Faculty Bibliography

Malignant lesions of the nasopharynx and paranasal sinuses often encroach upon the orbit. A series of nineteen patients who underwent partial or radical maxillectomy is presented to summarize the eyelid and orbital findings that required further treatment. Fifteen of these patients were left with an intact globe and a visually useful eye, but the defects of epiphora, eyelid malposition, dacryocystitis, and diplopia were visually threatening and required treatment. The cosmetic deformities and diplopia following maxillectomy and radiation are partially amenable to treatment with late bone grafting. Lacrimal outflow deficiencies were successfully treated with dacryocystorhinostomy. Only patients with ocular complications following maxillectomy are included in this series; therefore, the range of problems and their treatment confronting the ophthalmologist is summarized

Few medico-legal issues have generated as much controversy as informed consent--the right of patients to be fully informed about the risks, complications, and alternatives to a medical treatment or surgical procedure before deciding whether or not to submit to it. This paper discusses the complexities inherent in the legal doctrine of informed consent and their implications for dermatologic surgery. Particular emphasis is placed on the legal requirements for informed consent, as well as the problems associated with informing patients and their potential solutions.

Congenital lipomatosis of the face is characterized by collections of nonencapsulated, mature lipocytes which infiltrate local tissues and tend to recur after surgery. These lesions represent a distinct clinicopathologic entity that has not been previously reported in this location in children. Three children with congenital lipomatosis of the face were treated at the Institute of Reconstructive Plastic Surgery over a 2- to 14-year follow-up period. In each instance, pathologic evaluation by light and electron microscopy revealed similar lesions sharing the following morphologic criteria: (1) nonencapsulated tumors containing mature fat cells, (2) infiltration of adjacent muscle and soft tissue, (3) absence of malignant characteristics, (4) absence of lipoblasts, (5) presence of fibrous elements in conjunction with increased numbers of nerve bundles and vessels, and (6) hypertrophy of subjacent bone. All three lesions recurred after numerous excisions, some of which were extensive. All were benign by histologic examination and remained so for as long as 14 years. Surgical treatment improved the aesthetic appearance of each child despite evidence of tumor persistence. Although these tumors are benign, we recommend an early aggressive surgical approach to control the infiltrative nature of their growth and to improve facial appearance

A direct and simple operation of transfer of the anterior belly of the digastric muscle with its attached tendon is presented. It was carried out in 36 patients, with three minor complications. It has proved effective in paralysis of the mandibular division of the facial nerve as a primary or secondary procedure. In ablative resections where this branch of the nerve is intentionally sacrificed, it is advised to do the muscle and tendon transfer as part of the primary operation. In aesthetic operations or where the status of the nerve (post-operatively) is not specifically know, it is advised to wait for spontaneous return for an interval of 3 to 6 months. If the improvement is not satisfactory, then this technique may be considered

Twenty-one patients had full-thickness chest wall defects reconstructed at the New York University Medical Center in the last ten years. Marlex mesh provided chest wall stability in 5 patients. In 9 patients with radiation ulcers Marlex mesh was not required; a severe fibrotic reaction had obliterated the pleural space and prevented paradoxical motion. Partial sternal resections did not require Marlex stabilization, while a total sternectomy resulted in marked ventilatory insufficiency in a patient who would have benefited from the use of a stabilizing material. Random pattern flaps were used initially; more recently, axial pattern, myocutaneous, and myocutaneous free flaps were employed. Necrosis developed in 4 (36%) of the 11 patients with random pattern flaps, but was not seen with the newer flap techniques. Myocutaneous free flaps provided uncomplicated coverage of and stability to three large, potentially contaminated defects. It seems that with the currently available flap techniques and the methods of chest wall stabilization, immediate repair of all full-thickness chest wall defects is possible

Repairs of surgically produced wounds require fore-thoughts and planning individualized for particular patients and particular original conditions. Nowhere is this more important than in patients treated by Mohs' methods for cutaneous cancers. Indications for early and late repair and methodology by a variety of grafts and flaps are explored and illustrated.