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Lower-extremity wounds with exposed tendon, bone, or orthopedic hardware present a difficult treatment challenge. In this series of patients, subatmospheric pressure therapy was applied to such lower-extremity wounds. Seventy-five patients with lower-extremity wounds, most of which were the result of trauma, were selected for this study. Dressings made of sterile open-cell foam with embedded fenestrated tubing were contoured to the wound size and placed into the wound. The site was covered with an adhesive plastic sheet. The sheet was placed beneath any external fixation devices, or the fixation device was enclosed within the sheet. The tubing was connected to the vacuum-assisted closure pump. Continuous subatmospheric suction pressure (125 mmHg) was applied to the wound site. The wounds were inspected and the dressings were changed every 48 hours.Vacuum-assisted closure therapy greatly reduced the amount of tissue edema, diminishing the circumference of the extremity and thus decreasing the surface area of the wound. Profuse granulation tissue formed rapidly, covering bone and hardware. The wounds were closed primarily and covered with split-thickness skin grafts, or a regional flap was rotated into the granulating bed to fill the defect. Successful coverage was obtained without complication in 71 of 75 patients. Wounds have been stable from 6 months up to 6 years.

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Twenty-seven consecutive pediatric patients presenting to the orthopaedic surgery or plastic surgery services were reviewed after completion of wound care with the Vacuum Assisted Closure (V.A.C.) system. Each patient presented with complex soft tissue wounds requiring coverage procedures. Patients with acute wounds and wounds present after nonsuccessful attempts at surgical closure (dehisced incisions and failed flaps) were treated. All soft tissue defects healed without extensive coverage procedures using the V.A.C. system. In the majority of patients, use of the V.A.C. system produced a profuse bed of granulation tissue over all exposed bone, tendon, joint, and/or hardware, which could be covered with split thickness skin graft. Other patients were treated successfully with delayed primary closure, local flap advancement (one patient underwent a pedicled cross-leg flap), or by secondary intention. Use of the V.A.C. device is valuable in increasing the rate of granulation tissue formation and healing of extensive soft tissue injuries in pediatric patients. This vacuum system aids in the debridement of necrotic tissue and local soluble inflammatory mediators that may inhibit the proliferation of granulation tissue. These improvements in the local wound environment seem to accelerate wound healing compared with traditional methods. Before the development of the V.A.C. system, a minimum of nine patients within this group would have required free tissue transfer to obtain adequate coverage. The V.A.C. device seems to permit earlier coverage with local tissue or split-thickness skin grafting techniques, thereby decreasing the need for extensive microvascular tissue transfers in pediatric patients.

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Congenital chest wall deformities include five types: pectus excavatum (funnel chest), pectus carinatum (pigeon breast), Poland's syndrome, defects of sternal fusion, and miscellaneous dysplasias and skeletal disorders. Of these five types, two, pectus excavatum and Poland's syndrome, are defects of the skeletal chest wall. These two specific anomalies comprise the vast majority of congenital defects of the chest wall and, as depression deformities, are readily amenable to surgical correction.

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Fixation of the injured mandible to the maxilla is a proven method of stabilizing mandibular fractures and ensuring proper occlusion. The authors report their results with new specialized intraoral bone screws (IMF Screw System; Howmedica Leibinger, Inc., Carrollton, TX) that are designed for the purpose of achieving intermaxillary fixation (IMF). Nineteen patients were placed into rigid IMF using IMF screws alone. Indications were nondisplaced mandibular fractures; symphyseal, body, and angle fractures; midfacial fractures requiring temporary IMF; and edentulous patients with any of these fracture types and an adequate prosthesis. All procedures were performed with the patient under general anesthesia. The authors found that the operative time was markedly shorter than with standard IMF techniques, patient satisfaction was high, and there were no infections related to the screws. All 19 patients remained in stable, accurate occlusion and had adequate healing. One patient continues to have paraesthesias in the mental nerve distribution after screw removal. Although there is the potential for tooth and nerve injury when screws are placed improperly, the IMF Screw System seems to be a safe and reliable method of achieving secure mandibular fixation.

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Four patients are presented who suffered full-thickness loss of the scalp, exposing the skull. Removal of the outer table, immediate application of a split-thickness skin graft, and treatment with the VAC for 3 to 4 days resulted in approximately 100 percent graft take in each case without complications. When compared with the usual two-stage approach to skin grafting the exposed skull, this method spares the patient a longer hospital stay and a second operative procedure, and it results in a significant cost savings.

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Degloving injuries of the hand and foot pose difficult reconstructive and rehabilitation challenges. After an excellent experience with split-thickness skin grafting with the vacuum-assisted closure device, we began studies with full-thickness skin grafts and traumatized skin. The device has been used with successful reapplication of full-thickness degloved skin in two patients. The first patient suffered degloving of the foot; the second patient, degloving of the hand.

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Pedicled cross-extremity flaps for wound coverage have been replaced, in most cases, by free tissue transfer. Classically, cross-leg flaps have been problematic because of difficulties with immobilization and positioning of the extremities from the time of initial coverage to detachment. Three children with severe foot and ankle trauma had cross-extremity flaps using linkage of bilateral lower-extremity external fixators in place of traditional casting. Cross-leg flaps were used in two patients, and a cross-foot flap was applied in one. Each flap survived completely, and the linking fixators were disassembled at the time of flap detachment. No complications were related to the donor site or the flap itself or were caused by the fixation. Lower-extremity range of motion was regained rapidly, and each patient resumed essentially normal gait and activity. Addition of external-fixator stabilization aids greatly in wound care, as well as general ease of patient mobility and positioning. External fixation facilitates the use of cross-extremity flaps in pediatric patients in whom free tissue transfer may not be optimal.

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Exenterative pelvic surgery is commonly performed for advanced carcinoma of the cervix and selected cases of locally advanced colorectal cancers. Low-lying lesions that are locally invasive in contiguous organs require resection of the perineal body en bloc with the resected specimen. The resulting defect, both in the pelvis and the perineum, creates a difficult management problem. Dead space in the pelvis, especially with adjunctive irradiation, leads to delayed wound healing and prolapse of small bowel into the pelvis. Small bowel obstruction and/or fistula formation are the greatest sources of morbidity in the operative group. Fifteen patients underwent exenterative pelvic procedures (total exenteration, 1 patient; posterior exenteration, 8 patients; abdominoperineal resection, 6 patients). All patients were reconstructed by transpelvic placement of the rectus abdominis muscle (muscle only, 4 patients; muscle with skin grafting, 8 patients; musculocutaneous, 3 patients). Eighty-seven percent received radiation therapy. One patient had Crohn's disease and all others had carcinoma. Healing was complete in 12 of 15 patients at discharge. There were no complications related to pelvic dead space (i.e., bowel obstruction, perineal fistula), with a mean follow-up time of 24.3 months. Small bowel was effectively excluded from the pelvis to the level of the acetabular roof by computerized axial tomography scan. The transpelvic rectus abdominis muscle flap is effective in preventing major morbidity after exenterative pelvic surgery.

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Large midline abdominal hernias are reconstructed with bilateral rectus turnover flaps in a series of 15 patients. Each rectus muscle is turned over from a retracted lateral position to the midline, providing a complete abdominal closure with fascia and muscle. The repairs were frequently reinforced with synthetic materials, but synthetic material was not placed over bowel and simply sutured to the edge of a large hernial defect. The rectus turnover method of reconstruction appears to have significant advantages over the use of synthetic material alone. Successful hernia repair was accomplished in all patients. The surgical technique and complications encountered are described in detail.

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Thirteen patients have undergone reconstruction of large lumbosacral myelomeningoceles with bilateral paralumbar fasciocutaneous flaps. Fasciocutaneous flap closure is supported by a rich vascular network with three main dominant vascular territories. In the middle third of the flaps, a prominent transverse segmental vascular pattern originating from the muscular perforators and lateral cutaneous branches of the costal groove segment of the lower intercostal arteries was noted. The parascapular and scapular fascial branches of the circumflex scapular artery supplied the upper lateral portion of the flaps. Prominent lateral extensions of the superficial circumflex iliac arterial system formed the dominant fascial vasculature of the lower lateral flap, richly arborizing with the middle segmental intercostal extensions. All 13 patients tolerated the procedure without blood transfusion and without perioperative complications. Stable, durable cutaneous coverage was achieved in all patients. Two postmortem neonate humans with large lumbosacral myelomeningoceles were studied angiographically. Radiopaque silicone-rubber-lead-chrome matrix (Microfil) was infused under physiologic pressures in a 7-day neonate after successful defect closure with bilateral fasciocutaneous flaps. The flaps were reevaluated postmortem, and high-contrast, digitally enhanced computed radiographic imaging confirmed the rich vascular support of the bilateral fasciocutaneous flaps, identifying the dominant vascular pedicles. Rich vascularity was further documented by photographing the orange opaque Microfil cast vessels through the reelevated flaps. A second postmortem (stillborn) myelomeningocele specimen was studied with barium infusion with particular emphasis on the anomalous lumbar aorta. Angiographic studies provide a new understanding of the unique vascular anatomy of both the anomaly and the paralumbar fasciocutaneous flap.

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OBJECTIVES: The use of deep inferior epigastric artery (DIEA) rectus abdominis muscle flaps in conjunction with inguinal lymphadenectomy to treat patients with squamous cell carcinoma (SCC) of the penis having high-volume inguinal lymph node metastases causing skin breakdown and secondary infection is described. METHODS: Three patients with invasive SCC of the penis who had extensive unilateral inguinal nodal metastases with skin breakdown and secondary infection underwent pelvic lymphadenectomy and attempted wide resection of the superficial and deep inguinal lymph nodes. One patient had unresectable deep inguinal metastases and received postoperative radiation therapy. A DIEA rectus abdominis muscle flap was utilized to close the resulting groin defect. RESULTS: Pathologic analysis demonstrated no pelvic lymph node metastases in any of the patients, superficial inguinal lymph node metastases in 1, and superficial and deep inguinal lymph node involvement in 2. All wounds healed well. The 2 patients with deep inguinal metastases experienced local disease progression. One patient died 7 months postoperatively of complications from chronic renal failure but had no evidence of tumor recurrence or wound problems. Another patient died of recurrent disease. CONCLUSIONS: A rectus abdominis muscle flap may be a useful adjunct for managing certain patients with penile cancer and extensive suppurative inguinal lymph node metastases.

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Use of the rectus abdominis muscle as a free or pedicled flap is generally well tolerated by patients and accomplishes its intended purpose with minimal morbidity. In chronic or nonacute situations, high rates of success of tissue transfer and low donor site morbidity is expected. We have reviewed our results in 26 patients undergoing inferiorly based rectus abdominis muscle flaps with particular attention to the donor site. Patients with multiple injuries, who have had recent abdominal laparotomy, have a significantly higher morbidity rate. Dehiscence of the abdominal wound in 3 patients and a mortal donor site infection in 1 patient after transfer of a rectus flap has led to a careful examination of the cause for these complications. Careless closure of the midline laparotomy wound with subsequent elevation of a rectus flap lends itself to ischemia of the fascia and potential dehiscence. This is especially true in seriously ill patients on ventilators with abdominal distention and nutritional compromise. Alternate sources of tissue should be used if practical in these patients.

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Chronic dental infection is the most common cause of draining sinus tracts of the face and neck. These lesions can be a diagnostic challenge to the clinician who is not familiar with dentocutaneous fistula. Diagnostic errors can result in multiple excisions, biopsies, and ineffective long-term antibiotic therapy. Patients may require excision of the fistula once the dental abscess has been successfully treated by root-canal therapy or extraction. Nine patients are reported.

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Increasing sophistication in generating soft tissue by tissue expansion has resulted in the evolution of differential expanders. These prostheses attempt to asymmetrically generate tissue for specific reconstruction, most commonly the breast. Using the pig model, differential expanders were placed in the rib area. A square grid was marked over the area, and the expander inflated. For each grid subunit, the surface area was calculated, the thickness measured, and the volume calculated. Subunits in the area of preferential expansion exhibited the greatest increase in surface area, however, these same subunits exhibited pronounced thinning of the tissue. The corresponding volume of these subunits was greater than that of nonexpanded subunits, but the increase was less than when comparing subunit surface area. All expanders were displaced superiorly during the course of inflation. These findings are of clinical significance in that the mastectomy scar and nipple reconstruction both are situated in the area of minimal thickness. Displacement of differential expanders must be anticipated so that the resultant inframammary fold will ultimately be symmetrical with the opposite side.

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The chest-wall deformity associated with Poland's syndrome was reconstructed in eight male patients 16 to 38 years old (average age 20 years). Follow-up ranged from 1 to 10 years. Two patients had custom silicone implants placed subcutaneously. In one of these patients, the edge of the implant could be seen. Three patients had transfer of an ipsilateral pedicled latissimus dorsi muscle flap with intact thoracodorsal nerve. All these patients had noticeable atrophy of the flap, and one underwent subsequent implantation of a custom silicone implant beneath the flap. Three other patients had a custom silicone implant covered immediately by a latissimus dorsi muscle flap. All four patients who had a combination of silicone implant and latissimus dorsi muscle flap had satisfactory correction of their deformity.

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The changes in skin morphology over time are a consequence of both chronologic aging and the accumulation of environmental exposure. Through observation, we know that actinic radiation intensifies the apparent aging of skin. We have investigated the effects of aging and actinic radiation on the ability of fibroblasts to contract collagen-fibroblast lattices. Preauricular and postauricular skin samples were obtained from eight patients aged 49 to 74 undergoing rhytidectomy. The samples were kept separate, and the fibroblasts were grown in culture. Lattices constructed with preauricular fibroblasts consistently contracted more than lattices containing postauricular fibroblasts. The difference in amount of contraction in 7 days between sites was greatest for the younger patients and decreased linearly as donor age increased (r = -0.96). This difference may be due to preauricular fibroblasts losing their ability to contract a lattice as aging skin is exposed to more actinic radiation.

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High thoracic epidural anesthesia was administered by anesthetists in 20 patients undergoing submuscular breast augmentation. An average of 12 ml of 2% lidocaine was instilled after sedation with midazolam, 2-6 mg. The augmentation procedure averaged 90 minutes. In 3 patients, the block developed more rapidly on one side than the other, but soon became symmetrical in all; additional subcutaneous infiltration of lidocaine was necessary in 1 patient because of infraclavicular pain; ephedrine, 10 mg was needed in 2 patients to treat hypotension (greater than 20% decrease in blood pressure). Three patients felt infraclavicular pressure; 1 had a brief sensation of breathlessness; 3 had nasal stuffiness from Horner's syndrome associated with the block; none developed headache, back pain, or paresthesias; and 3 had postoperative nausea. The average time from the end of the procedure to patient discharge was 96 minutes. In this limited series, high thoracic epidural anesthesia for submuscular breast augmentation was extremely satisfactory.

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Lower eyelid retraction may be due to vertical deficiency of the anterior lamella, supporting cartilage, or posterior lamella. We have used autologous cartilage grafts from the conchal bowl for reconstruction of the central lamella, reestablishing and augmenting support of the lower lid. The positioning of the graft is dependent on the specific anatomic deficiency, and the etiology of the lid retraction must be carefully evaluated. In patients with posterior lamella deficiency, the contracted lower lid retractors and conjunctiva are released and the graft is placed facing the bulbar conjunctiva and is allowed to reepithelialize. In patients in whom there is an associated skin deficiency, composite auricular grafts are used. We present our experience in 33 patients with lower lid retraction. Twenty-three patients required placement of a cartilage graft only, while 10 patients had an associated skin deficiency requiring placement of composite cartilage. In nine patients the cartilage graft was seated against the bulbar conjunctiva and allowed to reepithelialize. Reepithelialization was complete within 3 1/2 weeks in all but two of these patients. This technique has provided stable lid support in all 33 patients.

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A needle or other foreign body that has penetrated the skin superficially can be located and removed fairly easily. If it is too deeply embedded to be palpated, it should be located by use of an image intensifier and two venipuncture needles. If this is unsuccessful, exploration and removal must be done in the operating room.

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