Juris Bunkis

The posterior calf fasciocutaneous free flap

Four clinical cases are presented that represent our initial experience with a new fasciocutaneous free-flap unit. The territory of this flap incorporates the skin, fat, and fascia of the posterior calf region. Its design is based on the principle of the fasciocutaneous flap. Anatomic studies confirm that the blood supply to this flap is derived from a descending subfascial branch of the popliteal artery. The flap is well endowed with cutaneous sensory nerves, making it a potential neurosensory free flap. Our technique of flap design and elevation is presented, and potential advantages and disadvantages of this flap are discussed.

The rectus abdominis free flap for lower extremity reconstruction.

The authors present their successful experience with an attractive alternative to the latissimus dorsi and gracilis muscle flaps for lower extremity reconstruction—the free rectus abdominis muscle flap. The muscle flap has a dual blood supply, but the longer pedicle length and larger vessel diameter of the inferior epigastric vascular pedicle favor its use for free-tissue transfer. Surgical anatomy, technique, indications, and potential complications are outlined.

Experience with the transverse lower rectus abdominis operation for breast reconstruction.

Our initial experience with the lower rectus abdominis procedure for breast reconstruction in 19 patients is presented. Anatomic considerations, surgical technique, and results are reviewed. Errors in flap design and execution resulted in a disproportionately high complication rate, which improved following certain technical refinements. The lower rectus flap has proved to be an alternative to conventional techniques of breast reconstruction. As more experience is gained with this flap, its particular role in the reconstructive armamentarium will be more clearly defined.

Quantitative Analysis of Blood and Fat in Suction Lipectomy Aspirates

&NA; This study of suction lipectomy aspirates from 15 consecutive patients was undertaken to biochemically quantitate the blood‐to‐fat ratios of the aspirates. A wide variation in the blood‐to‐fat ratios (8 to 54 percent) was noted, but the authors failed to demonstrate any relationship between the blood‐to‐fat ratios and the suction lipectomy operative site. Prophylactic measures to allow treatment of patients in a consistently safe manner include (1) carefully screening of patients to exclude those with bleeding disorders or significant illnesses, (2) perioperative oral iron therapy, (3) infiltrating the operation site with a dilute epinephrine solution, (4) hydrating the patients adequately perioperatively, (5) using smallerdiameter cannulas for the aspiration, (6) minimizing aspiration once the aspirate turns grossly bloody, and (7) limiting the aspirate to a volume of less than 1750 ml for any operative procedure.

Fasciocutaneous flap coverage for periolecranon defects

Soft tissue defects in the periolecranon region are difficult to manage by standard techniques such as closure by approximation, split-thickness skin grafting, or healing by secondary intention. We employed cadaver injections and dissections to study the vascular anatomy of the periolecranon region in search of a suitable local flap for coverage of periolecranon defects. This report details our experience in 31 patients with a one-stage technique for elbow coverage employing a proximally based forearm fasciocutaneous flap. Surgical techniques and clinical applications are discussed; a satisfactory long-term outcome is documented in 30 of 31 patients. The advantages of using this model fasciocutaneous flap include enhanced vascularity, sensibility, and ease of elevation.

Pilomatrixoma Presenting as a Parotid Mass

A rare case of calcifying epithelioma of Malherbe presenting as a large parotid mass is reported in this paper. Preoperative evaluation and considerations are discussed. An exact diagnosis and definitive treatment in this patient consisted of superficial parotidectomy and histologic study.

Aspergillus Colonization Associated with Bilateral Silicone Mammary Implants

A case of Aspergillus niger fungal colonization associated with bilateral inflatable silicone mammary implants is reported. Painful fibrous capsular contractures without clinical evidence of infection or inflammation characterized the presenting symptoms. Operative findings included a cheesy-white exudate that surrounded the implants and turbid fluid within the implants. All specimens yielded a heavy growth of Aspergillus niger. Special stains of the fibrous capsules were negative for fungal invasion. The etiology and pathogenesis of Aspergillus colonization in this patient are postulated.

A free occipital hair-bearing flap for reconstruction of the upper lip

A free hair-bearing occipital scalp flap was employed for reconstruction of the upper lip in a young man who had sustained a close range shotgun blast to the face. The moustache free-flap provides an abundant source of hair-bearing scalp which has certain advantages over conventional techniques of repair. It is a one-stage operation, involves minimal donor site morbidity and uses hair-bearing scalp which is not usually affected by male-pattern baldness.

Pressure sore carcinoma.

The development of squamous cell carcinoma in pressure sores is a rare event, considering the high incidence of pressure sores within the elderly and paraplegic populations. The clinical courses of 10 patients with pressure sore carcinoma have been reviewed. The presence of a velvety, cauliflower-like growth on the surface of a long-standing pressure sore should alert the surgeon to the possibility of malignant degeneration. Most of these tumors are well-differentiated squamous cell carcinomas. Of the 10 patients, 8 (80%) died from massive local recurrence or distant metastases an average of 17 months after resection and flap closure despite having apparently localized disease. One patient was disease free when lost to follow-up at 2 years, and 1 patient is without evidence of recurrence or metastases 3 months postoperatively. Altered immunocompetence may play a role in the rapid progression and high mortality associated with this tumor after surgical manipulation.

Surgical treatment of nasal obstruction secondary to craniofacial fibrous dysplasia

Craniofacial fibrous dysplasia, a skeletal disorder most often affecting the mandible or maxilla, can cause a variety of complications. Nasal obstruction secondary to this unusual disorder presents a diagnostic and therapeutic challenge. The nasal obstruction in this case is due to expansion of fibrous lesions in adjacent bones as well as direct involvement of the turbinates with fibrous dysplasia. We describe the surgical correction of nasal obstruction in this unique setting and present a brief update of this intriguing disorder.