Rony Moscona

Free-fat injections for the correction of hemifacial atrophy.

Three adult patients with long-standing hemifacial atrophy were treated with repeated free-fat injections at 4- to 8-week intervals. The longest follow-up study to date is 18 months, and following the expected postoperative resorption, no further loss of bulk of injected fat has been observed. On palpation, the feel of the fat is normal, and facial expression is also good. The relative ease of this procedure, which does not entail any scarring, appears to justify more widespread use of free-fat injections to restore facial soft-tissue depressions.

Use of synthetic mesh for the entire abdominal wall after TRAM flap transfer.

&NA; Abdominal wall competence is a major concern of all plastic surgeons using the TRAM flap for breast reconstruction. Low hernia rates and adequate abdominal stability are standard expectations in abdominal wall closure. Described here is this institutions experience with the use of a large piece of synthetic mesh as a supplementary reinforcement for the entire abdominal wall in an attempt to stabilize it and achieve a superior abdominal aesthetic result. Twenty‐five consecutive patients had routine reinforcement with the extended mesh technique. Mean patient follow‐up was 24 months with a minimum of 1 year. No hernia or mesh‐related infection were encountered and only one patient had a lower abdominal bulge. We recommend the use of a large synthetic mesh for improved strength and aesthetic quality of the abdominal wall after TRAM flap breast reconstruction.

Viability of adipose tissue injected and treated by different methods: an experimental study in the rat.

Fat injection is being used for the correction of various soft-tissue defects. In this study, the manner of fat injection yielding the greatest transplant viability was examined. Autologous fat was obtained from the inguinal area of rats and subsequently reinjected to the nuchal region, an area naturally poor in subcutaneous fat. Before injection, the fat was processed by one or more of the following methods: suture of the recipient area, repeated washing to remove residual blood, and addition of insulin. Transplant status was evaluated by both macroscopic and microscopic examination of the recipient sites 2 weeks and 12 weeks after the injection. The results demonstrated that the injected fat remained in part as viable new fatty tissue in the nuchal area. No statistically significant improvement in the viability of the injection fat was noticed at 2 weeks and 12 weeks after its processing by the different methods just described. Significant positive correlation was demonstrated between the volume of the injected fat and the size of the bulging at the injection area only 2 weeks after the injection.

One-stage reconstruction of the scrotum following Fournier's syndrome using a probable arterial flap.

A one-stage procedure is described for restoring the scrotum in a patient who suffered from Fourniers gangrene. The proximal superiomedial-based thigh flaps employed are most likely arterial flaps. These flaps are also well innervated, which makes them ideal for the purpose of scrotal reconstruction.

A Comparative Immunohistochemical Study of Adenoid Cystic Carcinoma of the Skin and Salivary Glands

We performed an immunohistochemical study that compared a primary adenoid cystic carcinoma (ACC) of the skin with two salivary gland ACC. All three tumors stained positively and in identical fashion for epithelial membrane antigen (EMA), carcinoembryonic antigen (CEA), broad-spectrum keratins, and low-molecular-weight keratins. Both EMA and CEA were localized to the luminal surfaces and the secreted contents of the tubular structures and the ductlike structures of the cribriform formations. The staining reactions for both types of keratin were more intense in the cells lining the tubular structures and the ductlike structures of the cribriform formations. One of the two salivary ACCs stained positively for S-100 protein; the other was positive for vimentin. The cutaneous ACC was negative for both antigens. Leu-7 antigen was not detected in either type of ACC. These results show that primary cutaneous ACC and salivary ACC have similar immunohistochemical staining patterns for a number of antigens. We believe this similarity is due to the fact that these antigens are shared by the sweat glands and salivary glands, which are considered to be the respective sites of origin for these two types of tumors.

Free composite serratus anterior muscle--rib flap for reconstruction of severely damaged foot.

A 23-year-old man who underwent below-knee amputation of one leg and sustained extensive soft-tissue damage with a bony defect of the other foot presented an unusual reconstructive problem. By means of microsurgical techniques a free serratus anterior-rib flap was transferred to restore function of the foot. A four-year follow-up showed good rehabilitation.

Evaluation and comparison of aesthetic results and patient satisfaction with bilateral breast reduction using the inferior pedicle and McKissock's vertical bipedicle dermal flap techniques.

In the last two decades, McKissock’s technique for reduction mammaplasty was largely replaced by Robbins’s inferior pedicle technique. However, a substantial number of plastic surgeons still perform McKissock’s technique in the belief that it is superior to the inferior pedicle technique in terms of aesthetic results and complication rate. In this study, the authors compared the aesthetic results, complication rates, and patient satisfaction with the two techniques. Numerous studies in the past few years have shown an improvement in physical symptoms in addition to excellent patient satisfaction after breast reduction. However, almost all of these studies have used questionnaires that were mailed to the patients for evaluation. In the present study, aesthetic evaluations by the surgeon and an objective observer were performed in addition to evaluations by the patients themselves, thereby increasing the objectivity and the significance of the patients’ evaluations. Two groups of 24 and 27 patients were compared. The groups were almost identical in terms of demographic data and the amount of breast tissue removed. The aesthetic results were good to excellent in both groups, and the groups had similar complication rates. When the patients’ evaluations were compared with those of the surgeon and the objective observer, no significant difference was found between the observer and the patients. In one of the groups, the surgeon’s evaluations were significantly higher than those of the patients, although they were not significantly higher than the observer’s. In terms of aesthetic results, complication rates, and patient satisfaction, no differences existed between the groups. In addition, the patients’ evaluations were determined to be a reliable index of aesthetic results and, in these cases, they were often identical to objective evaluations.

Effect of hyperbaric oxygen on a rat transverse rectus abdominis myocutaneous flap model

&NA; The single‐pedicle transverse rectus abdominis myocutaneous (TRAM) flap is frequently associated with partial flap necrosis. Hyperbaric oxygen has previously been shown to increase the survival of skin flaps, although there has been no investigation of possible beneficial effects of hyperbaric oxygen on survival of the TRAM flap. The present study compares the effectiveness of hyperbaric oxygen therapy, normobaric 100% oxygen, a hyperbaric air‐equivalent mixture, and no treatment at all (control group), in the prevention of TRAM flap necrosis in a rat model. Forty‐eight animals were randomly assigned to one of the four above‐mentioned groups. The surviving area of the flap was evaluated 7 days after surgery. The hyperbaric oxygen treatment protocol consisted of five 9‐minute sessions breathing 100% oxygen at a pressure of 2.5 atmospheres absolute during the first 48 hours, starting within 1 hour of surgery. The areas of surviving skin paddles ranged from 38.5 percent in the control group to 52.5 percent in the group treated with hyperbaric oxygen. One‐way analysis of variance indicated that flap area survival was significantly greater in the hyperbaric oxygen group (F = 2.69, p = 0.05). Tukeys pairwise comparison and the two‐sample t test indicated that the group treated with hyperbaric oxygen differed significantly from the control group (Tukeys critical value = 3.8, rejection level = 0.05, t test p = 0.01). Our results suggest that the hyperbaric oxygen treatment protocol used improves survival in the rat TRAM flap. However, the optimal treatment protocol to achieve this objective even in the rat seems to be variable, and further studies are required before extrapolating these data to human applications. (Plast. Reconstr. Surg. 102: 416, 1998.)

Prevention of gastrointestinal bleeding in burns: the effects of cimetidine or antacids combined with early enteral feeding

The efficacy of prophylactic therapy with cimetidine or antacids combined with early enteral feeding to prevent gastrointestinal bleeding in patients with severe burns was evaluated. Fifty patients with burns exceeding 30 per cent of the total body surface area (TBSA) were divided into two groups, each of them treated by one of these agents in combination with early feeding. Bleeding was not encountered in either group. It is assumed that the combination of either agent with enteral feeding early in the post-burn course equally protected against gastrointestinal bleeding. Because of the ease and lack of side-effects of cimetidine in this series, its use was preferable.

The management of laryngotracheal stenosis in burned patients.

Following burns of the upper respiratory tract, laryngotracheal stenosis is associated with considerable morbidity. This paper deals with the cumulative effect of various pathologic processes involved in burn trauma of the upper airway. Emphasis is placed on the extended use of endotracheal intubation and the avoidance of tracheostomy whenever possible. When laryngotracheal stenosis develops, it may be safely and successfully treated by prolonged stenting, as has been borne out by our experience with the T-shaped silicone tubes. Limited reconstructive procedures can be performed to facilitate proper placement of the stent. In our opinion, laryngotracheal resection and reconstruction are not the procedures of choice in burn cases. Our experience in following the preceding guidelines is described. Three illustrative cases serve to exemplify the difficulties and problems involved in the various stages of treatment and the results obtained. The patients are symptom-free 18 to 24 months following stenting, and all enjoy an adequate airway and good voice. There were no complications resulting from this treatment and we suggest that it is worthy of trial.