Routine exteriorization in the treatment of civilian colon injuries: a reappraisal.

1. We have reviewed our experiences with colon injuries from 1972-76. 2. Mortality increases when there are more than four associated organ injuries, the principal cause of death being sepsis. 3. Primary closure in our institution has a mortality and morbidity comparable to most other series, but exteriorization of the colon wound has given the best results of any treatment. 4. We feel that solitary wounds of the colon, with only one or two associated injuries, with little fecal contamination, should be treated by closure plus exteriorization, with return to the peritoneal cavity (interiorization) at five to ten days.

Postoperative alopecia in a woman after a lengthy plastic surgical procedure.

Pressure-induced alopecia was reported in the past. We observed postoperative alopecia (presumably pressure-induced) after a plastic surgical procedure of a long duration. Shortly after the operation, the patient noted swelling and exudation of the scalp near the vertex. The symptoms abated in the course of a week. The hair loss occurred quite rapidly (within 48 hours) in the area of the previous symptoms on the sixth postoperative day. Irregular regrowth of short hairs was first noted after 6 weeks. The patient's last examination 10 weeks after the operation revealed a 4 x 4 cm area of baldness with few scattered hairs 5 to 6 mm in length. The cause is considered to be pressure-induced ischemia based on the following: preceding period of deep unconsciousness (the operation) and natural history of the disease.

The free scapular flap.

We present our early experience with a flap that should become important to the microsurgeon. The scapular flap is based on the circumflex scapular branch of the subscapular artery and is a versatile, hardy, easily dissected flap. We have used it in 14 cases where a fairly thin flap was indicated. Four of the 14 patients developed complications. Two developed hematomas after removal of the drains. These were evacuated without any loss of the flap. One patient had to be returned to the operating room because of thrombosis of the venous anastomoses, but the flap eventually survived in its entirety. One flap was lost from progressive venous insufficiency.

Use of pectoralis minor muscle in immediate reconstruction of the breast.

A technique is described in which the pectoralis minor muscle is rotated as a muscle pedicle flap to be used in immediate reconstruction of the breast. The advantages of this procedure are that it provides additional muscle coverage over the prosthesis as well as preventing lateral displacement. Seven patients have undergone this technique with excellent results.

Decreased thrombogenicity of vascular prostheses following gas denucleation by hydrostatic pressure.

The high rate of thrombosis of 1.0-mm polytetrafluoroethylene (PTFE) grafts has limited their use in microvascular surgery. One possible reason for this is the blood-gas interface due to entrapped air in the interstices. The present study examines the effect on patency rates of elimination of this blood-gas interface by high pressurization. Comparing pressurized and nonpressurized grafts in the same animals showed a patency rate of 100 percent at 7 days for treated grafts, while the control (nonpressurized) grafts had all clotted by 1 hour. The implications for microvascular surgery as well as vascular surgery in general are discussed.

Sclerosing lipogranulomatosis: a case report of scrotal injection of automobile transmission fluid and literature review of subcutaneous injection of oils.

For nearly a century, physicians and laypersons have attempted to repair, reconstruct, and embellish the human body in numerous ways by injecting various oils beneath the skin. Soon after Gersuny's first reported subcutaneous injection of oil, the local and systemic complications became apparent. Despite this, the practice of oil injections continues. "Medical grade" silicone injection was investigated in the 1960s to 1980s with varied success and complications. While few physicians practice oil injection therapy, some laypersons continue to subject themselves or their clients to the risk of the disfiguring complications of sclerosing lipogranulomata. Accidental high-pressure injection injury of liquids, so-called grease gun injuries, continues to provide a therapeutic challenge for the hand surgeon. Our case of a man who injected automobile transmission fluid into his scrotum illustrates the classical course and proper management of sclerosing lipogranulomata. A subcutaneous inflammatory and fibrosing reaction occurred with regional lymphadenopathy. The need for complete excision of all involved tissue to treat the condition successfully is illustrated. This case also illustrates the tendency of patients to conceal from their doctors the history of self-injection of foreign bodies. In cases of self-injection, psychological counseling might certainly be appropriate.

Establishment of normal ranges of laser Doppler blood flow in autologous tissue transplants.

Over a 3-year period, 136 patients were monitored following free autologous tissue transplantation using a laser Doppler flowmeter linked to a computerized data-acquisition system. This monitoring system has indicated perfusion compromise in free flaps more rapidly than clinical observation alone. Most important, this has resulted in an increase in salvage rate from 50.0 to 82.4 percent. In addition, our overall success rate has increased from 92.6 to 97.8 percent since introducing this monitor clinically. Computerization also has facilitated the collection of data, which has enabled us to establish expected values for postoperative blood flow in several types of donor tissues used for microvascular reconstruction. Finally, this computerized monitoring system has relieved personnel from basing decisions on subjective data.

Skin coverage in occupational hand injuries.

Intact skin is vital after occupational hand injuries. The best bone, tendon, and neurovascular repairs are meaningless without suitable skin coverage to protect them. This article presents various methods of providing skin coverage in the hand after occupational injuries and follows the same thought process that surgeons should use in selecting the most appropriate method of repair.

Use of the vascular punch in microsurgery.

End-to-side microvascular anastomoses continue to present technical difficulties. We have recently modified our technique when performing arteriotomy, utilizing an available vascular punch. Experience to date with this technique has been encouraging in the performance of arteriotomy for end-to-side anastomoses. This technique has been particularly useful in patients with arteriosclerotic vascular disease. There have been no complications related to the technique, and we feel it may provide the best arteriotomy for end-to-side anastomosis.

Routine use of laser Doppler flowmetry for monitoring autologous tissue transplants.

This is a report of a prospective study in which 41 consecutive autologous tissue transplants were monitored using the Laserflo BPM model 403 laser Doppler monitor (TSI Inc., St. Paul, MN). Flaps were monitored both intraoperatively and postoperatively, and clinical flap monitoring was compared with laser Doppler monitoring. Twenty-nine flaps had no problems as indicated by clinical or Doppler measurement. Twelve flaps underwent 13 reexplorations; one flap was explored twice. Five venous and five arterial anastomoses were corrected, with complete survival of the flaps. Three hematomas were evacuated. Two of these flaps failed. There were no instances where the laser Doppler indicated a problem with flap viability that subsequently did not merit reexploration. There were no instances of flap failure undetected by the laser Doppler. In comparison to the clinical monitoring, laser Doppler monitoring was more rapid and more precise in identifying problems with the flap. The use of this monitor has improved our salvage rate for flap reexploration from 50 to 85% and has provided a more objective standard for both nurses and physicians to evaluate flaps in the perioperative period.

Restoration of sensation in paraplegia by a sensory innervated plantar fillet free flap. Case report.

Sensory denervation most likely is the key factor to the multiple physiological derangements that predispose paraplegic patients to recurrent decubitus ulceration. A sensory innervated plantar free flap offers the ability to provide soft tissue coverage and to regain sensory innervation of the ulcer prone area in patients with recurrent ulceration. We present a patient in which an innervated plantar free flap was used to restore sensation to the sacral area in a patient with recurrent ulceration.

Chain saw injuries to the face.

Chain saws may produce devastating facial injuries when the blade kicks back after striking a hard object. A review of experience with 12 male patients indicates that in addition to extensive ragged lacerations of skin and soft tissues, bone and teeth are frequently fractured. Eye injuries are rare, but the eyelids may be extensively damaged. Management includes debridement and exploration of the wounds, repair of soft tissues, removal of fractured roots, and application of arch bars if the jaw is fractured.

Closure of myelomeningocele using skin from stillborn twin.

We report a case of homologous skin transplantation from a stillborn twin to the surviving twin for coverage of a myelomeningocele defect. Genetic studies were not available preoperatively, however, similar morphogenetic anomalies of the twins suggested monozygosity. Long-term follow-up revealed a well-healed graft. Cutaneous genetics and literature review of twin homologous skin transplantation are presented.

Salvage of free tissue transfers using thrombolytic agents.

During the period 1985 to 1988, salvage of free tissue transfers with streptokinase and urokinase was performed in six patients with 83.3 percent success. The no-reflow phenomenon, manifested by poor intraflap flow in spite of a patient arterial anastomosis, was present in four successful patients. Streptokinase was used in four patients with 100 percent success with a dose range of 50,000 to 125,000 U. Urokinase was used in two patients with 50 percent success with a dose range of 50,000 to 100,000 U. Successful cases were reexplored within 6 hr of indication of ischemia. The unsuccessful case was reexplored 9 hr after ischemia as indicated by a laser Doppler flowmeter. Subflap hematoma occurred in one patient. A technique is described that selectively perfuses the free flap with the thrombolytic agent and prevents systemic complications.

Vascularized tissue transfer for closure of irradiated wounds after soft tissue sarcoma resection.

During the years 1985 to 1989, 82 patients were included in the soft tissue sarcoma protocol. Preoperative irradiation (50-54 Gy) was performed in all patients before tumor extirpation. Microwave hyperthermia was performed in conjunction with radiation in patients who had gross tumor remaining after initial biopsy. Primary closure with vascularized tissue (flaps) in lieu of conventional wound closure by skin approximation led to less complications (19% versus 51%), fewer secondary procedures for wound closure (10% versus 35%), shorter average hospitalization (15 versus 48 days) and greater limb salvage rate (97% versus 91%). The authors conclude that vascularized tissue (flaps) for primary wound closure in irradiated tissue leads to improved wound healing, and should be considered the procedure of choice for heavily irradiated soft tissue sarcoma defects.

Evaluation of failed sphincter pharyngoplasties.

A review of 30 failed sphincter pharyngoplasties is presented. Failure may be caused by inappropriate surgical planning, inadequate surgical technique, or inappropriate patient selection. Problems with surgical planning and technique that lead to failure were low flap placement, flap dehiscence, and flaps not approximated in midline. Problems with patient selection that lead to failure were large velopharyngeal gap on videofluoroscopy, and residual speech (articulation) deficits. Careful pre- and postoperative evaluation has led to refinement of the surgical procedure and improved outcome. Success rate improved from 67.65% in the first 5 years to 86% in the last 5 years of this 15-year series.

Rhinophyma: a thirty-five-year experience.

We have treated rhinophyma by a variety of methods during the past 35 years. We describe our current management, which has given the most satisfactory results and fewest problems.

Pedicled free flaps: indications in complex reconstruction.

Pedicled free flaps are indicated when distant composite tissue is required for wound coverage and adjacent recipient vasculature is unsuitable for microvascular anastomosis. Carrier vessels from a noninjured extremity temporarily nourish the flap while neovascularization between the wound bed and the flap occurs. This process is augmented by intermittent occlusion of the vascular pedicle to prepare the flap for pedicle division. Rigid immobilization must be maintained to prevent avulsion of the flap. Laser Doppler monitoring of the flap during the ischemic training period permits division of the pedicle with confidence. This technique permits transfer of large flaps to compromised wounds with the advantage that the microvascular anastomoses can be performed safely away from the zone of injury. Provided immobilization can be maintained, flaps based on either a lower extremity or wrist carrier can reach virtually any area of the body.

Routine clinical use of laser Doppler flowmeter to monitor free tissue transfer: preliminary results.

Preliminary results indicate that a new laser Doppler flowmeter is more easily understood by nursing personnel than other laser Doppler units currently available. This monitor has demonstrated its capability in identifying and predicting tissue ischemia before clinically determined failure. Further evaluation of the device is warranted to define its use more clearly in the clinical setting.

Hydrostatic pressure reduces thrombogenicity of polytetrafluoroethylene vascular grafts.

A prime factor in the thrombogenicity of synthetic materials in contact with blood is the blood-gas interface. Small pockets of gas, known as gas nuclei, are trapped within surface interstices. The resulting blood-gas interface denatures plasma proteins and activates clotting factors and platelets. Expanded polytetrafluoroethylene (ePTFE) vascular prostheses 1 mm in internal diameter were placed in saline under 6,000 psig hydrostatic pressure for 2 h in an attempt to dissolve all gas nuclei (i.e., to denucleate). Carotid-carotid bypasses were performed in rats using 280-mm lengths of ePTFE. All 10 control grafts lost patency in 5 min, whereas the 14 denucleated grafts had a median patency duration of 300 min (P less than 0.01). In 15-mm-long rat femoral artery interpositional ePTFE grafts, 90% of controls thrombosed within 10 min, whereas only 7% of denucleated grafts thrombosed over the duration of the 7-day observation period (P less than 0.001). Denucleation also resulted in a significant reduction (P less than 0.02) in 111In-labeled platelet adhesion to 36% of control. Scanning electron microscopy confirmed the reduced accumulation of platelets on denucleated grafts. These data suggest that the removal of trapped air with hydrostatic pressure significantly reduces the thrombogenicity of ePTFE microvascular prostheses and may have application to other clinical (catheters, valves, tubing, etc.) or experimental (micropipettes, electrodes, etc.) materials that interface with blood.