Applications of hyperbaric oxygen in otolaryngology head and neck surgery: facial cutaneous flaps.

Hyperbaric oxygen therapy is of significant benefit in the setting of an ischemic flap of the head and neck. Mechanistically, hyperbaric oxygen decreases local tissue edema and improves oxygen delivery to compromised tissues. Both capillary and fibroblast in-growth occur at a greater rate with hyperbaric oxygen therapy, and there is an increase in the tensile strength of the wound. Additional indications in the head and neck include traumatic composite amputations, necrotizing soft-tissue infections, and osteoradionecrosis of the facial skeleton.

Fibrin sealant: a novel method of fixation for an implantable ultrasonic microDoppler probe.

While free tissue transfer affords the reconstructive microvascular surgeon the ability to provide coverage for complex wounds, the postoperative monitoring of these flaps continues to evolve. The most recent advance has been the development of an implantable microDoppler probe to provide an early warning signal for vascular obstruction. The current system relies on the use of a silicone cuff to secure a 1-mm probe to the outflow vein. The release force to remove the probe from the cuff is reported to be 1/10 of a pound (45 g). A disadvantage of this system is the need for a circumferential, relatively inelastic device around the vein. Should the cuff be too tightly secured to the vein, the potential for outflow obstruction exists. Moreover, if the probe is not well-approximated to the vein, no signal is produced. Finally, the fact that a foreign body remains in the wound after completion of the monitoring period remains a concern. The authors have investigated a new method to adhere the probe, using a commercially available fibrin sealant. The use of this biocompatible substance has the potential to obviate the need for the current method of fixation, and the associated concerns.

Adolescent gingival squamous cell carcinoma: Report of a case and review of the literature.

In this article we describe a case of adolescent squamous cell carcinoma of the gingiva. The tumor presented as an ulcerative lesion of the gingiva that was originally thought to be pseudoepitheliomatous hyperplasia. The pathologic differentiation between squamous cell carcinoma and pseudoepitheliomatous hyperplasia is discussed and a review of the literature with respect to pediatric and adolescent oral squamous cell carcinoma is presented. The reported case illustrates the difficulties that may be encountered in attempting to histopathologically distinguish between pseudoepitheliomatous hyperplasia and well-differentiated squamous cell carcinoma of the oral cavity.

Quantitative swab culture versus tissue biopsy: a comparison in chronic wounds.

Soft tissue infection present a significant obstacle to the healing of chronic wounds. Historically, the gold standard for determining wound bacterial bioburden has been the quantitative tissue biopsy. Nevertheless, tissue biopsies are not universally used in today's healthcare setting. Likely reasons include damage to healing tissue, the lack of facilities to process tissue biopsies, significant pain in sensate soft tissue, and increased expense with this modality. More recently, quantitative tissue swab culture has been suggested as a means to determine the wound bioburden. The authors prospectively studied 38 patients with chronic wounds of various etiologies to evaluate the correlation between quantitative wound biopsy and swab culture. Of the 38 biopsies performed, 74% indicated infection. Simultaneous swab culture of these 28 biopsies indicated infection in 22 of the 28 cases for a correlation of 79%. The authors concluded that quantitative swab culture provides a valuable adjunct in the management of chronic wounds.

Distraction osteogenesis of the midface: a new implantable distraction device.

This report describes the use of a new implantable device for distraction osteogenesis of the maxilla in treatment of midface hypoplasia seen in craniofacial syndromes. The technique of distraction osteogenesis is a recent advance in plastic surgery for treatment of bone growth disorders. The device is totally implantable except for the activating pin and can provide up to 30 mm of total advancement. We will describe our surgical technique and distraction protocol, illustrated by a case report of the device successfully used in a child with Crouzon syndrome.

Reduction in morbidity after iliac crest bone harvesting: the concept of preemptive analgesia.

The technique of autologous iliac crest bone grafting is an important aspect in the treatment of patients with cleft lip, cleft palate, and other craniofacial disorders. In patients with cleft lip and palate, the alveolar bone graft creates a continuous maxillary arch, closes the oronasal fistula, provides bony support for facial soft tissue and teeth, and facilitates orthodontic movement of teeth. The anatomic and physiologic benefits of this and similar autologous bone graft procedures are apparent. However, pain at the donor site represents a significant source of postoperative morbidity. This study was conducted to evaluate postoperative pain and the ability to perform activities of daily living after bupivacaine infiltration to iliac crest donor sites. Thirty-four alveolar bone graft patients (18 females, 16 males) treated at two teaching hospitals were included in the study. Eleven of the patients received intraoperative bupivacaine at the iliac donor site and 23 did not. A questionnaire was returned by all participants, and telephone follow-up was obtained. Responses to postoperative pain, time period to ambulation, and ability to perform activities of daily living were evaluated. Patients who received postoperative bupivacaine experienced delayed onset of postoperative pain, earlier ambulation, and were able to return to normal daily activity in a shorter period of time than those patients who received no local anesthesia. The concept of preemptive analgesia and its application to craniofacial surgery is discussed.

Magnetic resonance imaging in the early diagnosis of group A beta streptococcal necrotizing fasciitis: a case report.

Early diagnosis of invasive group A beta streptococcal (GABS) infection has been achieved in a patient using magnetic resonance imaging (MRI) complemented by needle aspiration. Life-saving treatments of GABS infection that include immediate surgical debridement along with the administration of i.v. antibiotics, gamma globulin, and hyperbaric oxygen were then implemented successfully to prevent the development of streptococcal toxic shock syndrome. While MRI is valuable in making early diagnosis of GABS, it should not delay surgical intervention.

Edlich drive: a metaphor for the Edlich tradition.

Richard F. Edlich, MD, the Raymond F. Morgan Professor of Plastic Surgery and Professor of Biomedical Engineering, has been honored with the naming of a new road at North Fork Business Park: Edlich Drive. North Fork Business Park is a high-technology center for biomedical research, and the designation of this new road celebrates Dr. Edlich's instrumental role in the formation of a successful partnership between the University of Virginia and private industry. This partnership provides a mechanism to move technology from the laboratory to the marketplace and, ultimately, to the patient's bedside. Dr. Edlich's unparalleled contributions to his community include the establishment of the Emergency Department at the University of Virginia, the implementation of a regional emergency medical system, and the development of the Pegasus Emergency Flight Operations. Other accomplishments include the founding of the Ira DeCamp Regional Burn Center and the Department of Rehabilitation Medicine. "Drive" aptly characterizes Dr. Edlich's unfailing commitment to his many roles as physician, research scientist, community leader, and mentor for medical students and residents.

Chondritis of the ear: a late sequela of deep partial thickness burns of the face.

Chondritis of the ear is a late sequela of deep partial thickness burns of the face. It is the purpose of this article to describe two patients who came to the emergency department 21 days and 35 days after sustaining deep partial thickness burns of the face from explosions. The patients were hospitalized for incision and drainage of the infected wound that included excision of the infected cartilage complemented by systemic antibiotic therapy.

Grease burns of the hand: preventable injuries.

Grease burns to the hand represent a serious and preventable hazard. These injuries account for over 10% of all major burns seen in the emergency department. These burns occur when the cook attempts to move a pan with burning cooking oil and inadvertently spills the oil on the hand holding the pan. These burns are usually full thickness because of either the high temperatures of the flaming oils or the subsequent ignition of clothing. This article describes a patient who received severe partial and full thickness burns to the dominant hand following a grease burn in the domestic setting. Prevention through improved consumer education and warning labels for cooking oils should reduce the incidence of these serious injuries.

Evolution of powered surgical instruments.

The history of powered surgical instruments has paralleled their need in surgery, particularly surgery involving hard tissue like bone or teeth. This development was of great importance, as the sophistication of procedures became more demanding, requiring the use of implants. The fields of neurosurgery, orthopaedics, otology, and dentistry have all played key roles in the development of the high-powered surgical instruments that are now used in every surgical and dental subspecialty. Power modalities that include pneumatic and electric sources along with the development of interchangeable accessories have revolutionized the surgical field, making procedures both safer and faster. Many physicians, dentists, and companies continue to contribute to this exciting and rapidly evolving industry.

New instruments, bone liners, and tray for finger joint arthroplasty.

Titanium circumferential grommets have been developed for finger joint arthroplasty that fit on the base of the silicone implant stems to protect the flexible hinge from tearing and fracture. To facilitate grommet insertion, new intramedullary bone rasps have been devised with a reverse cutting tooth pattern, an extended shaft for an improved view of the surgical field, and a redesigned cutting head to allow for grommet insertion. Surgical accessibility and ease of recognition have been facilitated by the development of color-coded sizers. All of the instruments necessary for finger joint surgery are available in a molded tray that has also been redesigned with a transparent lid and clearly labeled compartments for accurate determination of instruments and implant sizers.

A new device for securing meshed split-thickness skin grafts.

This report describes the design, operation, and biomechanical performance of the Auto Suture Multifire Graftac-S disposable surgical staplers and absorbable tacks. The performance of this reloadable stapler has been compared to that of the Auto Suture Multifire Premium disposable skin stapler. The Premium stapler forms stainless steel staples to close the wound. The Graftac-S ejects absorbable tacks into the graft from a cartridge, which can be reloaded during a single operation. In two clinical trials of 10 patients each, the Graftac-S delivered absorbable tacks which were biocompatible and successfully secured the graft to the wound. The most obvious advantage of this device is that it obviates the need to remove the staples from the wound later. By the tenth postoperative day, about 90% of the tacks had extruded spontaneously, thereby reducing the amount of postoperative care required; discomfort to the patient during removal of the stainless steel staples is eliminated.

Electric heating pad burns.

Patients with sensory deficits are especially prone to heating pad burns. Two cases are reported of patients with anesthetic skin who received partial and full-thickness burns of their feet from an electric heating pad. These burn injuries could have been prevented if the patients understood the potential hazard of heating pads.

Biomechanical performance of a disposable graft stapler with absorbable skin tacs.

A stapler has been specially designed for fixing skin grafts to the underlying wound. The stapler has a loading unit which can be reloaded with cartridges of absorbable tacs. Each tac is made of a polymer which is biocompatible with tissue. The stapler ejects the tac into the graft, reliably securing it to the underlying tissue. The force and work required to eject the tacs were significantly less than that needed to form the metal staples. The most obvious advantage of the tac is that the majority of the tacs spontaneously extrude after the first dressing change. The performance of the disposable graft stapler with absorbable skin tacs has been compared to that of the disposable skin stapler with metal staples.

Evaluation of new absorbable Lactomer subcuticular staple.

The most recent advance in skin sampling is the Auto Suture SQS -20 disposable stapler. It approximates and everts wound edges, placing one synthetic absorbable pin in the dermis each time the instrument handle is activated. Staple wound closure was accomplished four times faster than sutural closure of the dermis. Wounds with staple pin closure exhibit superior resistance to infection than wounds approximated by dermal sutures. Although sutures provide more immediate wound security, as measured by wound breaking strength, than dermal pins, the breaking strength of wounds subjected to either dermal pins or dermal sutures were not significantly different 14 days after wounding.