Transesophageal echocardiography in the diagnosis of traumatic rupture of the aorta.

BACKGROUND: Rupture of the aorta is a major cause of death after motor vehicle accidents. Survival depends on early diagnosis, and emergency aortography is the standard imaging method. Although transesophageal echocardiography is noninvasive and can provide high-resolution images of the aorta, information about its value in patients with trauma is limited. We conducted this study to assess prospectively the value of transesophageal echocardiography in the emergency evaluation of patients at risk for aortic injury. METHODS: Transesophageal echocardiography of the aorta was attempted in 101 patients admitted to the emergency room with a diagnosis of possible traumatic rupture of the aorta. Echocardiography and aortography personnel were notified simultaneously of the arrival of the patient, and the two tests were performed sequentially by operators who were blinded to the results of the other test. The sensitivity and specificity of transesophageal echocardiography were calculated on the basis of the results of aortography of the arch, surgery, or autopsy. RESULTS: Transesophageal echocardiography was attempted in 101 patients. The study was successfully performed in 93 patients but could not be completed in 8 because of lack of cooperation on the part of the patient (7 patients) or maxillofacial trauma (1 patient). Despite a high injury-severity score (mean, 29.6), transesophageal echocardiography was performed without complications, and within a mean (+/- SD) of 29 +/- 12 minutes. Eleven of the 93 studies (12 percent) demonstrated rupture of the aorta near the isthmus. The findings were confirmed in 10 of the 11 patients by aortography (9 patients), surgery (9 patients), or autopsy (1 patient), yielding a sensitivity of 100 percent and specificity of 98 percent for the detection of injury to the aorta. There was one false positive echocardiogram. CONCLUSIONS: Transesophageal echocardiography is a highly sensitive and specific method of detecting injury to the thoracic aorta. This technique can be used safely and quickly in critically injured patients with suspected traumatic rupture of the aorta and compares favorably with arch aortography.

Midventricular obstruction associated with chronic systemic hypertension and severe left ventricular hypertrophy.

Midventricular obstruction is an uncommon finding previously defined by catheterization and angiographic techniques in patients with hypertrophic cardiomyopathy. This study describes the clinical and echocardiographic findings of 10 consecutive patients (mean age 73 years) with severe concentric left ventricular (LV) hypertrophy and the unusual finding of a dynamic systolic obstruction located in the midportion of the left ventricle. All patients were known to have chronic hypertension, and none had a history or family history of hypertrophic cardiomyopathy. In each case, a well-defined, high velocity, turbulent jet was identified by Doppler color flow imaging and subsequently confirmed with conventional Doppler techniques. Septal and posterior wall thickness averaged 1.67 and 1.57 cm, respectively. Mean LV mass index was 199 g/m2 and ejection fraction averaged 78%. Peak systolic velocity obtained by continuous-wave Doppler averaged 2.7 m/s and appeared as either a "late-peaking" or a "spike and dome" configuration. Seven of 10 patients gave a history of syncope or severe presyncope at the time of echocardiographic examination. At a mean follow-up of 1 year, syncope or presyncope had resolved in 5 patients in whom medication was adjusted based on the ultrasound study, but persisted in 2 patients in whom diuretic therapy was continued. It is concluded that obstruction to systolic flow can occur at the mid-LV level in some patients with severe concentric LV hypertrophy and avoidance of medication known to lower LV volume may relieve symptoms of transient inadequate cardiac output.

The platysma muscle. Anatomic considerations for aesthetic surgery of the anterior neck.

Our current principles for the treatment of anterior neck deformities originally evolved from cadaver dissections and clinical observations. These principles have been applied over the past seven years in nearly 100 patients. We combine as indicated submandibular lipectomy, excision of the submental fat pad, chin implantation, creation or tightening of the platysma muscular sling, and skin tightening and resection. The muscular sling is created or tightened anteriorly by approximation or imbrication of the platysma muscle in the midline. Skin is removed posteriorly, utilizing a complete or lower facelift incision. Using these techniques, we have not found posterior tightening of the platysma muscle or the creation of platysma flaps to be necessary, although we would certainly use them if other alternatives were ineffective.

Medial approximation of the platysma muscle in the treatment of neck deformities.

The platysma muscle has become recognized as a key to the correction of deformities of the neck. We believe that the decussation of the medial fibers of the platysma muscle is critical to the support of the submental region and is a factor in the pleasing angle between the neck and the chin. The approximation of the medial borders of the platysma has been described in combination with other direct approaches to the anterior neck or with aggressive repositioning or flaps of the platysma. We have achieved pleasing results in the treatment of neck deformities in a variety of clinical situations by medial approximation of the platysma through a short submental incision without other manipulations of the platysma and without complications in 45 patients. All have been followed for more than 1 year.

Skin grafts from the sole of the foot: case report and literature review.

An area of skin loss on the weight-bearing area of the sole of the foot was successfully reconstructed with a split-thickness skin graft taken from the non-weight bearing area of the sole. Excessive callus formation adjacent to the graft was not noted, and the donor site is convenient and concealed. Grafts up to 6 x 10 cm may be taken from the average adult foot.

Experience with the Fasanella-Servat operation for ptosis of the upper eyelid.

A quick, simple, and reliable operation for the correction of mild to moderate ptosis in the presence of fair to good levator function was described by Fasanella and Servat nearly two decades ago. This operation consists of resection of the conjunctiva, tarsus, and müller's muscle using a conjunctival approach. We have performed this operation in 39 patients with good to excellent results in 38. Our criteria and experience are described.

A quantitative examination of the use of fluorescein in predicting viability of skin flaps.

The use of fluorescein as a predictor of skin viability in the rat flap model of avascular skin necrosis is well known in the field of plastic surgery. Inherent in this model are several faults that must be corrected if it is to become a valid standard. Fluorescence readings are one of the main variables in flap models. By carefully shaving rat backs with a double-edged razor, taking fluorescence readings in a uniformly darkened space, carefully tattooing the exact extent of both the bright and the mottled areas of fluorescence on the flap, and placing a plastic barrier between the flap and the body to prevent any part of the flap from acting as a graft, we were able to quantitatively predict which portions of a flap would survive and which would die after fourteen days. The bright fluorescent area (mean = 11.99 cm2, SEM +/- 0.53 cm2) is equal to the amount of tissue that will survive (mean = 11.91 cm2, SEM +/- 0.50 cm2; NS), while the sum of the nonfluorescent area and the mottled fluorescent area (mean = 27.69(2), SEM +/- 0.52 cm2) is equal to the amount of tissue that will die (mean = 27.99 cm2, SEM +/- 0.52 cm2; NS).

The anatomical basis for common cosmetic anterior neck deformities.

The anatomical basis for some common anterior neck deformities, the key to which is the presence or absence of decussation of the platysma muscles at the midline, is described. A plea is made to be specific in describing these deformities, and to approach corrective surgery anatomically.