented a rapid and reliable method of finding lost injection valves. (A frustrating footnote, however, is that 1 week later the port had again migrated and could not be located. Since the further anticipated gain was marginal, the bladder was already nearly expanded, and the expense for repeated ultrasound was a consideration, no further attempts were made to locate this port by ultrasound for further filling).

We report here a patient who sustained posttraumatic skin and soft-tissue loss of the right thigh. Replacement of approximately 750 cm2 of split-thickness skin graft with adjacent skin serially expanded and advanced demonstrates the applicability of this technique to cover large tissue defects. Despite infection and exposure, we believe that expansion can proceed safely on an outpatient basis, providing that systemic toxicity does not develop and the exposure does not mechanically preclude expansion.

Juvenile aponeurotic fibromas, although locally recurrent, generally do not metastasize. This observation supports the practice of incomplete excision of the tumor to preserve the function of the involved extremity. We report on a patient with a juvenile aponeurotic fibroma of the palm, who returned 5 years after the second local surgical excision with metastatic fibrosarcoma of the lungs and bones.

Ex vivo hypothermic perfusion has been shown to enhance short-term survival of organs before transplantation. The effects of perfusion, control of media pH, and systemic drug treatment were studied utilizing superficial epigastric free flaps in Sprague-Dawley rats. Viability of the flaps could be reliably maintained (9/10, 90%) for 72 hours using simple storage in phosphate-buffered Ringer's (pH 7.8) at 4 degrees C. Pretreatment with prostaglandin E1 was of slight benefit. Flap perfusion with or without pharmacologic agents was not beneficial.

Fifty-day-old female, albino Sprague-Dawley rats were induced with DMBA, a potent carcinogen that reliably causes multiple breast tumors. Prophylactic subcutaneous mastectomy was performed 2 weeks after injection. Control animals had no breast tissue removed and developed 5.14 tumors per animal, or 1.3 tumors per quadrant. Animals subjected to 50 percent (unilateral) mastectomy developed 5.4 tumors per animal, with 0.72 tumors per surgical quadrant. Animals that underwent 75 percent (three quadrant) mastectomy developed 4.33 tumors per animal, or 0.48 tumors per surgical quadrant. The incidence of tumors was significantly reduced in the surgical areas. However, the risk of any animal developing a breast neoplasm was not reduced in direct proportion to the percentage of breast tissue removed. We believe that this model may prove valuable in evaluating prophylactic subcutaneous mastectomy.

The effectiveness of prophylactic mastectomy in the prevention of breast tumors was studied in spontaneous breast-tumor-forming C3H mice. Prolactin levels were assayed to determine if this hormone was related to the incidence of mammary tumors. Two-hundred and fifty-six 1-month-old C3H mice were divided into four groups (control, 1; sham surgery, 2; mammectomy 50 percent, 3; and mammectomy 100 percent, 4). At the time of sacrifice (0 to 1 year postoperatively) estrus cycles were determined, ventral skin (breast) and ovaries were removed for histology, and serum was collected for prolactin assays. Prolactin levels 24 hours postoperatively were significantly elevated (p less than 0.01) in groups 2 to 4 when compared with group 1. Six months postoperatively, prolactin levels were significantly higher (p less than 0.05) in mice with tumors compared with those without tumors in groups 3 and 4. There were no differences in tumor incidence between the four groups. At 12 months postoperatively, no differences in prolactin levels were noted, but group 2 animals had the highest incidence of mammary tumors (89 percent; p less than 0.01) when compared to groups 3 and 4. Mammary tumor incidence was not decreased by 50 percent or 100 percent mammectomy in C3H mice. Prolactin levels rose in response to surgery and/or anesthesia and remained elevated only in tumor-bearing mice who underwent mammectomy, an occurrence similar to that reported in humans.

A subinfective dose of Staphylococcus aureus (6 X 10(6)) does not produce wound infection in the rat model. Reducing the dosage (concentration) of epinephrine results in decreased numbers of viable bacteria in tissue and a lower incidence of wound infection in this model.

We believe that biostereometrics can be useful to the craniofacial surgeon in providing a highly accurate, reproducible diagnostic and presurgical tool that is inexpensive and noninvasive. It can help visualize complex pathologic bony abnormalities, resolve ambiguous CT scans, and predict soft-tissue changes secondary to alterations in bony contours when used in conjunction with CT scans and cephalograms.

The use of 1-mm ID by 1-cm-long expanded polytetrafluoroethylene microvascular grafts in various positions in two experimental animals did not compare favorably with the use of autogenous vein interposition grafts in controls. Light microscopy and scanning electron microscopy showed that early fibrin deposition at the anastomosis lines is followed by fully activated coagulation of the grafts. Use of antiplatelet and anticoagulant drugs, changes in techniques, and alterations in the graft material are possible future directions for improved patency with expanded polytetrafluoroethylene microvascular grafts.

In an attempt to find a vasoconstrictor with less detrimental local and systemic effects than epinephrine, the effects of phenylephrine, a pure alpha agonist, on tissue gas tension, bleeding, infection rates, and lidocaine absorption were studied. All concentrations of phenylephrine significantly reduced tissue PO2 within 10 minutes of injection, and reduction of PO2 was dose-dependent. Phenylephrine 1:10,000 produced significant bacterial growth when simultaneously injected with 6 X 10(6) Staphylococcus aureus. Bacterial growth was insignificant with 1:20,000 phenylephrine and absent with 1:40,000 phenylephrine. Blood loss from a standard wound was significantly reduced at all concentrations of phenylephrine. Lidocaine absorption was significantly reduced with 1:20,000 and 1:40,000 phenylephrine. In a rat model, 1:40,000 phenylephrine significantly reduced blood loss and lidocaine absorption, produced minimal reduction of tissue PO2, and did not enhance bacterial invasion.

Replacement of lost or injured tissues with similar tissues is a major goal of the reconstructive surgeon. A relatively new modality, tissue expansion, appears to be an helpful adjunct in achieving this goal by providing tissues for reconstruction that are near at hand, possess similar characteristics to the lost tissue, and can even enhance vascularity within an ischemic area. Although the technique is a useful one, its indications and contraindications are incompletely defined. We have used this technique 65 times in 42 patients during a 2 1/2 year period. The overall complication rate has been 22 percent, similar to other reconstructive techniques, but the consequences of these complications have been relatively minor and have not, for the most part, added significantly to patient morbidity.

The management of severely burned and exposed supportive osseous tissues is not fully standardized. We present two patients in whom extensive debridement and decortication of the involved bone may have contributed to subsequent stress fractures. We propose an alternative therapeutic approach for this problem, including: minimal debridement of the bone, early coverage of the exposed bone with vascularized muscle, and adequate prophylactic protection.

A series of forty-six flexor-tendon grafts in forty-one patients is evaluated. All of these patients presented less-than-optimum situations for tendon-grafting due to persistent joint stiffness, deep cicatrix, preliminary skin-grafting procedures, nerve damage, or severe multiple injuries.The results show a worth-while gain of flexion in the proximal interphalangeal joint of the fingers, but a poor gain in the distal interphalangeal joint. In the thumb this gain in flexion is less important for function if the intrinsic muscles are adequate. However, the importance of a flexor-tendon graft in the severely injured hand is judged by the contribution to the over-all function rather than the exact degree of motion obtained.