Anatomic and clinical considerations of an internal mammary artery harvest.

In an effort to understand the perceived correlation of internal mammary artery harvesting and wound healing difficulties in the inferior margins of the sternotomy incision, we showed the cutaneous vascular perfusion in the sternal and xiphoid areas by India ink injection studies in cadavers. With these studies, we demonstrated an inherent paucity of nutrient supply to the inferior sternum and xiphoid area. The classic internal mammary artery harvest further compromises the blood supply to these areas. We believe that limiting the most inferior dissection of the internal mammary artery and not including the distal bifurcation leaves intact the lateral musculophrenic nutrient supply to the inferior sternum and xiphoid area and to the ipsilateral abdominal rectus muscle. These guidelines will help to prevent ischemic complications of this area and may aid in reconstruction. If the bifurcation is harvested, we believe that the removal of the avascular xiphoid cartilage at the time of the initial bypass procedure may eliminate this as a potential septic focus.

A rational approach to wound difficulties after sternotomy: the problem.

One hundred fifty-one patients with mediastinitis after median sternotomy were treated by a single surgeon over a 6-year period. The infections were analyzed in regard to the depth of infection, time of presentation, and the mediastinal defect. Preoperative evaluations included computed tomographic (CT) scans, testing for sternal stability, and the level of contamination. Intraoperative evaluations included bone, inflammatory tissues, Gram stain, and cultures. Treatment options included rewire procedures (20 patients), immediate reconstruction (63 patients), or delayed reconstructions (88 patients). The issues of exposed prosthetic material, right ventricular laceration, long-term intravenous antibiotics, Candida infections, and reexploration of the healed mediastinum after flap reconstruction are discussed. The overall approach to postoperative healing difficulties after sternotomy is examined.

A rational approach to wound difficulties after sternotomy: reconstruction and long-term results.

One hundred fifty-one patients were reconstructed after median stemotomy by a single plastic surgeon over a 6-year period. The treatment included immediate reconstruction (63 patients) and delayed reconstructions (88 patients). Ninety eight percent of the patients had definitive healing at 6 weeks with an overall 30-day mortality of 4 percent. The issues of long-term intravenous antibiotics, perceived skin deficiency, cardiac decompensation, Candida infections, and reexploration of a healed mediastinum after flap reconstruction are discussed. Follow up (4 months to 6 years) of patients treated with reconstruction compared favorably with patients treated with rewiring procedures (20 patients) in regard to strength, chest wall stability, pulmonary function testing, and functional return to hobbies and employment.

Enhancing nerve regeneration across a silicone tube conduit by using interposed short-segment nerve grafts.

Isolated nerve segments may inherently contain all of the necessary factors required to support regeneration within a silicone tube conduit placed across a nerve gap. Thirty-six adult Lewis rats each weighing approximately 250 g were randomized into three groups. A sciatic nerve gap (13-15 mm in length) was bridged by an empty silicone tube (Group I), a silicone tube containing a short 2-mm interposed nerve segment (Group II), or a nerve autograft (Group III). At 16 weeks postoperatively, no regeneration was observed through the empty silicone tube. In contrast, regeneration across the silicone tube containing the isolated nerve segment was equivalent to that noted through nerve autografts as assessed by histological, electrophysiological, and functional criteria. Thus, an interposed nerve segment will extend the length of successful nerve regeneration through a silicone tube conduit.

Salvage of the massively traumatized lower extremity.

The prognosis of massive lower extremity injuries has been significantly altered by improved free flap success rates and a better appreciation for the need to perform an early aggressive debridement and reconstruction. Although some successes may be spectacular, many functional failures have been observed despite successful flap transfer. Reflections on the emerging principles and the lessons learned from the past decade of heroic efforts spent treating these injuries will reveal methods that may decrease the number of functional failures. These methods were observed by comparing the functional results of tibial reconstruction patients versus foot resurfacing procedures.

Improving reemployment rates after limb salvage of acute severe tibial fractures by microvascular soft-tissue reconstruction.

Patients with severe open tibial fractures may have a low rate of reemployment after reconstruction. Sixty-five limb-salvage patients were followed for at least 2 years to determine the factors that influence future employment. The preinjury conditions found to influence reemployment included age less than 40, higher education, and white-collar employment. Early postinjury reconstruction and established bone continuity are advantageous to the patient, and the likelihood of reemployment is improved. Reconstructive surgeons may improve employment rates by early soft-tissue coverage, bone grafting (immediate cancellous or free bone transfers), and complete healing. Ambulation follows if bone continuity is established early, and the patient has gained an early advantage on the way to employment and a purposeful future. The reemployment rate has improved to 67 percent in the 15 limb-salvage patients reconstructed after the initiation of aggressive intervention by the reconstructive surgeon. This equals the reemployment rate of traumatic below-knee amputees previously reported.

Quadrilateral space syndrome: diagnosis and operative decompression technique.

We present a series of five patients with quadrilateral space syndrome. All patients had the diagnosis made on the basis of (1) tenderness over the quadrilateral space, (2) paresthesia over the lateral shoulder and upper posterior arm, and (3) deltoid weakness associated with decreased shoulder abduction. A history of trauma was present in each patient. The operative technique described utilizes a cosmetically acceptable incision and is without the need to divide the deltoid from its origin on the scapular spine. The technique minimizes postoperative bleeding and facilities rehabilitation. Arteriography of the posterior circumflex humeral artery was not found necessary to make the diagnosis of axillary nerve entrapment in the quadrilateral space.

Vascular prosthetic complications: success of salvage with muscle-flap reconstruction.

Prosthetic vascular complications such as exposure and infection represent one of the most challenging and devastating complications in surgery. Nineteen patients underwent a retrospective review of the efficacy of soft-tissue flap coverage in the management of vascular prostheses complications. These patients were divided into three groups. Group 1 included 14 patients with documented culture-positive infection. Group 2 comprised 4 patients with culture-negative exposed grafts. Group 3 included 1 patient with autogenous vein and documented culture-positive infection. The most common vascular procedure requiring flap reconstruction was aortobifemoral in groups 1 and 2. One femoral-distal reconstruction was performed in group 3. Graft complications occurred at an average of 4.8 months after vascular reconstruction in group 1, 11 months in group 2, and 1 month in group 3. Follow-up was obtained on all patients. Initial flap reconstruction was successful in 43 percent of group 1, 100 percent of group 2, and 100 percent of group 3. Reoperative therapy for flap coverage in group 1 was successful in 62.5 percent. Overall, 79 percent of patients obtained a closed wound after reconstructive attempts in group 1. Recurrence appeared to be independent of graft material, microbiology, or graft location. Debridement and muscle coverage of exposed or infected vascular grafts has produced clinical salvage.

Breast reconstruction utilizing implants: a local experience and comparison of three techniques.

The breast reconstruction patient requires accurate information about the complications, failures, and additional surgeries associated with implant reconstruction. In this series of consecutive patients, we examine three methods of implant reconstruction: (1) immediate with a permanent implant/expander (86 patients/107 breasts), (2) delayed with a permanent implant/expander (57/73), and (3) delayed serial expansion with gel/saline (54/68). Implant/expander reconstructions had an equal interval to completion (immediate 118 days, delayed 127 days), a significant need for revisions (immediate 57 percent, delayed 30 percent), and a similar complication rate (10 percent) and failure rate (3.5 percent). The delayed serial expansion patients were completed with one operation 66 percent of the time, and only 9 percent required revisional surgery. The data obtained from the largest private health care provider in the state confirmed a significant difference (p = 0.003) in the need for revisional surgery between immediate and delayed reconstructions. The data showed immediate implant reconstructions to (1) be safe (low failure rate), (2) require more capsular intervention procedures, (3) have a greater expense, and (4) have good aesthetic results (90 percent Baker class I or II) because of revisional surgery. The immediate implant breast reconstruction patients are committed to their reconstruction and undergo revisional surgery to improve their aesthetic result. Delayed implant reconstruction patients are less likely to undergo further surgery to correct capsular deformities.

The fate of plates and screws after facial fracture reconstruction.

Rigid plate and screw fixation is the mainstay of treatment for complex fractures of the facial skeleton. Complications of plate and screw fixation include prominence, infection, exposure, and migration. Five hundred and seven patients undergoing plate and screw fixation for facial fractures (1112 fractures) from 1983 to 1988 were followed for complications. Sixty-one patients (12 percent) required hardware removal. The location on the facial skeleton influenced symptoms and the rate of hardware removal. Infection and exposure may be decreased with antiseptic irrigations, avoiding mucosal damage, attention to proper mucosal closure, and correct placement of plates. Prominence may be decreased by the use of microplates in the supraorbital, frontal, and naso-orbital-ethmoid locations.

Microvascular soft-tissue transplantation for reconstruction of acute open tibial fractures: timing of coverage and long-term functional results.

Seventy-two patients with Gustilo grade IIIB open tibial fractures were treated with free-tissue transfers. If successful free-tissue transfer for soft-tissue reconstruction is performed within 15 days of injury, the risk of major complications is 3.6 percent. Long-term retrospective follow-up (mean 42 months) revealed successful limb salvage in 93 percent, good aesthetic results in 80 percent, and patient satisfaction in 96 percent. However, 66 percent of patients exhibited significantly decreased range of motion of the ankle, 44 percent experienced swelling and edema requiring elastic support and activity modification, and 50 percent occasionally required an assistance device for ambulation. The long-term employment rate was 28 percent, and no patient returned to work after 2 years of unemployment. In contrast, 68 percent of amputees after lower extremity trauma over the same period returned to work within 2 years. Patients need to realize the disruptive nature of this injury on their family, job, and future.

Treatment of long-standing thoracostoma and bronchopleural fistula without pulmonary resection in high risk patients.

A chronic bronchopleural fistula and a fibrotic postthoracotomy space in a patient with poor functional respiratory reserve is a difficult problem. The classic management of bronchopleural cutaneous fistulas has been with further pulmonary resection to healthy bronchus, repair of the bronchus directly, and a thoracoplasty or myoplasty technique to obliterate the cavity. In a high risk patient, further pulmonary resection and thoracoplasty may be contraindicated. Myoplasty techniques alone without control of the fistula have limited success. In the last 4 years, we have treated six patients with right-sided thoracostomas after a primary open drainage procedure for bronchopleural fistula and empyema. The air leak was controlled with inversion of the sinus tract, fibrin glue, and muscle flap cavity obliteration. An average of two muscle flaps per patient were used, including the contralateral latissimus dorsi muscle. An 83 percent success rate has been achieved with this procedure in patients who otherwise would not be considered surgical candidates. Attention to the details described, including direct suture closure of the bronchial sinus, obliteration of the cavity by local muscle flaps, and avoidance of mechanical positive pressure ventilation, will make extended thoracotomy, pulmonary resection, and thoracoplasty unnecessary in these high risk patients.

Cavitron assisted liver resection in a child.

Resection of a liver tumor using the cavitron ultrasound dissector is described. The technique is safe and minimizes blood loss.

Functional limb salvage combining gastrocnemius neurotization and posterior tibial nerve grafting: a case report.

Functional limb salvage requires motor and sensory reconstruction of the extremity. An avulsion of the tibial nerve in the popliteal fossa after arthroscopy is presented. Functional limb recovery necessitated intraoperative nerve mapping by awake stimulation, neurotization of the gastrocnemius muscle bellies, and interfascicular posterior tibial nerve grafting. Eighteen-month follow-up demonstrated good gastrocnemius motor function and protective sensation on the plantar surface. The patient is ambulatory without the need of an assistive device.

Free nipple graft reduction mammoplasty.

Free nipple graft reduction mammoplasty is the procedure of choice in patients with massive breast hypertrophy, or those high-risk patients less able to undergo a more extensive procedure. A major criticism of the technique is that it creates a flat, boxy breast that lacks projection. A technical modification of free nipple graft reduction mammoplasty is presented. In this modification, a central, bulky, superiorly based dermal-parenchymal flap extending from the "key-hole" site to the superior aspect of the areola is designed. After tailoring, this central flap is folded superiorly and secured beneath the medial and lateral flaps to create the bulk of the breast mound. This central flap can be accurately tailored to achieve the desired breast size and projection. The medial and lateral breast flaps do not create the breast mound, and are only contoured over the top of this central flap to complement the final breast form.

Hand infections in the diabetic and the diabetic renal transplant recipient.

We present a series of 41 diabetic patients with severe tissue destruction and deformity secondary to hand infections. Thirty (73%) of the patients showed propagation of the infection to bone, tendons, or deep palmar spaces, and 26 of 41 (63%) required amputations. Sixty-three percent of the cultures were mixed; pure Staphylococcus aureus accounted for only 12%. Diabetics who were renal transplant recipients were at increased risk, with a 100% amputation rate and an average hospitalization of 41 days. Recommendations for management of diabetic hand infections are given to reduce the mortality and morbidity in these patients.

Locally applied hypothermia and microvascular muscle flap transfers.

The success rate for wound closure of grade III open tibia-fibula fractures with free muscle flaps is approximately 90%. Complications and loss of free flaps are due mainly to anastomotic problems, local anatomical considerations, or recipient vessel injuries, which prolong the ischemic time of the transferred free muscle tissue. We present the techniques used at the Shock Trauma Center of The Maryland Institute for Emergency Medical Services Systems (MIEMSS), which has allowed us a 100% success rate for the last 80 free muscle transfers performed. This surgical technique involves the use of locally applied hypothermia to decrease muscle metabolism and no-reflow phenomena. Representative cases are illustrated, which could have been failures because of increased ischemic time.

Local muscle flap in a venous hypertensive environment.

Local rotation muscle flaps are useful for soft tissue reconstruction in open grade III fractures of the lower extremity. Gastrocnemius or soleus muscle flaps provide early bone coverage and avoid a more demanding free tissue transfer. Deep vein thrombosis is common in injured limbs and venous hypertension may result in acute muscle flap necrosis. Loss of bone coverage and an increased risk of osteomyelitis follow. We present a successful soleus rotation flap for tibial coverage in a lower extremity with a documented major venous thrombosis.

Injection of illicit drugs into the granulation tissue of chronic ulcers.

Chronic skin ulcers are rare among healthy young adults. Local injection of cocaine and heroin has been identified as a cause of chronic skin ulcers in young adults abusing intravenous drugs. These patients use both engorged veins surrounding the ulcers and the granulation tissue itself for the injection of drugs. We believe that chronic skin ulcers in young adults should be a marker for intravenous drug abuse, and should be considered in the differential diagnosis of nonhealing wounds.