George B. Irons

Aplasia Cutis Congenita

Aplasia cutis congenita is an uncommon condition; fewer than 300 cases have been reported in the literature. Usually, the condition occurs as a focal scalp ulcer, but it may involve the full thickness of the skull or other areas of the body. Most lesions require coverage with a scalp flap, though only observation or split-thickness skin grafts may be adequate for smaller lesions. Four cases have been presented, representing a spectrum of therapeutic requirements from simple observation to emergency intervention to control life-threatening hemorrhage. The case of aplasia cutis congenita of the upper arm may represent a persistence of prenatal focal ischemia that has proved to be resistant to numerous attempts of split-thickness skin grafting.

The Case for Submuscular Implantation of Prostheses in Reconstructive Breast Surgery

Subcutaneous mastectomy has bean plagued by serious problems, especially capsule formation and poor cosmetic results. Since farretts presentation of submuscular implantation, we have had extensive experience with that technique and have found that it reduces capsule formation and yields excellent cosmetic results. Our technique is presented, along with results in 53 patients. The procedure is also advantageous in that it may consistently and safely be done as a one-stage procedure.

Pathology and surgery of primary tumors of the parotid.

Currently the practice of surgeons at the Mayo Clinic is tending toward more extensive procedures for both benign and malignant tumors. Total or subtotal conservative parotidectomy is most frequently used, with minimal morbidity, for benign mixed tumors; and more radical procedures are used consistently for high-grade malignancies. A renewed interest in radiation therapy as adjunctive treatment for the latter group has also developed.

Use of omental transposition flaps for soft-tissue reconstruction

Thirty-five patients with difficult wound problems underwent 35 reconstructive procedures using transposed greater omentum. The ages of the 28 female and 7 male patients ranged from 16 to 75 years, with an average of 50.5. At the time of omenlal transposition, 22 patients (63%) had evidence of radiation necrosis complicating their wounds, 24 (69%) had documented infections of their wounds before treatment, 30 (86%) had defects as a direct result of cancer, and 11 (31%) had recurrent carcinoma. The average duration of the defects, which were in the chest or abdominal wall, extremities, or pelvic floor, was 31.7 months. Small secondary revision procedures were occasionally required: however, the omentum remained the final solution to the problem for 26 (74%) of the 35 patients.

The greater omentum: extensions in transposition and free transfer.

The greater omentum may be utilized as a transposition flap for wound coverage of the chest, neck, abdominal wall, and upper extremities. Free microvascular transfer may be accomplished for wound closure in the scalp and skull as well as the lower extremities.

Rectus abdominis muscle flaps for closure of osteomyelitis hip defects.

In chronic defects of osteomyelitis good results can be achieved using radical debridement, long-term systemic antibiotics, and soft-tissue coverage with muscle flaps. In three patients, the rectus abdominis muscle was a reliable means of filling dead space and providing soft-tissue coverage, at the same time bringing in a new blood supply for these chronic hip joint wounds. There were no complications, and all wounds have remained closed at follow-up periods ranging from two months to one year.

One-stage reconstruction of massive craniofacial defect with gastroomental free flap.

: A large craniofacial defect resulting from a close-range shotgun blast is described. It involves the left hemimandible, the left maxilla, the hard palate with nasal support, the roof of the left orbit, and the left side of the oral lining. The defect was reconstructed using autogenous ribs for the facial skeleton. The remainder of the defect was repaired with a composite free tissue transfer of gastric wall and greater omentum on the right gastroepiploic vessels. The gastric wall was used to reconstruct the oral mucosa, the omentum was packed around the bone grafts for nourishment, and a split-thickness skin graft was placed on the outside surface. The technical aspects of the procedure are described and a two-year follow-up presented.

Use of muscular, musculocutaneous and omental flaps to reconstruct difficult defects.

These recently popularized flaps make reconstruction of some difficult defects possible in a single operation, with surprisingly good results. They have significant advantage over free flaps (except, perhaps, in the hands ofa few experts) because the chance of failure is considerably less. We do not propose that these flaps be used instead of local tissue (when available), or instead of split-skin grafting (when an appropriate bed exists). Additionally, in some instances, the use of muscle flaps would result in a significant loss of function. However, in suitable cases their use is a rewarding addition to the peviously available methods reconstruction.

Metastatic basal cell carcinoma: review of the literature and report of three cases.

Basal cell carcinoma is the most common type of malignant cutaneous neoplasm found in man. Rarely, however, is it life-threatening or does it metastasize. A review of the literature revealed 138 cases of metastatic basal cell carcinoma. We describe 3 additional patients with metastatic basal cell carcinoma who were treated at the Mayo Clinic during the past ten years. Patients with metatypical carcinoma (basosquamous) were excluded. All metastatic lesions were to regional lymph nodes, and two patients died of their disease. It is important to recognize this rare but lethal condition.

Management of radiation necrosis and advanced cancer of the chest wall in patients with breast malignancy

Aggressive resection, with individualized reconstruction by several methods, is of value in many patients with radiation necrosis and/or advanced breast cancer of the chest wall. Although this does not always significantly lengthen survival, it can improve the quality of life markedly in many instances. Remarkably large defects can be reconstructed with single-stage procedures.