Showing papers in "Plastic and Reconstructive Surgery in 1982"

Hemangiomas and vascular malformations in infants and children: a classification based on endothelial characteristics.

Abstract: … Those difficulties which have hitherto amused philosophers, and blocked up the way to knowledge, are entirely owing to ourselves. That we have first raids a dust and then complain we cannot see.

Breast reconstruction with a transverse abdominal island flap

Abstract: A rectus abdominis musculocutaneous island flap for breast reconstruction following mastectomy is presented. The vascular anatomy of the abdominal wall has been clinically studied in patients undergoing abdominal lipectomy. Cadaver dissections are shown, demonstrating the anatomy, arc of rotation, and design alternatives of the rectus abdominis flap. The surgical technique is demonstrated and representative patients are shown.

Breast Reconstruction after Mastectomy Using the Temporary Expander

Abstract: Breast reconstruction after a radical mastectomy using the temporary subcutaneous tissue expander is described. The main principle of this method is recovery of the amount of lost tissue through expansion of the remaining chest skin to large proportions and filling of the breast envelope with a smaller permanent mammary implant. Sixty-eight patients were reconstructed with an average follow-up of 18 months. Average expansion time for breast development was 6 weeks, with an average reconstructed breast size of 300 to 400 cc. Contralateral round dermal mastopexy with simultaneous nipple enlargement, contralateral subcutaneous mastectomy through a similar round dermal mastopexy, and reconstruction of the nipple are discussed.

Comparison of the effect of bacterial inoculation in musculocutaneous and random-pattern flaps.

Abstract: The response of musculocutaneous and random-pattern flaps to bacterial inoculation was studied in dogs by intradermal injection of bacteria and deposition of bacteria into stable wound spaces created by wound cylinders. No difference could be demonstrated in the susceptibility to bacterial challenge in the different portions of the musculocutaneous flap and in normal skin. A larger area of necrosis was observed in the random-pattern flaps, and the distal part was significantly more susceptible to necrosis. While the musculocutaneous flaps recovered rapidly from the bacterial inoculation, necrosis was observed in the random-pattern flaps. The bacterial count increased in the wound spaces surrounded by the random-pattern flaps, leading to full-thickness flap necrosis. The bacterial count decreased in the wound spaces surrounded by musculocutaneous flaps; there was evidence of healing around the wound cylinders. The musculocutaneous flap demonstrates a greater resistance to bacterial inoculation than the random-pattern flap on both its cutaneous and muscular surfaces.

The parascapular flap: a new cutaneous microsurgical free flap.

Abstract: We present the anatomic study and the clinical free transfer of a new donor site. This new flap is called the parascapular flap. It is under the dependence of a direct cutaneous artery that is a vertical terminal branch of the circumflex scapular artery, itself a branch of the subscapular artery. The flap is outlined along the free lateral border of the scapula, and it provides large surface coverage with easy primary closure of the donor site. The surface can even be extended by association of the flap with the latissimus dorsi muscle flap. With this flap, both skin and muscle areas are under the dependence of a single pedicle that is the subscapular artery.

The forearm flap.

Abstract: Our experience with the forearm flap based on the radial artery, one or two forearm veins and nerves is demonstrated in typical clinical applications (originator: Prof. Song, Beijing). This micro-neurovascular flap has been used as free flap including the osteocutaneous modality to resurface tissue defects in the neck, the upper and lower extremities. As a neuro-vascular island flap, it can cover defects of the ipsilateral hand.

Early cleft palate repair and speech outcome.

Abstract: Speech production and age at palatal repair were investigated in 80 cleft palate children. Children whose palates were repaired prior to the onset of speech production demonstrated significantly better speech than those whose palates were repaired between 12 and 27 months of age. The supposition that earlier palatal repair results in more normal speech development was, in fact, demonstrated in these cases. Rather than using chronologic age alone as the deciding factor in determining timing of initial palatal repair, the stage of each child's phonemic development should be considered if maximum speech potential is to be achieved and if speech development is to parallel normal noncleft peers. Determining this stage of development through early speech and language evaluations, beginning at 6 months of age, thus becomes an essential component in the habilitation of children with cleft palate. Continued research is needed to ensure against giving the obtainment of early speech normalcy disproportionate emphasis over craniofacial growth considerations. To this end, continued cooperative research between surgeons and speech pathologists is imperative in order to base these important decisions on substantiated findings.

Comparing radical mastectomy with quadrantectomy, axillary dissection, and radiotherapy in patients with small cancers of the breast

Abstract: From 1973 to 1980, we carried out a controlled study at the National Cancer Institute in Milan to consider the value of a conservative procedure in patients with breast cancer of small size. We randomized 701 patients with breast cancer measuring less than 2 cm in diameter and with no palpable axillary lymph nodes to Halsted radical mastectomy or to \"quadrantectomy\" with axillary dissection and radiotherapy to the ipsilateral residual breast tissue. We treated 349 patients with Halsted mastectomy and 352 with quadrantectomy. The two groups were comparable in age distribution, size and site of primary tumor, menopausal status, and frequency of axillary metastases. There were three local recurrences in the Halsted group and one in the quadrantectomy group. Actuarial curves showed no difference between the two groups in disease-free or overall survival. From these results, mastectomy appears to involve unnecessary mutilation in patients with breast cancer of less than 2 cm and no palpable axillary nodes.

The free scapular flap.

Abstract: The scapular flap is described, based on the posterior cutaneous branch of the inferior scapular artery. This flap has been successfully used in four clinical cases. The advantages of this flap lie mostly in its large, long, and very dependable vascular pedicle. It can be taken with the patient on his side or prone. The skin is thin and does not need defatting. The main disadvantage is the scar, which is on the posterior aspect of the scapula. This flap is very useful in the treatment of small defects of the ankle or lower leg.

Reduction mammaplasty and correction of ptosis with a short inframammary scar.

Abstract: The main sequelae of mammaplasties are scars, particularly visible when they trespass the breast limits. If the new inframammary fold is located higher than the original, the horizontal limb of the T-suture can be kept short and can be hidden beneath the breast. The glandular tissue is split vertically and overlapped for ptosis. For reduction, an inferior resection with medial or lateral remodeling is performed. The results are very satisfactory for ptosis and mild to moderate hypertrophy. High conical breasts with minimal scars are produced.

Histomorphologic evaluation of guinea pig skin and soft tissue after controlled tissue expansion.

Abstract: To evaluate the histologic changes attendant on tissue expansion in the guinea pig, self-inflating implants were placed in the dorsal subcutaneous space and the tissue response was sequentially studied at periods ranging from 1 to 18 weeks. Fixation artifacts have been minimized. The cellular response is relatively benign. The epidermis does not undergo thinning during expansion, although dermis and panniculus carnosus become significantly thinner. Atrophy of panniculus muscle is demonstrable. This study supports the hypothesis that tissue expansion results in a net gain of donor tissue.

An analysis of 133 pectoralis major myocutaneous flaps.

Abstract: Our experience with 133 consecutive pectoralis major island myocutaneous flaps in 126 patients is reviewed. The incidence of complications has been relatively low. Among the 133 flaps used in the head and neck area, 11 flaps (8 percent) failed to accomplish the intended purpose and required secondary repair. The pectoralis major myocutaneous flap with its abundant tissue and excellent blood supply and anatomic proximity provide a simple, reliable, and versatile method of primary reconstruction of various head and neck defects.

Chilling port wine stains improves the response to argon laser therapy.

Abstract: Twenty-three patients with facial port wine stains were studied to determine whether chilling lesional skin at the time of treatment could improve the outcome of argon laser therapy and whether this effect could be attributed to increased hemoglobin content of chilled sites, as hypothesized on clinical grounds. Each patient was biopsied in two representative and clinically identical sites, once at room temperature and once immediately after application of ice to the skin surface for 2 to 3 minutes. Two additional identical sites were treated with an argon laser in the same manner. Histologic sections of the port wine stain after application of ice tended to have a higher percentage of erythrocyte-filled vessels, but the effect of chilling on the dermal vasculature varied greatly among patients and was not statistically significant. In contrast, chilling of lesional skin prior to laser therapy resulted in a significantly better average outcome (p = 0.0002), with 57 percent of chilled sites superior to the paired room temperature control and none inferior. In nearly all instances of differential response, the site treated at room temperature manifested scarring, while the chilled site did not. Overall, after an average evaluation period of 4.8 months, 65 percent of the patients achieved a good or excellent result in the control site, and 87 percent achieved this result in the chilled site. These data establish the potential benefit of lesional modification prior to argon laser therapy and suggest that in the case of port wine stain chilling, this benefit is due to reduced heat injury of nonvascular elements in the skin.

Bacterial adherence to surgical sutures: A possible factor in suture-induced infection

Abstract: Surgical sutures are known to potentiate the development of wound infection. The purpose of this study was to investigate whether the capability of bacteria to adhere to various types of sutures has a significant effect on their ability to cause infections. Bacterial adherence to sutures was quantitatively measured using radiolabeled bacteria. In vitro adherence assays revealed remarkable variations in the affinity of bacteria to the various sutures: nylon bound the least bacteria while bacterial adherence to braided sutures (silk, Ti-cron, Dexon) was five to eight folds higher. The degree of infection obtained in mice in the presence of different sutures nicely correlated with their adherence properties. The different removal rate of adherent bacteria (glutaraldehyde-fixed) from various sutures by the tissue factors in mice supports the hypothesis that bacterial adherence to suture materials plays a significant role in the induction of surgical infection. Our observation points out at the need for careful suture selection in contaminated wounds. The adherence properties of sutures should be considered in any future surgical suture design.

Peripheral nerve injection injury with steroid agents

Abstract: The possible neurotoxic effects of five commonly used steroid agents were examined. Using histologic studies and studies of the microneural circulation, it was found the steroids can indeed cause neurotoxicity. The injection site was critical in effecting injury. Only intrafascicular injection caused damage. The damage produced varied with the agent used. Dexamethasone (Decadron) caused minimal damage, while hydrocortisone (Solu-Cortef) and triamcinolone hexacetonide (Aristospan) caused widespread axonal and myelin degeneration. Disturbance in the blood-nerve barrier correlated with the changes noted on light and electron microscopy, but is thought to be coincidentally and not causally related. In conclusion, it was shown that the intrafascicular injection of commonly used steroid agents had a direct toxic effect on peripheral nerve-fibers and caused a disruption of the blood-nerve barrier. Use of the more toxic agents in the vicinity of peripheral nerves should probably be avoided.

Extramammary Paget's disease.

Abstract: Extramammary Paget's disease is an in situ skin and mucosal carcinoma frequently associated with and probably arising in a subjacent or regionally proximate carcinoma Microscopic spread of tumor cells almost always extends beyond clinically apparent disease Surgical treatment requires carefully planned, systematic excision under precise histologic control An ideal treatment method remains to be developed Inadequate excision usually results in recurrences that can be successfully treated by reexcision Associated invasive carcinomas occur frequently, and mortality is high in these patients

Pharmacologic treatment of the failing skin flap.

Abstract: Pigs with random skin flaps were treated with phenoxybenzamine, isoxsuprine, or reserpine. No significant increase in flap survival was detected. In selected animals, cutaneous blood flow was measured using the microsphere technique. Of the drugs tested, reserpine was the only one to cause a significant increase in cutaneous blood flow. Previous clinical and experimental studies on the treatment of failing skin flaps are reviewed. The important criteria for designing future pharmacologic studies are discussed.

The free scapular flap.

Abstract: 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.

Late posttraumatic enophthalmos: a correctable deformity?

Abstract: Long-established posttraumatic enophthalmos with a seeing eye is a correctable deformity. A method utilizing principles of craniofacial surgery is described that provides the advantages of (1) wide exposure, (2) free mobilization of the displaced zygoma, (3) direct inspection of the orbital defect, and (4) restoration of the balance between the orbital contents and bony surroundings, which allows (5) the permanent correction of traumatic enophthalmos using autogenous material.

Electron microscopic evaluation of guinea pig skin and soft tissues "expanded" with a self-inflating silicone implant.

Abstract: An electron microscopic study of guinea pig skin and soft tissue after expansion by self-inflating silicone implant for periods of 7 weeks to 8 months revealed definite ultrastructural changes. In the epidermis, the cells of the malpighian layer contained larger groups of tonofilaments forming tonofibrils. Intercellular spaces in all layers of expanded epidermis were much more reduced than in normal epidermis. The basal lamina and the laminar surfaces of the basal cells demonstrated more undulation than those of the controls. The expanded dermis contained large bundles of compacted collagen fibers, as well as thin collagen fibers, active fibroblasts, and a few myofibroblasts. The subcutaneous tissue contained a paucity of adipose tissue and thickened collagen fibers in the interlobular spaces. The skeletal muscle showed larger amounts of sarcoplasm in relation to myofibrils. An increased number and size of mitochondria were found with sarcomeres abnormally arranged. The capsule around the implant was composed of active, elongated, and flattened fibroblasts and bundles of collagen fibers with variable fiber width. Intracellular collagen fibers were found in the cytoplasm of the fibroblasts. Myofibroblasts in the capsule were observed more often in early expanded tissue. Small blood vessels in the capsule showed multiplication of the basal lamina or were surrounded by a very wide, homogenous material. Inflammatory cells were not found in the capsule. Such findings are important in developing and evaluating future skin-expansion research in humans and animals.

Clinical trials of amniotic membranes in burn wound care.

Abstract: Four test conditions of increasing complexity were used to evaluate the clinical efficacy of amniotic membranes as biologic dressings on donor sites and burn wounds in children. These were the clean-skin donor-site wound, the uncontaminated shallow partial-thickness burn wound, the bed of freshly excised full-thickness wounds, and the granulating surface of colonized burn wounds. The rate of epithelialization under amniotic membranes was the same as that under 5% scarlet red ointment or 0.5% silver nitrate solution dressings. Preservation of a healthy excised wound bed and maintenance of a low bacterial count in contaminated wounds paralleled the experience with human allograft dressings despite technical difficulties and the absence of vascularization of amniotic membrane and its fragile structure. Tentative conclusions are drawn as to the mechanisms by which biologic dressings exert their beneficial effects.

The biologic behavior of basal cell carcinoma: analysis of recurrence in excised basal cell carcinoma: Part II.

Abstract: On the basis of a study of 188 cases of basal cell carcinoma of the face, the differences between the characteristics of recurrent and incompletely excised lesions are stressed. There was almost no difference in the recurrence rate of completely excised lesions and those in which there was histologic evidence of tumor at one of the margins. On the basis of these findings, a policy of conservative management of incompletely excised basal cell carcinoma is outlined.

Complications of surgery for radiotherapy skin damage.

Abstract: Complications of modern surgery for radiotherapy skin damage reviewed in 28 patients who had 42 operations. Thin split-thickness skin grafts for ulcer treatment had a 100 percent complication rate, defined as the need for further surgery. Local flaps, whether delayed or not, also had a high rate of complications. Myocutaneous flaps for ulcers had a 43 percent complication rate, with viable flaps lifting off radiated wound beds. Only myocutaneous flaps for breast reconstruction and omental flaps with skin grafts and Marlex mesh had no complications. The deeper tissue penetration of modern radiotherapy techniques may make skin grafts and flaps less useful. In reconstruction of radiation ulcers, omental flaps and myocutaneous flaps are especially useful, particularly if the radiation damage can be fully excised. The pull of gravity appears detrimental to myocutaneous flap healing and, if possible, should be avoided by flap design.

The effect of prolonged ischemia time on osteocyte and osteoblast survival in composite bone grafts revascularized by microvascular anastomoses.

Abstract: Twenty-six adult mongrel dogs were used to investigate the effect of prolonged ischemia on osteocyte and osteoblast survival in composite bone grafts revascularized by microvascular anastomoses. The bone grafts were stored in chilled (+5 degrees C) Collins-Terasaki solution, and ischemia time varied from 90 minutes to 48 hours. With histologic techniques and fluorochrome bone labeling it was shown that the bone marrow, the osteocytes, and the osteoblasts could completely survive up to 25 hours of ischemia. Although bone grafting techniques are employed routinely in many orthopedic and plastic surgical procedures, our knowledge is incomplete concerning the ischemic period tolerated by osteocytes and osteoblasts in these grafts. This information is essential when bone transfer on microvascular pedicles is employed, since 3 to 6 hours of ischemia time may be necessary in these operations. The present experiment has shown that osteocytes and osteoblasts can survive a rather long ischemic period if the medullary nutrient blood supply is later reconstituted. This fact adds validity to the technique of free vascularized bone grafts in reconstructive surgery.

Paralysis of the mandibular branch of the facial nerve

Abstract: A direct and simple operation of transfer of the anterior belly of the digastric muscle with its attached tendon is presented. It was carried out in 36 patients, with three minor complications. It has proved effective in paralysis of the mandibular division of the facial nerve as a primary or secondary procedure. In ablative resections where this branch of the nerve is intentionally sacrificed, it is advised to do the muscle and tendon transfer as part of the primary operation. In aesthetic operations or where the status of the nerve (post-operatively) is not specifically know, it is advised to wait for spontaneous return for an interval of 3 to 6 months. If the improvement is not satisfactory, then this technique may be considered.