Implementation of delayed intervention in open approach rhinoplasty for patients with supratip scarring.

INTRODUCTION: The columellar incision and dissection which were integral steps in open rhinoplasty play a crucial role in achieving optimal results. However, scarring in the supratip region may pose challenges to skin circulation, potentially leading to complications such as flap loss. OBJECTIVES: This study aims to establish the safety and efficacy of the open rhinoplasty technique as a viable alternative for patients with substantial scars in the supratip region typically addressed using the closed rhinoplasty technique. PATIENTS AND METHODS: Patients with scars on the tip or supratip region were operated clinic between February 2010 and March 2023. To mitigate the risk of tip necrosis, a meticulous two-step delay approach was employed. In the initial outpatient procedure, performed under local anesthesia, we opted for a columellar incision. Subsequently, the columellar arteries were identified and cauterized to facilitate the delay procedure. Following a ten-day interval, all patients underwent standard open rhinoplasty. RESULTS: The columellar artery delay procedure proved instrumental in executing successful open rhinoplasty without compromising skin circulation between the scarred supratip and columellar incision line. CONCLUSION: Our findings suggest that the columellar delay procedure effectively prevents flap loss in open rhinoplasty patients with scars in the supratip and columellar regions. This brief outpatient intervention, lasting approximately ten minutes, provides a reliable method for adopting the open approach in primary rhinoplasty cases, irrespective of prior scarring. LEVEL OF EVIDENCE: Level IV, therapeutic study.

A new heart failure model in rat by an end-to-side femoral vessel anastomosis.

OBJECTIVE: The aim of this study was to develop a new shunting procedure for producing heart failure in the rat incorporating microvascular techniques and avoiding an abdominal operation. METHOD: We performed an end-to-side anastomosis between the femoral vein and the femoral artery just proximal to their trifurcation into the saphenous, epigastric, and distal femoral vessels. RESULTS: Of the 15 rats which underwent this procedure, six died within 48 h. The nine surviving animals were sacrificed and examined six weeks following surgery. All nine had developed cardiac hypertrophy and cardiac failure. CONCLUSION: This model provides a relatively simple and reproducible means of creating high output heart failure and cardiac hypertrophy in the rat without necessitating abdominal surgery.

Murine neutrophil migration during the course of an intra-abdominal abscess.

Studies of neutrophil migration in heterogeneous groups of septic patients have reported elevated, normal, and depressed neutrophil mobility. This experiment, conducted in a standardized murine population, measured neutrophil migration under agarose during the course of a chronic intra-abdominal abscess initiated by cecal ligation. Compared with both control (unoperated) and sham celiotomy mice, those mice with an abdominal abscess showed elevations of 22% and 14% of directed and random migration, respectively, at 48 hours. They had 30% to 40% decreases in these functions at days 4 through 10. Murine neutrophil migratory response during the course of an intra-abdominal abscess consisted therefore of an early elevation followed by a prolonged depression. Such a biphasic response could underlie the variable findings of neutrophil studies in septic patients. This model could be further applied to the study of the effects of chemotherapy and immunologic adjuvants on abscess course and neutrophil function, as well as to the study of the mechanisms of neutrophil response to sepsis.

Computed tomographic diagnosis of acute aortoiliac catastrophes.

Whole-body computed tomography (CT) was used as an initial examination in stable patients whose symptoms were suggestive of aortoiliac emergencies. In three cases, CT provided highly specific diagnoses in three different aortoiliac complications. Computed tomography proved to be a fast and reliable diagnostic tool in emergency settings.

Neutrophil delivery to wounds of the upper and lower extremities.

Clinical observations and experimental evidence indicate that wounds of the lower extremity are more susceptible to infection than are wounds located elsewhere on the body. The details of this regional relative immunoincompetence are not described. In this initial study of regional inflammatory response, neutrophil delivery to standard wounds of the upper and lower extremities was measured in 15 human volunteer subjects using a quantitative skin-window technique. Neutrophil delivery proved to be relatively deficient in the lower extremity. Neutrophil delivery (mean +/- SEM) was significantly lower to the lower-extremity wounds (5,890 +/- 590 cells per cubic millimeter) than to the upper-extremity wounds (16,600 +/- 1,680 cells per cubic millimeter). This lower neutrophil response may be a part of the lower extremity's increased susceptibility to infection. Further functional study of regionally collected neutrophils may provide more details of differences in regional inflammatory response. The mechanisms underlying these differences remain undescribed.

Topical antimicrobial toxicity.

Three topical antibiotics and four antiseptics (1% povidone-iodine, 0.25% acetic acid, 3% hydrogen peroxide, and 0.5% sodium hypochlorite) were directly applied to cultured human fibroblasts to quantitatively assess their cytotoxicity. The four antiseptics were found to be cytotoxic; all of the cytotoxic agents except hydrogen peroxide were subsequently found to adversely affect wound healing in an animal model. Comparison of bactericidal and cytotoxic effects of serial dilutions of these four topical agents indicated the cellular toxicity of hydrogen peroxide and acetic acid exceeded their bactericidal potency. Bactericidal noncytotoxic dilutions of povidone-iodine and sodium hypochlorite were identified. These experiments provide evidence that 1% povidone-iodine, 3% hydrogen peroxide, 0.5% sodium hypochlorite, and 0.25% acetic acid are unsuitable for use in wound care. This sequence of experiments could be used to identify bactericidal, noncytotoxic agents prior to their clinical use.

Aeromonas hydrophila infections following clinical use of medicinal leeches: a review of published cases.

Ten Aeromonas hydrophila infections following postsurgical leech applications have been reported. These cases indicate that postsurgical wounds and damaged tissue can provide entry for either acute or delayed A. hydrophila infection. These infections can range from localized cellulitis to progressive myonecrosis and sepsis. These infections may occur with measurable frequency in groups of patients exposed to leeches. Based on this review, it is recommended that leeches be applied only to tissue with a reasonably certain arterial supply; that patients receive antibiotics against A. hydrophila prior to leech administration; and that consideration be given to prolonged antibiotic administration to patients discharged home with open wounds or questionably viable tissue after leech administration.

Clinical leech use in a microsurgical unit: the San Francisco experience.

One microsurgical unit's experience with leech application to 67 patients is surveyed. Five illustrative cases are presented to explain strategies of leech use, and plans for future research are discussed.

Self-administered bolus jejunostomy feeding and gastric fluid reinfusion in patients with gastric atony.

Twelve patients with profound gastric atony were taught to administer their own tube jejunostomy bolus feedings and, when necessary, to manage their gastric secretions by connecting their gastrostomy and jejunostomy tubes. These techniques allowed 11 of 12 patients to obtain reasonable nutrient intake and eight of the 12 to successfully reinfuse retained gastric secretions; alleviating the need for intravenous fluid replacement and expediting hospital discharge. Seven patients were able to resume some oral intake at home after resolution of their gastric atony. In the sufficiently motivated patient with gastric atony from multiple causes, these techniques provide alternatives to indefinite hospitalization with cumbersome and expensive intravenous hyperalimentation or constant infusion enteral alimentation.

Endoscopic balloon dilation of outlet stenosis after gastric bypass.

Eighteen of 22 patients with stenotic gastrojejunostomies following gastric bypass surgery were successfully corrected by endoscopically placing a guidewire through the narrowed outlet and then passing a dilating balloon catheter over the wire. No complications occurred. All procedures were done without general anesthesia, and 64 per cent were done without hospitalization. This procedure can spare patients prolonged hospitalization for nasogastric decompression or reoperation, the two standard approaches to this problem. Successful use of this technique to dilate obstructed gastric partitions and distal esophageal strictures suggests that it may be considered for any gastrointestinal stenosis within reach of the endoscope.

Microvascular reconstruction of the lower extremity in the elderly.

The natural changes of aging increase perioperative medical risk factors in the elderly population. Aggressive preoperative patient evaluation and perioperative monitoring can effectively decrease morbidity and mortality rates to equal those of younger patients. The surgical strategy must take into account the increased incidence of atherosclerosis in the inflow and free-tissue transfer recipient vessels. Lower extremity microvascular reconstruction can be performed safely and successfully in the elderly patient.

Hand reconstruction with partial toe and multiple toe transplants.

Microsurgical transplantation of toes to the hand can serve as an excellent method of reconstructing the severely traumatized hand. This article reviews the authors' experience with 188 great-toe and second-toe transplants. Detailed operative sequence and postoperative care are also discussed.

Lower extremity replantation.

Replantation of the traumatically amputated lower extremity is a technically feasible surgical undertaking. Successful outcome must be judged by functional achievements of the patient toward returning to the preinjury level. Appropriate patient selection significantly increases the potential for obtaining a satisfactory outcome. Patients in whom peripheral nerve injury precludes return of sensation in the extremity or in whom severe joint destruction will yield an immobile extremity will have marginal results. The risks of replantation, including blood transfusions, sepsis, and prolonged hospitalization, must be weighted heavily against prosthetic substitution as an alternative. If the lower extremity can be successfully replanted, however, this provides a superior functional and aesthetic result for the patient. Salvage replantation to preserve maximal functional length and durability of an extremity must always be considered when assessing a patient with a traumatic amputation. Free-tissue transfer to salvage a threatened replanted limb must be similarly a part of the armamentarium of the replantation surgeon. Although lower limb replantation may continue to be controversial, improved surgical techniques and increasing experience make it an excellent alternative to prosthetic substitution. In the well-motivated patient, an excellent result may be achieved.

Treatment of chronic osteomyelitis of the lower extremities with debridement and microvascular muscle transfer.

Of our 55 patients treated for lower extremity osteomyelitis, 91% underwent debridement and microvascular muscle flap coverage with eradication of their infections and restoration of ambulation. This series of patients helps to solidly establish the efficacy of this approach to the treatment of osteomyelitis.

Cellular and bacterial toxicities of topical antimicrobials.

Cellular and bacterial toxicities of four commonly used topical antimicrobials (1% povidone-iodine, 3% hydrogen peroxide, 0.25% acetic acid, and 0.5% sodium hypochlorite) were assayed in vitro using cultures of human fibroblasts and Staphylococcus aureus. All agents tested at full strength killed 100 percent of exposed fibroblasts. Fibroblast toxicity exceeded bacterial toxicity with serial dilutions of hydrogen peroxide and acetic acid. Dilutions of povidone-iodine (1:1000) and sodium hypochlorite (1:100) were identified where no fibroblast toxicity occurred while full bactericidal activity persisted.

New perioral arterial flaps: anatomic study and clinical application.

We studied the vascular anatomy of the perioral region by dissecting fresh cadavers. The anatomy of perioral branches of the facial artery consistently confirmed the existence of a septal branch and an alar branch to the upper lip and a vertical labiomental branch to the lower lip. New regional flaps supplied by these perioral arterial branches are proposed in this paper. The mucosal flap from the upper lip supplied by the deep septal branch or the alar branch of facial artery can be used to restore lower lip defects. A composite flap from the lower lip supplied by the vertical labiomental branch of the facial artery can be used safely to restore combined defects of the upper lip and nose or partial defects of the lower lip.

Arterial supply of the anterior ear.

Twenty cadaver auricles were injected with a latex solution to define the arterial supply of the anteroauricular surface. Two arterial networks exist, the network of the triangular fossa-scapha and the network of the concha. Both eventually communicate on the anthelix. The triangular fossa-scapha network originates from one subbranch of the upper auricular branch of the superficial temporal artery and from branches of the posterior auricular artery that come through the earlobe and triangular fossa and over the helical margin. The conchal network is provided by two to four perforators that come from the posterior auricular artery, piercing the conchal floor. Auricular branches of the superficial temporal artery in the preauricular region and their communications with the posterior auricular artery also were confirmed. We believe that a greater understanding of the detailed arterial anatomy in this area allows one to develop safely a variety of surgical techniques for reconstruction of the ear.

Injuries associated with mandible fractures sustained in motor vehicle collisions.

Motor vehicle collisions are second only to altercations as the most common cause of mandible fractures. This article details in a retrospectively studied group the incidence of isolated mandible fractures and associated injuries in patients who were involved in motor vehicle collisions. This group consisted of 148 patients with mandible fractures listed in the University of Mississippi's trauma registry during the past 5 years. In almost all patients, associated injuries occurred with mandible fractures that were caused by motor vehicle collisions, with an incidence of 99.3 percent. Facial and head lacerations and facial fractures were the leading associated injuries, occurring in more than half of the patients who had a mandible fracture. Closed head injury is the major life-threatening associated injury and cause of mortality. The life-threatening injuries occurred in 64.8 percent of patients in this study. The mortality rate in this group of patients was 8.1 percent. These data suggest that mandible fractures from motor vehicle collisions should never be viewed as an isolated injury but rather as part of a spectrum of significant and sometimes life-threatening injuries that require thorough trauma evaluation at the time of presentation.

Economics of microsurgical cases and routine cases in a medical center.

This report describes the economic impact of microsurgical cases and routine plastic surgery cases in our medical center. The study is based on a financial analysis of the practices of two surgeons. Financial data of patient encounters (admission to the hospital or a surgical unit) identified with each surgeon were categorized into microsurgical and related cases and routine cases (including cosmetic procedures and general hand cases). Revenues, costs, and profits were tabulated. Data were analyzed for 2 fiscal years (1994-95 and 1995-96). Analysis of the first fiscal year showed that microsurgery encounters (n = 188) generated $4.4 million in revenue with a profit margin after direct costs of $2.5 million (57 percent) and a net profit, after indirect costs, of $1 million (23 percent). Routine encounters (n = 262) generated $1.7 million with a net loss of -$145,000 after direct and indirect costs. In the second fiscal year, microsurgery encounters (n = 230) had income of $4.7 million, a profit over direct costs of $2.5 million (53 percent), and a net profit after indirect costs of $0.9 million (19 percent). Routine cases (n = 202) in the same period earned $1.3 million with a net loss of -$107,000. This analysis formulates a comprehensive definition of microsurgical practice and shows that cases within this definition generated dramatically higher hospital incomes and profits compared with routine plastic surgical practice. In the circumstances of our medical center, development of this subspecialty is fiscally justifiable.

Use of 20 cm or longer interposition vein grafts in free flap reconstruction of the trunk.

Between January of 1993 and September of 1995, six microsurgical free tissue transplants were performed using saphenous vein grafts ranging from 20 to 39 cm in length. All six free flaps survived. Two wounds were caused by radiation injury and two by tumor resection. The remaining two free flaps were performed for contour deformity and spinal cord coverage. All of the recipient sites were located on the trunk. In each case, an arteriovenous loop was created before the microvascular anastomosis to the free flap. There was one arterial thrombosis requiring thrombectomy and revision of the anastomosis. Three patients developed minor wound complications that responded to local wound care. Each of the flaps successfully provided wound coverage, and in two cases the flaps tolerated further radiation results. Long interposition vein grafts can be used for difficult microsurgical reconstructive procedures with reliable results when no local recipient vessels are available. Versatility is therefore afforded in placement of the flap and the choice of recipient vessels, making this option a useful one in the treatment of complex wounds of the trunk.