In this study, the effects of smoking on skin flap survival were evaluated. For purposes of comparison 12 female rats were divided into four groups.Group 1 comprised nonsmoker, nonpregnant rats; group 2 nonsmoker, pregnant rats; group 3 smoker, nonpregnant rats and group 4 smoker pregnant. On each subject a standard 4 X 10 cm McFarlane dorsal skin flap was raised.On the seventh day postoperatively, the flaps were traced on a transparent sheet marking off the necrotic areas. The area of skin flap necrosis was assessed by 'netcad' digital imaging analysis program.The area of skin flap viability in the pregnant groups was greater than in the nonpregnant groups. The nonsmoker pregnant group's flap viability was the highest and the smoker nonpregnant group's viability was the lowest.This result supports the conclusion that pregnancy enhances flap viability and produces some defensive factors against some of the adverse effects of smoking. (c) 2005 The British Association of Plastic Surgeons. Published by Elsevier Ltd. All rights reserved.

PURPOSE:Hard palate mucosal grafts have been used successfully in posterior lamellar reconstruction. Atypical surgical findings, techniques, and complications related to the hard palate donor site are reported herein. DESIGN:Interventional case series. METHODS:The medical records of five patients who were cared for in an institutional practice between 1987 and 2002 were retrospectively reviewed. All patients had unusual donor site findings discovered during or after hard palate mucosal grafting for eyelid or socket reconstruction. RESULTS:Seven eyelid reconstructions with hard palate grafts were performed on the five patients (three male, two female), with an age range of 14 to 73 years at surgery. Patients were followed for an average of 6 years (range: 9 months to 11 years). Unusual hard palate findings during surgery or the postoperative period included hard palate and maxillary sinus malignancy, torus palatinus, and persistent donor site bleeding that provoked gastric variceal bleeding in a patient with preexisting liver disease. Atypical surgical techniques included both inadvertent and intentional harvesting of hard palate tissue over the midline palatine raphe. CONCLUSION:Hard palate grafting is a successful and commonly practiced approach to eyelid and socket reconstruction. An awareness of unusual anatomic findings or techniques associated with the hard palate donor site may improve surgical outcomes and decrease patient morbidity.

Tran, Nho V MD*, **; Petty, Paul M MD*; Bite, Uldis MD*; Clay, Ricky P MD, FACSa; Johnson, Craig H MD*; Arnold, Philip G MD, FACS* Author Information

Purpose To describe the clinical course and histopathologic features of a patient with adrenocortical carcinoma metastatic to the orbit. Methods Case report and literature review. Results A 24-year-old man first came to medical attention because of symptoms referable to a 4.47-kg, nonfunctioning carcinoma of the left adrenal cortex. Several metastases ensued, including a large tumor to the right superior lateral bony orbit with extension to the brain, temporalis fossa, and orbit proper. The tumor was resected with the use of a combined neurosurgical, ophthalmic, and craniofacial approach. The patient died of widespread metastatic disease 15 months after the orbital operation. Conclusions Metastasis to the orbit from adrenocortical carcinoma is rare. Surgical resection is the treatment of choice, with adjunctive radiation therapy and chemotherapy in some cases. The prognosis is poor.

Purpose To describe the use of the Norian Craniofacial Repair System (CRS) calcium phosphate bone cement in the restoration of craniofacial skeletal defects. Methods Consecutive case series. Results Calcium phosphate bone cement was used to repair craniofacial skeletal defects in three patients. Indications included repair of a posttraumatic orbital floor defect causing hypo-ophthalmos, reconstruction of frontal craniotomy and temporalis muscle donor sites in a patient who had undergone resection of an invasive squamous cell carcinoma, and augmentation of a post-traumatic anterior maxillary skeletal defect. The primary outcome measure was the restoration of bony volume and support. The use of calcium phosphate bone cement in these patients was effective and without complications. Conclusions Norian CRS calcium phosphate bone cement is useful in the repair of craniofacial skeletal defects.

Familial gigantiform cementoma is a rare autosomal dominant tumor that is benign but can result in disfigurement of the facial skeleton. Two families with a total of five patients presented for treatment. Because of a lack of opportunity to obtain treatment early, three of the patients presented in adult life with massive tumors requiring extensive resection and complex reconstruction in multiple stages. The two female patients had chronic anemia caused by multifocal polypoid adenomas of the uterus and required hysterectomy before treatment. The last three patients had elevated alkaline phosphatase levels before tumor resection, and these levels decreased after surgery. With extensive resection of the tumors and reconstruction of both the soft tissues and facial skeleton, good functional and aesthetic results can be obtained. There has been no tumor recurrence with 3 years of follow-up.

Figure John B. Erich was born in Chicago, Illinois, on January 14, 1907. He was the son of Alma Don and John F. Erich. At the age of 17, he attended Crane Junior College and graduated 2 years later. He continued his education by attending the University of Illinois and received a Bachelor of Science degree in 1929. With diploma in hand, he embarked on pursuit of a career in medicine. The West Suburban Hospital in Oak Park, Illinois, signed him on as a general medicine intern and resident in July of 1931. In this same period, he taught prosthetic dentistry at the University of Illinois. The strenuous education and multispecialty interests of John Bernhardt Erich did not distract him enough to prevent him from meeting Edith Gebhardt of Chicago, Illinois. They married on March 26, 1932. In that same year, he was conferred with the degree of Doctorate of Medicine and Doctor of Dental Surgery. In June of 1933, he became one of Gordon New's first plastic surgery residents at the Mayo Clinic in Rochester, Minnesota. From 1933 to January 1, 1938, his services evolved to include laryngology and oral surgery. He became a first assistant in laryngology on April 1, 1934 and received his Masters in Oral Surgery in that same period. In October of 1938, he was appointed to full consultant in laryngology and plastic surgery at the Mayo Clinic. By 1940, he was appointed to the faculty of the Mayo Graduate School of Medicine.John B. Erich, D.D.S., M.D.During the 1940s, the United States, already engaged in World War II, had a shortage of trained plastic surgeons. This shortage was magnified by those unfortunate soldiers who suffered from the devastating maxillofacial trauma incurred with the new more powerful weapons of artillery, tanks, and mortars. No more a trench war, but one of saturation bombing and an era of the mechanized army. This led the War Department to cite Dr. John Erich to direct the training of fellows in the budding specialty of plastic surgery in an effort to better treat these devastating injuries of maxillofacial trauma. Prior to this effort, the treatment of complex maxillofacial wounds involved many subspecialties and crossed many territories anatomically and practically. An organized approach was nonexistent. By 1944, Drs. John Erich and Louis T. Austin authored and illustrated their 600-page text entitledTraumatic Injuries of Facial Bones (An Atlas of Treatment), which became the standard. Included in this text were many technical illustrations that were photographs of model skulls repaired after specifically crafted defects had been created by the authors. Grateful for their work, Ross T. McIntire, Rear Admiral, MC, U.S.N., The Surgeon General of the Navy, expressed his thanks: “Traumatic Injuries of Facial Bones arrives at a time when sound knowledge in the handling of these injuries is most needed....this will be of use to all surgeons.”2 The Foreword written by Donald C. Balfour stated: “The principles of plastic surgery are best exemplified in the management of maxillofacial injuries and deformities, where the accomplishment of satisfactory results demands intelligent planning, perfect technique and exacting attention to every detail.”2 The treatment of the facial bones as a structural unit began and provided the foundation for which current treatment of facial fractures has evolved. This book provided the template for which hooked arch bars became the predecessor of what we commonly refer to as the Erich arch bars used for mandibular-maxillary fixation worldwide(Fig. 2).Fig. 2: Hooked arch bars and intermaxillary traction.Other more experienced surgeons recall the additional techniques and appliances devised by Dr. Erich and used in mandibular and maxillary fractures and nasal deformities. He proposed the use of the listing seagull incision to lengthen the shortened columella in cleft lip nasal deformities.3 Of the more intriguing is the tandem of nasal appliances used in conjunction with a head band. The first of these appliances consisted of two small bars covered in rubber tubing, which were inserted high in the nostrils, posterior to the nasal bones. These small rods inserted into clamps that rotated on a transverse rod that could be fixed in any position. This was fitted to the center of a head band and worn for 2 weeks. This appliance was used to support the nasal bridge in a severely comminuted fracture (Fig. 3). After 2 weeks, the first appliance was removed and a second was attached to the head band. This appliance consisted of two lateral metal plates cushioned with felt. Each plate could be moved medially and laterally. This was used to narrow the nasal bridge and was worn for 2 weeks as well (Fig. 4).Fig. 3: Head band with primary nasal appliance.Fig. 4: Plaster head cast with secondary nasal appliance.In addition to his efforts in the treatment of trauma, oral and maxillofacial surgery, and cleft lip and palate repair, he developed a growing interest in postextirpation oncologic reconstruction. This work would spawn an additional tome. In 1951, Charles C. Thomas published an additional book authored by Drs. John B. Erich and Gordon B. New, entitled The Use of Pedicle Flaps of Skin in Plastic Surgery of the Head and Neck. This illustrated pedicled myocutaneous flap reconstruction and was a forerunner to many reconstructive surgical texts. John B. Erich became an active officer of the American Board of Plastic Surgery. He was certified by that board as a specialist in plastic surgery in 1942. He was first author on over 143 peer-reviewed articles. He was an active member of numerous societies: American Medical Association, American College of Surgeons, American Association of Plastic Surgeons, American Society of Plastic and Reconstructive Surgeons, Society of Head and Neck Surgeons, American Academy of Ophthalmology and Otolaryngology, American Laryngology, Rhinology and Otology Society, and American Laryngological Association. He served as president of the American Society of Maxillofacial Surgeons in 1951 and vice president of the American Fracture Association from 1954 to 1961. He became the chairman of the Section of Plastic Surgery and Otolaryngology (now known as the Section of Plastic and Reconstructive Surgery) on July 1, 1955 and occupied that post until July 1, 1967, where he then became a senior consultant in plastic surgery. Other members of the Plastic Surgery Section included Drs. G. B. New, F. A. Figi, F. Z. Havens, K. D. Devine, E. L. Foss, T. J. Litzow, J. Simons, and J. K. Masson. At that time, consultations were taken on the south desk of the sixth floor in the Plummer Building. A large part of the practice was oncologic work, involving the nasal cavities, pharynx, and larynx. The abundant experience in head and neck surgery resulted in the training of the first otolaryngologic surgeon for the newly formed Otolaryngology Department at the Mayo Clinic, John G. Lillie. Most surgeries occurred at St. Mary's Hospital and on the eleventh floor of the Kahler Hotel, with postoperative convalescence on the tenth floor. Rooms were decorated with fine furniture, high-back chairs, and Oriental rugs. In the early 1950s, this practice was to move to the Colonial Building and subsequently into the newly built Rochester Methodist Hospital. By 1956, trunk and extremity reconstruction became more an integral part of the practice. Hand surgery continued to remain primarily the domain of the orthopedic surgeons until the middle of the 1960s. Despite all his achievements and accolades, Dr. Erich remained a humble, conservative, and generous man. He rarely attended conferences out of town in an effort to remain close to his work with his patients and department at home. His practice included oral and maxillofacial surgery, cleft lip and palate repair, and urogenital reconstruction and finally evolved into the first cosmetic practice at the Mayo Clinic. Those close to him knew him for the love and care he gave to his wife, friends, and patients. He retired from practice in 1976 after many devoted years to his chosen field and became a staff member emeritus. In the spring of 1993, John B. Erich died of natural causes. Peter J. Capizzi, M.D. Uldis Bite, M.D. Phillip G. Arnold, M.D. John E. Woods, M.D. Mayo Clinic; Rochester, Minn. 55905 Acknowledgments We are indebted to Miss Mert Johnson and Dr. J. K. Masson for their insight.

We retrospectively reviewed 119 consecutive patients who underwent cleft palate repair at the Mayo Clinic to determine the incidence of postoperative fistula formation, to assess possible contributing factors, and to review the methods of surgical management. Fistulas of the secondary palate were included, but nasal-alveolar fistulas and intentionally unrepaired anterior palatal fistulas were excluded. Six patients whose repairs were performed after 2.5 years of age were excluded to ensure a more uniform patient population. Cleft palate fistulas occurred in 13 of the 113 patients (11.5 percent). The median age at repair was 8.2 months, and the median follow-up period was 5.2 years. Several variables were analyzed by means of the log-rank test to determine their significance in postoperative fistula formation. Sex, extent of clefting (as estimated by the Veau classification), and type of palatal closure did not significantly affect the rate of fistula formation. However, patients who had palatal closure at an age younger than 12 months had a lower incidence of fistula formation (7.8 percent) than children whose closures were performed between the ages of 12 and 25 months (19.4 percent) (p = 0.058). The strongest predictor of the occurrence of a cleft palate fistula was the surgeon performing the procedure (p = 0.008). Fistula repair was deemed necessary in 11 of 13 patients, and 91 percent of these fistulas were healed with a single operation. Most of these fistulas were closed by using local flaps and two-layered closures. Cleft palate repair carries a significant but acceptable risk of fistula formation, which can be managed with local flaps. Fistula occurrence is related most to the experience level of the operating surgeon.

We describe a technique for expansion and primary closure of massive and large recalcitrant abdominal-wall hernias in the middle and lower abdomen utilizing expanders placed in the lateral abdominal wall between the external oblique and the deeper complex of the internal oblique and transversalis fasciae. Since this technique describes expansion of the lateral abdominal wall, insertion incisions are made in the lateral abdominal wall away from the primary zone of injury surrounding the abdominal hernia and without interrupting the blood supply or innervation to the abdominal-wall muscle, fascia, or skin. This technique described in four patients with massive abdominal-wall hel nias, has been used successfully for primary closure with vascularized autogenous abdominal-wall fascia, obviating the need for interposition of prosthetic material or extraabdominal flaps.

Only 27 cases of Paget's disease of the groin have been reported to the present. Our aim was to describe the clinical behavior and treatment of this disease. A retrospective analysis of patients seen at the Mayo Clinic over a period of 25 years (January of 1970 to December of 1995 ) was undertaken. We included patients with lesions of the groin (isolated or associated with penile, scrotal locations) and with histologic confirmation of the diagnosis. We found seven patients, all male; three patients had isolated lesions. Their mean (SD) age was 78 (8.3) years. Special stains and immunohistochemistry confirmed the diagnosis in all patients. A wide local excision was performed in every patient. Three patients had recurrence: one of them died with multiple pulmonary metastases 4 years later. Two patients presented with history of associated malignancy (prostatic and renal cell carcinoma). Pager's disease of the groin is extremely infrequent. its origin seems not to be a simple extension from the genital area. Most diagnoses can be made by light microscopy. Wide local excision with free margins is the treatment of choice. Local recurrence occurs in half of patients with tumor-free margins by frozen section: long-term follow-up is warranted. Distant metastases occur rarely, although they can be fatal.

Rochester, Minn. From the Section of Plastic and Reconstructive Surgery at the Mayo Clinic and Mayo Foundation. Received for publication October 5, 1995. Presented at the 61st Annual Scientific Meeting of the American Society of Plastic and Reconstructive Surgeons, in Washington, D.C., in September of 1992. Uldis Bite, M.D., F.R.C.S.(C) Division of Plastic Surgery Mayo Clinic 200 First Street, S.W. Rochester, Minn. 55905

A technique is described wherein the approach to the orbital cavity, with resection of its roof and lateral wall, is facilitated by a single burr hole and local en bloc removal of the lateral and supraorbital margins. A satisfactory decompression with reduction of proptosis of the orbital contents and a good cosmetic result is achieved without the need for a large dural exposure. The approach may be combined with removal of the anterior wall of the frontal sinus in cases where the lateral aspect extends appreciably laterally. Access to the orbital roof and lateral wall is straight forward and can be coupled with further removal of the floor lateral to the infraorbital nerve and medial wall. Advancement of the orbital rim upon bone replacement adds to orbital volume, creating better mechanical advantage for eyelid closure.

We described a patient with a ruptured silicone gel breast implant and distant migration as an interesting, albeit rare, complication of breast implants. Magnetic resonance imaging vividly demonstrated the anatomic route of dissection, from the ruptured implant to the medial region of the elbow, and provided an unusual perspective of a perplexing clinical problem. We hoped to bring this unusual situation to the attention of physicians who see patients with breast implants. In our article, we stated that “as many as 80%” of implants develop capsular contracture. This figure is reiterated in a recent physician update published by the American Society for Aesthetic Plastic Surgery.1Physician Update on Aesthetic Plastic Surgery. Long Beach (CA): American Society for Aesthetic Plastic Surgery, 1992 SummerGoogle Scholar New implants may be associated with a lower incidence. We did not recommend routine use of magnetic resonance imaging to detect rupture of breast implants, although it may help identify gel that has extravasated into the regions of the brachial plexus and arm. These sites are difficult to assess with ultrasonography. Moreover, we did not intend to make a statement about the safety of silicone gel breast implants. We leave that decision to the Food and Drug Administration. Silicone Gel Breast ImplantsMayo Clinic ProceedingsVol. 68Issue 1PreviewMembers of the Division of Plastic and Reconstructive Surgery at the Mayo Clinic in Rochester, Minnesota, are concerned with the case report entitled “Detection of Migratory Silicone Pseudotumor With Use of Magnetic Resonance Imaging,” by Persellin and colleagues, which was published in the September 1992 issue of the Mayo Clinic Proceedings (pages 891 to 895). Full-Text PDF

A congenital heterotopic gastrointestinal and respiratory cyst arising from the upper lip is reported. The lesion was excised directly with a satisfactory aesthetic result. Long-term follow-up is recommended because of a report of recurrence of this type of lesion after 13 years.

The authors describe a technique for lateral orbital rim and malar advancement in patients in the older pediatric age group. The technique makes use of a strip craniotomy containing the supraorbital margin, greater sphenoid wing, and temporal bone, with en bloc inclusion of the lateral orbital rim, zygoma, and malar prominence. The method allows a contoured yet stable construction secured in a tongue-in-groove fashion with plate-and-screw fixation. It creates a symmetrical reconstruction of both frontal and lateral orbital aspects in the untreated or inadequately treated older plagiocephalic child with orbital dystopia. The accompanying malar recession is likewise corrected.

A simple technique for orbital aperture expansion to facilitate placement of ocular prostheses is described. Both superolateral and inferolateral orbital margins are released by means of a single burr hole craniectomy of the frontosphenoid bone behind the orbital process of the frontal bone. Vertical and horizontal marginal lengthenings are performed by a rotatory displacement of one bone segment alongside the other. The expanded osseous aperture is secured with wire and plate-and-screw fixation following a supraorbital rim craniectomy to allow an adequate fit. The result provides for easier access of ocular prostheses and tissue expanders.The method has been applied to a series of patients with microorbitalism due to unilateral or bilateral congenital anophthalmia over the past 3 years without complication and with excellent results. Three-dimensional re-formatted CT reconstructions of the craniofacial skeleton are shown preoperatively and postoperatively.

This report demonstrates the utility of split-thickness cranial grafts harvested by craniotomy in the reconstruction of the entire forehead in an en bloc fashion. The technique allows a cosmetic recontouring of large surfaces of the cranial vault in particular, with little or no need for multiple extracranial grafts. Computer imaging and three-dimensional graphic reconstruction lend themselves well to preoperative planning.